Katy - I’m about to send it to everyone I know. Me and my 350 million homies need the gold that’s in it. Thanks for writing it. Let’s help the people we love save themselves. 🥰
This is the article most healthcare policy writing fails to produce. The rules exist. The protections exist. But the system is architected so that patients never find them, and the consent process is designed to strip them away before treatment starts. You just handed people the map.
The part that stopped me was the Medicare rate framework. Most patients have no idea that the "price" on their bill is a fiction anchored to a Chargemaster number that bears no relationship to cost. The fact that 150% of Medicare is reasonable and the average commercial outpatient rate is 250% tells you everything about where the margin lives. The gap between those two numbers isn't overhead. It's extraction.
The iPad consent workflow is worth its own article. The shift from paper to digital wasn't about efficiency. It was about removing the patient's ability to edit terms in real time. Paper you can cross out. An iPad you just tap through. The design is the mechanism.
I appreciate you making this free and shareable. The people who need this most are the ones least likely to have a policy background. That's the whole problem, and this helps close the gap.
Thank you so much for this thoughtful feedback. The way you put it - as basically consent theater - captured the spirit of what I was trying to describe perfectly.
I'm with you Moorea! When I lived in Germany I literally moved my mother next door bc I didn't know what else to do when she needed medical care because it was so unaffordable state side! We still had private US insurance at the time, but paid cash for her care overseas. That should NOT be the only way! I'm forwarding this to so many people as well!
I’m glad you found good doctors! One I saw in a cash-only clinic did not even provide me with increased access or time. I truly think a lot of doctors in our country have a God complex. They seem to think that merely by showing up, they can do no wrong.
Katy, first let me thank you for providing this very thorough guide to everyone for free. I worked on both the provider side and the insurer side of healthcare for my entire career. I understand all the factors that come into play to determining what is in that medical bill. I also feel sorry for those people that have no understanding whatsoever and then have to navigate the billing issue, not to mention the pre-authorization process, case management, PBM formularies and on and on. You have provided so much information in layperson terms as well as excellent resources and strategies. What I am wondering is does this process work when covered with an employer plan? I know that the contracts providers have with insurers stipulate reimbursement at the contracted rate. So, if a person has out of pocket costs due to co-pays or meeting deductibles can a person use this process to get a lower rate on those using the 150%, or so, over Medicare reimbursements? Katy, you rock!
Yes, definitely true with employer insurance because so many people have high deductibles. That’s why I mention how to go to your HR department and ask for anything you pay cash for to be applied to your deductible. But also, if you’re using your insurance card, you’re getting your plan’s crappy negotiated rate, so you can always negotiate something else and then submit for reimbursement on a claim reimbursement form through your portal.
Thanks. I'm retired and was asking for this poor souls that still have to use their employer plan. Provided people read the comments. I get so much from the comments section.
Thank you, just subscribed. I am in the nightmare of $800,000 of medical debt (for my husband) that started from an uninsured bout of sepsis that mushroomed into multiple surgeries in a very short time period and stage 4 sacral pressure sore that nearly killed him, long term hospitalizations, withheld care cost him his foot and a nursing home tried to sue us. Two years later, we are still trying to get him better, with me, a real estate person, basically doing all home care, wound dressing, including for the amputation which still hasn't healed, superpubic catheter changes, colostomy maintenance, all errands, all cooking and I run the family business, which couldn't afford the insurance in the first place. In the meantime, the medical bills are all at collections, while I can barely afford the bandages, supplies, and pain doctor visits, because no freaking primary will prescribe a little bit of Tramedol.
All that said, he is recovering, the sacral wound is nearly closed, he walks everyday with his walker and does what he can with weights. He is fighting hard to get back his life. He is 62, not about to die. We have a pending suit over the sacral wound (14 inches across by 7 inches deep) and the nursing facility offered us a settlement when they found out I had evidence of their negligence. Of course they have not paid what they agreed to last September, but at least I am not being dragged into court, when I cannot leave him for more than a few hours at a time.
Today I decided to begin fighting for better terms and I literally prayed for help and your article came into my feed.
I hope this is enough of a horror story for you. It literally could not be worse, unless he had died.
Really excellent specific advice, especially if you're "in the system" like millions of people are.
In 2018, I opted out of the system, by telling Blue Cross/Blue Shield that I now longer wanted to pay their $1800/month for me to be insured. (Didn't even include my wife.)
I'd had an open heart surgery in 2010 (waking up in the cardiac ICU seeing Obama signing the health care law). Insurance covered that one and I felt like all my previous premiums kind of "paid off" in that the surgery and all the pre-op testing was essentially paid for except the deductibles.
But 8 years of *constantly* increasing monthly premiums and I was done.
I'd heard about Samaritan Ministries health care where fellow believers help pay each others' medical bills. I checked in to various groups and went with Samaritan Ministries because a heart condition that was more than 5 years previous didn't count as a pre-existing condition. I doubled checked of course and it was true - I was fixed in 2010 and now it was 2018. Also, they allowed various alternative treatments and supplements to be shared.
Come 2021 and I developed a bacteremia due to a dog bite (occupational hazard) and my repaired valve from 2010 got obliterated. Open heart surgery #2 was scheduled for Valentine's Day 2022 (I got to pick the day actually and I thought it was appropriate). Since I was self-pay, I got to see the real costs behind the veneer prior to the procedure. The hospital bursar office sent me the comparison between insurance coverage and self-pay costs for the surgery so I would know ahead of time: nearly $500,000 for insurance covered and $64,000 for self-pay ( I still have that email because it is so ridiculous). I was post-op for extra days due to some complications and the total bill was nearer to $80,000. But I had that paid off within 3 months, thanks to fellow believers who help share in each others' medical bills (based on Act 2).
I always now ask what the cost will be for whatever I need to be seen for. It ALWAYS throws the receptionist and other office people for a loop. But they eventually do get back to me and when you pay cash/check, you get MAJOR discounts because, well, they like actual money.
One thing I can say is that the health insurance industry is truly a racket - and legalized, too.
I can not recommend highly enough to seek out a cooperative to be part of (like Samaritan Ministries). Most are faith-based but there may be some that are not. What a game changer!
Just had emergency surgery some weeks back. I knew to request an itemized bill, but didn't think to specify CPT codes. So we shall see what I get. I will ask again if it's not what I need.
My husband worked in hospital finance, and I often heard him talking about various rates (Medicare and a big commercial carrier). I know charges are always, in his words, the starting point for negotiation.
From a hospital/dr standpoint, Medicare rates are abysmal and don't actually pay the bills. If everyone was on Medicare, hospitals and drs wouldn't survive financially. Knowing this makes me feel reluctant to expect Medicare rates, or anything close. Your percentages at least offer a range of what is reasonable.
I definitely noticed on the admission consent in ED the little statement I was asked to initial acknowledging that not all providers were necessarily in network. Wish I had known about your little addition to that statement. But at least I can protest the bills if they come and are outrageous.
Hospitals should ensure all ED and inpatient providers are in-network. It's not as if I had a choice of which ED group staffs my in-network hospital.
Does this apply also to inpatient providers? I was just assigned the admitting internist, surgeon, and ID dr. Not like I had any choices.
Thanks again for the info and instructions for looking at Medicare rates!!! I just began looking at a couple of items, and oh, boy... charged >$500 for something that Medicare pays ~$50 for.
Insurance has already paid for an outpatient follow up thing ($380) for which Medicare pays ~$40. And insurance has paid the majority of my hospital stay. I'm primarily aiming to reduce the amount of deductible/non-covered costs that I must pay.
I'm going to be looking at charges for stuff I didn't receive; they ordered several meds that I declined, but every night the nurse brought it to my room and asked if I wanted it. I'm not paying for that stuff.
Would you bother asking for reduction for what insurance has already paid?
Sometimes it seems it's a matter of who files first as to who gets paid by insurance vs patient.
Katy. Check us out. www.aequumhealth.com. Connect with me on Linked in if you would like to discuss how your thoughts above align with our purpose. Perhaps you can help me find an Administrative Service Organization, a claims administrator, who is interested in innovating and solving a challenge the Department of Labor has yet to resolve (they were to deliver this solution before 2022).
Aequum is a Latin neuter noun and adjective meaning "what is right, fair, or equitable," "level ground," or "equal footing/terms". It represents the concept of equity or fairness, often contrasted with jus strictum (strict law) in legal contexts. It is the neuter form of aequus (equal, balanced).
I will. I am not involved in the everyday, and your interaction may have been before I joined. Interested in helping the Trump 2 Administration with a challenge that will give effect (and make it much easier to accomplish) to what you proposed above.
Thanks. I believe the best option for achieving "consumerism" in health care, as you describe here, is to conduct a price check in advance when possible. Coupling that with effective repricing and aequum representation is a "triple play". A superior, systemic process is required to achieve the first step.
As note above, I am looking for an Administrative Service Organization, a claims administrator, interested in innovating and solving a challenge the Department of Labor has yet to resolve (they were to deliver a solution before 2022).
Katy - I’m about to send it to everyone I know. Me and my 350 million homies need the gold that’s in it. Thanks for writing it. Let’s help the people we love save themselves. 🥰
Thank you Tiffany!! I hope everyone does! We shouldn’t have to fight the billing borg but we all do!!! Just hoping we can help some people!!
As my favorite comedian Adam Carolla says... Let's save some freaking babies!
Thanks so much Moorea! I hope it doesn’t come to that for everyone!!
This is the article most healthcare policy writing fails to produce. The rules exist. The protections exist. But the system is architected so that patients never find them, and the consent process is designed to strip them away before treatment starts. You just handed people the map.
The part that stopped me was the Medicare rate framework. Most patients have no idea that the "price" on their bill is a fiction anchored to a Chargemaster number that bears no relationship to cost. The fact that 150% of Medicare is reasonable and the average commercial outpatient rate is 250% tells you everything about where the margin lives. The gap between those two numbers isn't overhead. It's extraction.
The iPad consent workflow is worth its own article. The shift from paper to digital wasn't about efficiency. It was about removing the patient's ability to edit terms in real time. Paper you can cross out. An iPad you just tap through. The design is the mechanism.
I appreciate you making this free and shareable. The people who need this most are the ones least likely to have a policy background. That's the whole problem, and this helps close the gap.
Thank you so much for this thoughtful feedback. The way you put it - as basically consent theater - captured the spirit of what I was trying to describe perfectly.
What a great resource for navigating this disaster of a Healthcare system that our government has created (intentionally or otherwise)!
The only way it could be better is if I had it 20 years ago 🤣😋
LOL thanks so much Devin!! I just wish it wasn’t necessary.
Thanks so much for this, Katy. I'll be forwarding this to many friends.
My own personal solution to the dysfunctional health care system was to leave the states. 🤣
I'm with you Moorea! When I lived in Germany I literally moved my mother next door bc I didn't know what else to do when she needed medical care because it was so unaffordable state side! We still had private US insurance at the time, but paid cash for her care overseas. That should NOT be the only way! I'm forwarding this to so many people as well!
Exactly, Tiffany. Paying cash abroad is cheaper than being insured stateside. And sometimes the care’s even better.
For me as a cash pay patient better care was almost always the rule even if only because of increased access and time
I’m glad you found good doctors! One I saw in a cash-only clinic did not even provide me with increased access or time. I truly think a lot of doctors in our country have a God complex. They seem to think that merely by showing up, they can do no wrong.
So so so true. It’s a white coat religious cult.
🎯
They're the priests, and then there's the largest cult in the world, which says "follow the science" while doing the opposite.
This is a phenomenal article, and I just shared it with my family. It is full of practical tips to pull the curtain back on hospital billing!
Oh thank you so much!! Hope it helps people!
Omg, this -> “Dear Hospital, you never gave me a price, so now we’re using mine. Love, America” 🔥
This article is gold! Thank you for being one of a very few willing and able to share this information!
Thanks so much Richard! Pass it on to the folks who need it!!
This is wild.
The shenanigans we have to do to not be screwed - truly wild!!
Katy, first let me thank you for providing this very thorough guide to everyone for free. I worked on both the provider side and the insurer side of healthcare for my entire career. I understand all the factors that come into play to determining what is in that medical bill. I also feel sorry for those people that have no understanding whatsoever and then have to navigate the billing issue, not to mention the pre-authorization process, case management, PBM formularies and on and on. You have provided so much information in layperson terms as well as excellent resources and strategies. What I am wondering is does this process work when covered with an employer plan? I know that the contracts providers have with insurers stipulate reimbursement at the contracted rate. So, if a person has out of pocket costs due to co-pays or meeting deductibles can a person use this process to get a lower rate on those using the 150%, or so, over Medicare reimbursements? Katy, you rock!
Yes, definitely true with employer insurance because so many people have high deductibles. That’s why I mention how to go to your HR department and ask for anything you pay cash for to be applied to your deductible. But also, if you’re using your insurance card, you’re getting your plan’s crappy negotiated rate, so you can always negotiate something else and then submit for reimbursement on a claim reimbursement form through your portal.
Thanks. I'm retired and was asking for this poor souls that still have to use their employer plan. Provided people read the comments. I get so much from the comments section.
Thank you, just subscribed. I am in the nightmare of $800,000 of medical debt (for my husband) that started from an uninsured bout of sepsis that mushroomed into multiple surgeries in a very short time period and stage 4 sacral pressure sore that nearly killed him, long term hospitalizations, withheld care cost him his foot and a nursing home tried to sue us. Two years later, we are still trying to get him better, with me, a real estate person, basically doing all home care, wound dressing, including for the amputation which still hasn't healed, superpubic catheter changes, colostomy maintenance, all errands, all cooking and I run the family business, which couldn't afford the insurance in the first place. In the meantime, the medical bills are all at collections, while I can barely afford the bandages, supplies, and pain doctor visits, because no freaking primary will prescribe a little bit of Tramedol.
All that said, he is recovering, the sacral wound is nearly closed, he walks everyday with his walker and does what he can with weights. He is fighting hard to get back his life. He is 62, not about to die. We have a pending suit over the sacral wound (14 inches across by 7 inches deep) and the nursing facility offered us a settlement when they found out I had evidence of their negligence. Of course they have not paid what they agreed to last September, but at least I am not being dragged into court, when I cannot leave him for more than a few hours at a time.
Today I decided to begin fighting for better terms and I literally prayed for help and your article came into my feed.
I hope this is enough of a horror story for you. It literally could not be worse, unless he had died.
Take care of your health and avoid hospitals!
That’s the best strategy :-)
A billion percent!!
https://podcasts.apple.com/us/podcast/man-in-america-podcast/id1603141405?i=1000774559010
Really excellent specific advice, especially if you're "in the system" like millions of people are.
In 2018, I opted out of the system, by telling Blue Cross/Blue Shield that I now longer wanted to pay their $1800/month for me to be insured. (Didn't even include my wife.)
I'd had an open heart surgery in 2010 (waking up in the cardiac ICU seeing Obama signing the health care law). Insurance covered that one and I felt like all my previous premiums kind of "paid off" in that the surgery and all the pre-op testing was essentially paid for except the deductibles.
But 8 years of *constantly* increasing monthly premiums and I was done.
I'd heard about Samaritan Ministries health care where fellow believers help pay each others' medical bills. I checked in to various groups and went with Samaritan Ministries because a heart condition that was more than 5 years previous didn't count as a pre-existing condition. I doubled checked of course and it was true - I was fixed in 2010 and now it was 2018. Also, they allowed various alternative treatments and supplements to be shared.
Come 2021 and I developed a bacteremia due to a dog bite (occupational hazard) and my repaired valve from 2010 got obliterated. Open heart surgery #2 was scheduled for Valentine's Day 2022 (I got to pick the day actually and I thought it was appropriate). Since I was self-pay, I got to see the real costs behind the veneer prior to the procedure. The hospital bursar office sent me the comparison between insurance coverage and self-pay costs for the surgery so I would know ahead of time: nearly $500,000 for insurance covered and $64,000 for self-pay ( I still have that email because it is so ridiculous). I was post-op for extra days due to some complications and the total bill was nearer to $80,000. But I had that paid off within 3 months, thanks to fellow believers who help share in each others' medical bills (based on Act 2).
I always now ask what the cost will be for whatever I need to be seen for. It ALWAYS throws the receptionist and other office people for a loop. But they eventually do get back to me and when you pay cash/check, you get MAJOR discounts because, well, they like actual money.
One thing I can say is that the health insurance industry is truly a racket - and legalized, too.
I can not recommend highly enough to seek out a cooperative to be part of (like Samaritan Ministries). Most are faith-based but there may be some that are not. What a game changer!
Bravo! Love Samaritan!
This showed up in my feed in a timely fashion.
Just had emergency surgery some weeks back. I knew to request an itemized bill, but didn't think to specify CPT codes. So we shall see what I get. I will ask again if it's not what I need.
My husband worked in hospital finance, and I often heard him talking about various rates (Medicare and a big commercial carrier). I know charges are always, in his words, the starting point for negotiation.
From a hospital/dr standpoint, Medicare rates are abysmal and don't actually pay the bills. If everyone was on Medicare, hospitals and drs wouldn't survive financially. Knowing this makes me feel reluctant to expect Medicare rates, or anything close. Your percentages at least offer a range of what is reasonable.
I definitely noticed on the admission consent in ED the little statement I was asked to initial acknowledging that not all providers were necessarily in network. Wish I had known about your little addition to that statement. But at least I can protest the bills if they come and are outrageous.
Hospitals should ensure all ED and inpatient providers are in-network. It's not as if I had a choice of which ED group staffs my in-network hospital.
Hi Amy, glad it was helpful! In the ED, all providers must bill you at in-network rates, even if they’re OON, under the No Surprises Act.
Oh, good to know!
Does this apply also to inpatient providers? I was just assigned the admitting internist, surgeon, and ID dr. Not like I had any choices.
Thanks again for the info and instructions for looking at Medicare rates!!! I just began looking at a couple of items, and oh, boy... charged >$500 for something that Medicare pays ~$50 for.
Insurance has already paid for an outpatient follow up thing ($380) for which Medicare pays ~$40. And insurance has paid the majority of my hospital stay. I'm primarily aiming to reduce the amount of deductible/non-covered costs that I must pay.
I'm going to be looking at charges for stuff I didn't receive; they ordered several meds that I declined, but every night the nurse brought it to my room and asked if I wanted it. I'm not paying for that stuff.
Would you bother asking for reduction for what insurance has already paid?
Sometimes it seems it's a matter of who files first as to who gets paid by insurance vs patient.
I’ll send it to my network!! Great work once again!
Thank you so much Dr. R!
Katy. Check us out. www.aequumhealth.com. Connect with me on Linked in if you would like to discuss how your thoughts above align with our purpose. Perhaps you can help me find an Administrative Service Organization, a claims administrator, who is interested in innovating and solving a challenge the Department of Labor has yet to resolve (they were to deliver this solution before 2022).
Connect with me on Linkedin: https://www.linkedin.com/in/jack-towarnicky-5878787/
FYI, they don't call us aequum for nothing.
Aequum is a Latin neuter noun and adjective meaning "what is right, fair, or equitable," "level ground," or "equal footing/terms". It represents the concept of equity or fairness, often contrasted with jus strictum (strict law) in legal contexts. It is the neuter form of aequus (equal, balanced).
Thanks Jack! You might ask your law firm partner about their experience with me and my group of nuns ;) They might not remember, but I do.
I will. I am not involved in the everyday, and your interaction may have been before I joined. Interested in helping the Trump 2 Administration with a challenge that will give effect (and make it much easier to accomplish) to what you proposed above.
Separately, wWhat does "ND ScM" stand for?
ND is naturopathic doctor and ScM is a masters in epidemiology. The school I went to made it ScM instead of MS like normal people, ha!
Thanks. I believe the best option for achieving "consumerism" in health care, as you describe here, is to conduct a price check in advance when possible. Coupling that with effective repricing and aequum representation is a "triple play". A superior, systemic process is required to achieve the first step.
As note above, I am looking for an Administrative Service Organization, a claims administrator, interested in innovating and solving a challenge the Department of Labor has yet to resolve (they were to deliver a solution before 2022).
Perhaps you can make a referral.