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health / Stones & Bones / volume 9 number 10, October 2007 DOSE OF REALITY When you get a bill from the utility company, you know you are supposed to pay the amount stated on the bill. Likewise, when a mechanic hands you a bill for fixing your car, or you get a billing from the bank that holds a mortgage on your house, you know you are expected to pay that bill in full. But beware the bill you get from your doctor or your hospital. Medical billers would like you to pay their bills in full, but usually they don’t expect you to. Medical billers are required to present detailed bills—called charge tickets, super bills or actual bills—to third-party payers such as insurance companies or Medicare, but as “The Business Web Site for Physicians, www.PhysiciansPractice.com,” states, these detailed bills do not have to be shown to patients. In fact, the site states, it is best for a medical practitioner to give the patient only a generic bill that contains few details because, “…the charge ticket contains the practice’s fee schedule. Those prices probably look huge to the patient who doesn’t know the practice is rarely paid in full.” But if you, the patient, are unaware of this fact, then you are likely to assume that a medical bill should be paid in full just like every other bill you receive. This is a sad state of affairs, because the medical billing system victimizes people unaware of how the system operates and who also may be members of that part of our society least able to pay for medical treatment. I know from personal experience that it also victimizes people who take pride in responsibly paying their bills and are not inclined to haggle, perhaps because doing so might imply questioning the value of a doctor’s services. Hospitals, doctors, and medical insurers tend to be more than a little reticent about letting patients know how the amounts shown on charge tickets (actual bills) relate to the money actually paid for services rendered, usually implying that this is proprietary information. However, government-sponsored investigations into charging and bill collecting practices as well as certain reporting requirements enforced by the Centers for Medicare and Medicaid (CMS) do make some of this information available to a person willing to put in the time to dig it out. Also, CMS and some other organizations (such as a few insurance companies and Preferred Provider Organizations, PPOs) openly publish their payment schedules. So if a patient gets enough specific information from a medical provider, he or she at least can determine what Medicare or these other organizations would pay for a particular provider service. Responding to the suggestion that uninsured patients have to pay more than insured patients or those on Medicare, providers usually claim that they charge everyone the same rates and are required to do so by CMS regulations. (Actually, the claim that they are legally bound to charge everyone the same is not quite correct. The CMS regulation only states that a provider cannot charge any patient less for a procedure than the provider charges Medicare patients.) Furthermore, providers typically do not mentionthat, by one mechanism or another, they award discounts to most patients. One such mechanism is the direct discount given to private health insurance companies, typically in the vicinity of 30 to 60 percent. Some providers award large discounts to uninsured patients who pay their bills promptly. Others may award various levels of financial assistance to low-income patients in amounts that depend upon the patients’ incomes. Providers may also enter into agreements with Health Maintenance Organizations (HMOs) or preferred provider organizations) to accept payment according to payment schedules established by those organizations, in the same fashion that they agree to participate in Medicare and abide by its payment schedules. In those cases the preset payment schedules, not the charges laid out on the providers’ actual billings, determine the payments—unless a doctor charges less than the schedule allows, in which case the payer pays the lesser amount. To avoid that possibility, www.PhysiciansPractice.com warns providers against losing money by setting their fee schedules lower than what is allowed by Medicare, other insurers, or provider organizations. But at the same time the site warns providers not to set their schedules too high lest they raise the ire of patients who become aware that the charging is radically different than the third-party allowances. Patients rarely achieve that awareness, so it is usual for providers to set their charging rates at 150 to 400+ percent of the Medicare allowances. Actually, 150 percent is sufficient because third-party payers such as insurance companies typically set their payment schedules at 115 to 140 percent of the Medicare rates. Of course, by setting the fees much higher, providers can make their customers feel better when those fees are highly discounted. Gouging the patient really only occurs when the uninsured or underinsured patient ends up, for one reason or another, paying in full the provider’s actual bill or an unfair portion of it. If you are uninsured do not hesitate to ask about the doctor’s discounting policy—and remember that even if you get a discount of 50 percent, you may be paying more than a privately insured patient or one on Medicare. Also a warning! Before being treated, a patient usually signs a statement that he will be responsible for the billed amount regardless of what part of it is paid for by third parties. The signature is meaningless if the patient is on Medicare or otherwise insured by a third party that has set limits on the payments to providers. However, the patient may indeed be responsible for the full actual bill if the provider is not a Medicare provider, or has not agreed to abide by the allowances set by some other insuring third party. It doesn’t hurt to ask. | ||
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