Monday, November 19, 2007

Why it’s Hard to Trust Anyone Associated with Medical Costs—Part 1

It’s that time of year again, when I get to arrange for a tests to make sure I am still cancer-free. One of these is a colonoscopy. Our school’s insurance provider has changed (again) and we now have Aetna (again). My current G.I. (that’s gastro-intestinal I think) doctor is not in my network. If I use an in-network provider, I pay 20% and Aetna pays 80%, and with an out-of-network provider, I pay 40% and Aetna pays 60%. Last time my doctor fell out of my network, I called and found that the in-network provider only worked out of the hospital (as opposed to a private clinic). I tried to compare costs by calling the hospital for a price, but it was fairly impossible. They have a negotiated rate with my provider and they don’t know what it is, and they don’t know how many band-aids or needles or whatever will be used they told me. But the cost for the bed alone made me conclude that it seemed safer, and possibly cheaper, and certainly more predictable to just pay more at an out-of-network provider who seemed to know what they charged.

This year, I decided ask Aetna directly, figuring THEY would know what their negotiated prices were. I talked to our insurance person at the health center who made the request. The response from Aetna was this:

Generally the hospital or provider will not provide an estimate for the cost of a procedure without having more information like a procedure code or the number of necessary visits.
This student can log on to Aetna Navigator to get a estimate for the cost of a colonoscopy in the provider's area. Please advise the following steps:
0. Enter username/password
0. Blah blah blah

Aetna Navigator will deliver a rough estimate for the cost of this procedure. Navigator calculates the cost based on historical claims information adjusted to take into account health care cost inflation, in the calculation of the estimated costs.

In other words, she was saying, she didn’t feel like trying at all—Those codes are in a book published by the American Medical Association. I could probably google them for her--But here’s the bigger question: This is the insurance company—do they really not have access to the procedure codes or the money they have spent at various venders (which shouldn’t even differ that much because they should have a negotiated price)? Where are all their past claim invoices, do they not have numbers and prices on them? Basically this woman was telling me that THE INSURANCE COMPANY DOES NOT KNOW WHAT THEY ARE PAYING.

In the end, I called around myself, and although I was able to get numbers, I was assured at two places that the negotiated rate was probably lower, but that THE SERVICE PROVIDERS DID NOT KNOW WHAT THESE RATES WERE, they just let the insurance company tell them. In one case, since I was talking to the woman in the billing office, I did think to ask if perhaps, they have done the procedure before (it is a very common procedure---probably half their business I’m guessing), that perhaps they have issued invoices or received checks from the insurance company that she could look at?

She said it was probably possible, but that such things were hidden deep inside the entrails of the computer and were very hard to get to—she would probably need help to gain access. But she suggested I call the insurance company because “they should have those negotiated rates” and after all, “you’re paying them to do the shopping.”

Indeed I am.

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