Medical Insurance tactics - An Account

[KEW]

I am fortunate to have pretty good benefits under BC/BS.
My doctor scheduled me for my annual MRI brain scan this week (I have a non-cancerous tumor to keep an eye on).

The next day I got a call from a perky young gal representing BC/BS (I mention perky because they usually have the personality of Lily Tomlin playing phone operator). She was friendly - expressed concern for my condition and let me know that my MRI was approved.
Next she told me that I could save some money by going to one of the Shopping Center MRI facilities in my area (which happen to also be much closer, as she was quick to point out).
I told her thanks, but I was concerned that the equipment and the radiologist might not be as good as the ones at the more established imaging centers.
She explained that BCBS had an extensive review procedure, and these other facilities would not be approved unless they had high scores.
I asked her what percentage of facilities reviewed got low scores.
She hesitated, then replied facilities hardly ever do poorly in these evaluations.
(It was telling that her voice relaxed when she made this last statement; poor gal has a job of befriending people then talking them into inferior health care.)
Well, the gig was up at this point, but since we were on the phone I asked her what the price difference was. $500-600 at the Shopping Center and $3600 at the dedicated medical complex!

My conjecture:
The major medical networks upgrade their equipment fairly often as a major selling point. I think it is easy money that the old equipment gets bought for pennies on the dollar and installed in these Shopping Center locations ("Open MRI" is the name of the ones in Shopping Centers around Atlanta). The equipment is probably still in decent shape, but not be state of the art. I suspect the employees are not as well paid, but they may still be very good. I have to believe the best radiologists are going to get actively recruited by the medical networks' larger paychecks.

My portion of the bill will be higher, but I'm willing to pay for the newer equipment (higher res, lower radiation) and radiologist (I had misdiagnosed readings in the past) when my brain is being scanned.
If it was a knee injury to evaluate, I would give it more thought and find out what my out of pocket would be (she didn't know that, which makes me think I have hit my annual max so BC/BS is footing the entire bill - makes sense that they would target the people that are going to cost them the most).

In any case, I thought I'd share in the hope this helps someone who might not be so skeptical as I am.

 

[96cobra10101]

excellent post!

 

[j_garcia]

Generic drugs are one thing, and I don't always opt for them. But "second hand" MRI? DEFINITELY when it comes to your BRAIN, I want current, not 5 years ago.

Wow, and on the same note, sorry to hear about that tumor. Hopefully nothing is going on with it and this is just a routine monitoring now that you know about it.

 

[Steve81]

Interesting phone call, though not inordinately surprising.

BC/BS's motives are pretty obvious and to an extent understandable: it's hard to run an insurance company and keep rates reasonably low if everybody is using the costliest possible options for everything. There's been similar "educational" pushes for generic drugs as well.

In the end, I'd perhaps not damn them too much; it's not terribly likely they examined your situation in depth before giving you the phone call. More than likely you just made some list compiled by a computer. As you say, if it were your knee instead of your brain, you might be a bit more open to the suggestion.

Of course, from a personal standpoint, I can appreciate the simplicity of Kaiser's system (my current insurance company/health care provider). Everything is under one roof; of course, whether the stuff under that roof is worth anything or not is another story, but I've had no complaints thus far.

 

[KEW]

Wow, and on the same note, sorry to hear about that tumor. Hopefully nothing is going on with it and this is just a routine monitoring now that you know about it.

Thanks for the concern. The doctor figures I've had it for over 30 years and we found it 3 years ago, so I am happy to say it is all routine at this point.

 

[jinjuku]

I had misdiagnosed readings in the past

At the costly, new equipment, presumably better paid radiologist place?

 

[lsiberian]

It's possible the other place is just as good and I'd certainly be interested in cheaper options if I were a consumer, but I'm a cheap skate.

 

[Steve81]

It's possible the other place is just as good

If nothing else, there are certain standards that do apply regardless of whether they're located in a mall or a medical park. While the radiologist at the mall may not be a Harvard man, he's probably not a two bit quack that peddles magic healing herbs on the side either.

 

[j_garcia]

It's possible the other place is just as good and I'd certainly be interested in cheaper options if I were a consumer, but I'm a cheap skate.

I am kind of a cheapskate too with some things, but not with something like this.

 

[KEW]

At the costly, new equipment, presumably better paid radiologist place?

No, at a low cost facility which I was referred to by my doctor (who was part owner of the facility I found out later)!
At that point, it hadn't occurred to me to question the facility and it was in the basement of a medical office building.

For the record, the expensive place is Emory. It is in the top 10 Academic Hospitals, and aside from Duke in NC, it is probably the best place to go in the South East. I actually decided not to use their MRI because I don't want to lose the better part of a day driving through Atlanta's traffic to get there and back. I spoke with a neurosurgeon to establish a good facility closer to home. I don't know if it will cost more or less, all I really care is that the quality is high.

 

[KEW]

excellent post!

Whenever I view you sig, I can feel my tumor stirring and start to grow... just sayin'!









In case it needs to be said, j/k - I think it is great, but part of the fun of it is getting freaked out over it!

 

[j_garcia]

 

[jostenmeat]

There is a fair chance I may see my brother tonight, who is a neuroradiologist, top tier trained the whole way, flying colors (resident of the year, etc), still actively trains other young doctors too (part of his job description). I'll be having dinner with friends that live across the street from him, and I know he was invited, but am not sure if he can actually make it. I will 100% see him Saturday night. If there is a specific question you want me to pass along, I'll see what I can do. If I don't see this thread before I might see him tonight, I guess I'll try to make a mental note of asking him to rank the brands of MRI machines in terms of brain imaging. Of course I'm not sure about just how much he knows, but recently a good mutual friend called him up while en route to an ER, and I know my bro was familiar enough with the machinery and doctors of the area (and who were currently present at the time no less, dunno how he knew) to reroute him to a place that was superior on both counts.

Regarding the price figures you threw out, this is one facet that is pretty confusing to many, including those in the industry, and therefore I would see what you can do to confirm. I suppose I'd ask the doc offices directly what it truly* would cost you*. 500 or 3600, that could be the line charges to the ins (which can almost be arbitrary, but I won't get into that), then there is the amount that the ins will actually pay out (do you know for a cold stone fact that they don't pay out even perhaps equally to them?!), and of the great amount that separates the resulting and respective differences, well that still could possibly be written off as an adjustment, but actually nevermind all of that:

Why would they care to call you? Is it because it costs THEM more money, and not so much you? Well that is a suspicion of mine. Maybe I'm as cynical as you. Then again, if they saved you from huge charges, I suppose you're more likely to stay on with your plan, and they would succeed in retaining a paying customer. It would also make sure you don't go the poor house, and are even still able to make payments to them to begin with, I guess?

Anyway, put the speculation aside, and ask the doc office that you prefer directly, how much you will be paying out of pocket for coinsurance, deductible, etc, including for both the use of the machine as well as the doctor's time. They can verify your insurance, and should be able to tell you.

 

[j_garcia]

Regarding the price figures you threw out, this is one facet that is pretty confusing to many, including those in the industry, and therefore I would see what you can do to confirm. I suppose I'd ask the doc offices directly what it truly* would cost you*. 500 or 3600, that could be the line charges to the ins (which can almost be arbitrary, but I won't get into that), then there is the amount that the ins will actually pay out (do you know for a cold stone fact that they don't pay out even perhaps equally to them?!), and of the great amount that separates the resulting and respective differences, well that still could possibly be written off as an adjustment, but actually nevermind all of that:

Why would they care to call you? Is it because it costs THEM more money, and not so much you? Well that is a suspicion of mine. Maybe I'm as cynical as you. Then again, if they saved you from huge charges, I suppose you're more likely to stay on with your plan, and they would succeed in retaining a paying customer. It would also make sure you don't go the poor house, and are even still able to make payments to them to begin with, I guess?

This is what I was thinking about the big disparity in those numbers. She likely quoted the "rate" not the negotiated rates, and in the end they will likely still pay out close to the same amount for either of them.

Anyway, put the speculation aside, and ask the doc office that you prefer directly, how much you will be paying out of pocket for coinsurance, deductible, etc, including for both the use of the machine as well as the doctor's time. They can verify your insurance, and should be able to tell you.

They will usually only give you a ballpark because they won't know for all procedures what the final out of pocket will end up being. This one seems straight forward, so they should be able to tell you exactly how much it is, though they may not want to tell you regardless of whether it ends up being close or not.

 

[jostenmeat]

This is what I was thinking about the big disparity in those numbers. She likely quoted the "rate" not the negotiated rates, and in the end they will likely still pay out close to the same amount for either of them.

What you call the "rate", or the charge amount, well the reason I called it arbitrary is that the law as I understand it requires that this rate cannot be changed no matter who you are giving it to. Therefore if you have one single payor out of a list of 100 ins companies you work with that actually pays you a huge amount for this (and they might not pay barely at all for other services) you need to make sure that this rate is high enough that you don't lose out on the high payor. That's why I think of these figures as arbitrary, you might as well charge 1 million dollars for anything including just putting on a band-aid, because the only thing that matters is what the ins have negotiated with doctor and with patient. But many people, again including those who "are in the industry", freak out over some enormous numbers they come across, omg my doc charges 10000000 bux for this thing, but in the reality as I know it, it's pretty much an arbitrary number.

 

[KEW]

There is a fair chance I may see my brother tonight, who is a neuroradiologist, top tier trained the whole way, flying colors (resident of the year, etc), still actively trains other young doctors too (part of his job description). I'll be having dinner with friends that live across the street from him, and I know he was invited, but am not sure if he can actually make it. I will 100% see him Saturday night. If there is a specific question you want me to pass along, I'll see what I can do. If I don't see this thread before I might see him tonight, I guess I'll try to make a mental note of asking him to rank the brands of MRI machines in terms of brain imaging. Of course I'm not sure about just how much he knows, but recently a good mutual friend called him up while en route to an ER, and I know my bro was familiar enough with the machinery and doctors of the area (and who were currently present at the time no less, dunno how he knew) to reroute him to a place that was superior on both counts.

Regarding the price figures you threw out, this is one facet that is pretty confusing to many, including those in the industry, and therefore I would see what you can do to confirm. I suppose I'd ask the doc offices directly what it truly* would cost you*. 500 or 3600, that could be the line charges to the ins (which can almost be arbitrary, but I won't get into that), then there is the amount that the ins will actually pay out (do you know for a cold stone fact that they don't pay out even perhaps equally to them?!), and of the great amount that separates the resulting and respective differences, well that still could possibly be written off as an adjustment, but actually nevermind all of that:

Why would they care to call you? Is it because it costs THEM more money, and not so much you? Well that is a suspicion of mine. Maybe I'm as cynical as you. Then again, if they saved you from huge charges, I suppose you're more likely to stay on with your plan, and they would succeed in retaining a paying customer. It would also make sure you don't go the poor house, and are even still able to make payments to them to begin with, I guess?

Anyway, put the speculation aside, and ask the doc office that you prefer directly, how much you will be paying out of pocket for coinsurance, deductible, etc, including for both the use of the machine as well as the doctor's time. They can verify your insurance, and should be able to tell you.

The charges of $500-600 vs $3600 were what BC/BS presented as the facilities billed amount. You are right that the insurance may wave their wand and say that only $2000 of the $3600 is allowable. I pay 10% of the allowable fees (unless I have met my annual max, which is likely).

Thanks for the offer. The best questions I can think of are:
1) to ask how big of a difference in quality he sees between different MRI facilities, and whether it matters much.
2) any guidelines for avoiding poor MRI facilities (contingent upon Item 1 mattering).
3) What does a new top notch MRI go for (this, more a simple curiosity than anything else).

A list of best machines sounds nice, but I don't know if he would know model numbers off the top of his head.

 

[j_garcia]

What you call the "rate", or the charge amount, well the reason I called it arbitrary is that the law as I understand it requires that this rate cannot be changed no matter who you are giving it to. Therefore if you have one single payor out of a list of 100 ins companies you work with that actually pays you a huge amount for this (and they might not pay barely at all for other services) you need to make sure that this rate is high enough that you don't lose out on the high payor. That's why I think of these figures as arbitrary, you might as well charge 1 million dollars for anything including just putting on a band-aid, because the only thing that matters is what the ins have negotiated with doctor and with patient. But many people, again including those who "are in the industry", freak out over some enormous numbers they come across, omg my doc charges 10000000 bux for this thing, but in the reality as I know it, it's pretty much an arbitrary number.

Exactly. My son was hospitalized (ambulance, emergency/ICU, two days stay, etc...) two years ago and the initial statement came with charges that came to $124K!!!! The ACTUAL negotiated rate for everything ended up being like $40K, of which we had to pay something like $3K after the insurance paid.

 

[jostenmeat]

The charges of $500-600 vs $3600 were what BC/BS presented as the facilities billed amount. You are right that the insurance may wave their wand and say that only $2000 of the $3600 is allowable. I pay 10% of the allowable fees (unless I have met my annual max, which is likely).

Thanks for the offer. The best questions I can think of are:
1) to ask how big of a difference in quality he sees between different MRI facilities, and whether it matters much.
2) any guidelines for avoiding poor MRI facilities (contingent upon Item 1 mattering).
3) What does a new top notch MRI go for (this, more a simple curiosity than anything else).

A list of best machines sounds nice, but I don't know if he would know model numbers off the top of his head.

1) good question!
2) My guess is that the doc is by far the hugest factor, assuming a machine isn't totally irrelevant by today's standards, but if I'm lucky maybe I can glean something in this category.
3) $$$$. I remember years ago he was talking about MRI centers being cash cows, because they are expensive enough to be relatively rare, or something like that, I don't know how much his view on this subject has changed since he was talking about this. I'll ask.

oh, and I said "brands" for a reason, because I imagine model #s is pretty tough.

 

[Swerd]

Because your brain scan will be compared to those from previous years, another question you might ask is does it matter if this year's image is made by a different MRI facility and tech?

I'm also guessing that doc assessing the MRI image is the biggest cost. Most medicine practiced by teaching institutions is much more expensive. The radiologists at Emory probably also have a much more extensive and expensive malpractice insurance plan.

I have also heard that the Emory Radiology group is among the best in the US, not just the south east, but my experience is limited to cancer research treatment research.

 

[ParadigmDawg]

I can do a MRI in my garage if you want to come by.