Balance billing at center of new healthcare brouhaha on clarkhoward.com

When you have a medical procedure, a bill is generated, the insurer pays a negotiated amount and you have your co-pay. That should be the end of the story. But right now there's a fight in California about who gets stuck with the tab. Doctors and hospitals are furious that they bill one amount, yet the insurers come back saying they'll only pay a fraction of it.

In the push and pull, the weakest player here is the consumer. The doctors and hospitals are trying to pass unpaid costs off to the patient through a practice known as "balance billing." Clark has no idea how this fight will go in the Golden State, but he'll keep you updated.

The real solution here would be for customers to know the cost of medical care before a procedure and shop accordingly. But we're nowhere near this being the case.

The Society of Actuaries finds that paying for healthcare is the No. 1 concern of workers, cited by 70% of people. Right now there's a stalemate with employers, medical providers and consumers all hating the system. The only ones who like the system are the insurers.

The problem is we don't have a marketplace where insurers are required to practice normal capitalism. Clark has long been an advocate of vouchers for healthcare. Insurers would then have to compete for everyone's business and there wouldn't be exclusions for pre-existing conditions. This is not a justification for universal healthcare; it's just a call for healthcare vouchers.

Healthcare is a hot button issue for voters in '08. But both parties are stuck in a prior decade with their views. We need to move into the future and vouchers might be one way to get the job done.

What others are saying

Is the comment above accurate for Georgia? :"Balance billing
This is illegal in virtually all states. Providers enter into these contracts without a gun to their head. They have no complaint if the reimbursement rates aren't high enough.
By Greg @ 03/30/09 03:53:34 PMreport abuse
Medical proceedure costs
I had attempted to determine the cost of a recomended procedure to determine if I could afford the 20% co-pay. I was told over and over the information is "propriatory". The providers will not give you a cost nor an estimate period. I was not willing to throw the dice at the proceedure. This is not any resemblance of free market..it is concealed market. There is no moral compass in our health care system. I firmly beleive it should be handled by as many not for profit organizations who care to get into the game. The profit motive has not proven to be an honest broker in the care delivery of our system. As far as medication is concerned I would rather nationalize research and let the government sell/franchise the patents to big pharma. There is no integrity in Big Pharma..doing research/funding university research..verifying research to FDA...and owning FDA in the approval process and most related laws. This country needs to revamp health care from scratch, keep what works and scrap what does not.
By Lynne @ 10/10/08 02:26:55 PMreport abuse
Hospital billing after procedure
I have looked all over the internet for information on how to "verify" each item and procedure on my hospital bill. In particular, many of the medical descriptions are not readily recognized by the layman. So how does one know if he/she actually used this item or it was used in the process? How do I verify that I am being charged for items and processes that were actually a part of my surgical procedure and hospital stay?
By Pat Clark @ 08/22/08 10:30:02 AMreport abuse
Re: The list of fees would allow competition
If the fees listed are 500% of what the procedure actually cost, exactly how is this going to create competition? With your analogy restaurants would compete on prices you would never pay. So, when you sat down to order your meal the menu would show 100$ for a burger but when you actually pay and show them your "restaurant card" to bill comes to $10. But the published rates are $100. You still have no idea what the real price is until you buy the burger. Another customer has a different card and they may pay $15 or $20. The hungry tourist without a card at all pays $100. It is crazy and unless the inflation of prices is removed the list of fees is not going to do much other than draw attention to gross over billing practices of the industry. It is not going to create competition like shopping for food. I am afraid your analogy is a gross oversimplification of a broken system. You have to fix the over billing practices before you can have competition.
By Benton @ 05/22/08 09:35:39 AMreport abuse
Balance billing
This is illegal in virtually all states. Providers enter into these contracts without a gun to their head. They have no complaint if the reimbursement rates aren't high enough.
By Jay Hodges @ 05/21/08 07:09:39 PMreport abuse
RE: what are we going to do about it?
Here's what I would do about it:
1) Make it illegal to shift costs from uninsured patients
2) Start prosecuting Hospital administrators and insurance company executives under the RICO statutes.

If any other business operated and kept books like a typical hospital, the FBI and FTC would be all over them for fraud, corruption, and deceptive business practices.
By Jason Telman @ 05/21/08 02:44:15 PMreport abuse
The list of fees would allow competition!
The claim that a published fees for medical procedures is "worthless" is like saying restaurant menus with prices are worthless. To the contrary, a published fee schedule would allow patients and insurance companies to take their business to medical providers with the lowest fees. Hospitals don't want to do this because it would expose the fraudulent cost-shifting that occurs when they treat uninsured or indigent patients.
By Jason Telman @ 05/21/08 02:37:45 PMreport abuse
OK, what are we going to do about it?
This system is obviously dishonest. With Insurance Co's in control of our lawmakers, what can we do about this?
I think we need to brainstorm here.
By DDM @ 05/21/08 01:27:38 PMreport abuse
Re: Why can't hospitals publish a list of fees
They could put a list of fees together but it would be worthless. The fees would be the "sticker price" and have no relation to the price you really pay except that it is 500% more. For example, a CT scan might have a "sticker price" of $6,000 in the ER but the hospital has contracted rates with each large insurer. Every insurer has a different price. So, without insurance you would be billed $6k but under a contracted health plan the bill might be $1300. And that is just for one scan. This kind of pricing system is applied to all services and billing by hospitals and most doctors. The billing means nothing. It is all phony. This also helps the hospital when they give treatments to people who have no insurance and will never pay. The hospital can now claim, and potentially write off, that they lost $6k on the CT scan from an uninsured patient rather than the $1300 they really lost.
By Benton @ 05/21/08 01:25:59 PMreport abuse
The System is Ridiculous
Q: Why can't hospitals publish a list of fees for standard procedures? A: Because they want to hide the costs they shift from non-paying/uninsured patients to the ones with the ability to pay. The insurance companies counter this cost-shifting game by paying only a fraction of the bill. If Congress made cost-shifting illegal, much of this nonsense would stop.
By Jason Telman @ 05/21/08 12:11:56 PMreport abuse
US healthcare is amazing
It is astounding that nations smaller than many US cities can offer their citizens healthcare while people in the US debate vouchers, insurance premiums, and whether providing healthcare to every human being on US soil is somehow politically, philosophically, or economically "anti-American." Amazing.
By SDD @ 05/21/08 11:49:53 AMreport abuse
I know about balance billing!
At a former employer, I was supposed to 100% health care (that job didn't last long, less than 2 years!). Of course, my employer's healthcare provider was supposed to have negotiated discounted fees, say, $75 for a test instead of $100. Well, guess who got the bill for $25? Me, and this went on for any procedure me or my family had. It took days and weeks to clear the bills and most of the time the hospitals (they were the worst) would say it was "a mistake." Right. The bills were in the thousands of dollars, most of which was for normal family healthcare. What aggravation and time this caused me! I am certain the hospitals and doctors' offices knew what they were doing. Evidently, they got a pretty good return on the inappropriate bills they were sending out. People probably weren't paying attention or didn't want to take the time to protest and would just pay the damn thing even though they didn't owe it.

What happened to America?
By Mordie @ 05/20/08 09:00:00 PMreport abuse
Balance billing
I agree, I pay premiums out of my paycheck. My raise suffers when my employer pays more for increasing premiums. Then I pay a copay and then finally I also receive a bill in the mail for the uncovered amount. Ughh! ...some relief please... somebody?
By Gwen in Bham @ 05/20/08 05:27:35 PMreport abuse

Is the comment above accurate for Georgia? :"Balance billing
This is illegal in virtually all states. Providers enter into these contracts without a gun to their head. They have no complaint if the reimbursement rates aren't high enough.

By Greg @ 03/30/09 03:53:34 PMreport abuse

Medical proceedure costs

I had attempted to determine the cost of a recomended procedure to determine if I could afford the 20% co-pay. I was told over and over the information is "propriatory". The providers will not give you a cost nor an estimate period. I was not willing to throw the dice at the proceedure. This is not any resemblance of free market..it is concealed market. There is no moral compass in our health care system. I firmly beleive it should be handled by as many not for profit organizations who care to get into the game. The profit motive has not proven to be an honest broker in the care delivery of our system. As far as medication is concerned I would rather nationalize research and let the government sell/franchise the patents to big pharma. There is no integrity in Big Pharma..doing research/funding university research..verifying research to FDA...and owning FDA in the approval process and most related laws. This country needs to revamp health care from scratch, keep what works and scrap what does not.

By Lynne @ 10/10/08 02:26:55 PMreport abuse

Hospital billing after procedure

I have looked all over the internet for information on how to "verify" each item and procedure on my hospital bill. In particular, many of the medical descriptions are not readily recognized by the layman. So how does one know if he/she actually used this item or it was used in the process? How do I verify that I am being charged for items and processes that were actually a part of my surgical procedure and hospital stay?

By Pat Clark @ 08/22/08 10:30:02 AMreport abuse

Re: The list of fees would allow competition

If the fees listed are 500% of what the procedure actually cost, exactly how is this going to create competition? With your analogy restaurants would compete on prices you would never pay. So, when you sat down to order your meal the menu would show 100$ for a burger but when you actually pay and show them your "restaurant card" to bill comes to $10. But the published rates are $100. You still have no idea what the real price is until you buy the burger. Another customer has a different card and they may pay $15 or $20. The hungry tourist without a card at all pays $100. It is crazy and unless the inflation of prices is removed the list of fees is not going to do much other than draw attention to gross over billing practices of the industry. It is not going to create competition like shopping for food. I am afraid your analogy is a gross oversimplification of a broken system. You have to fix the over billing practices before you can have competition.

By Benton @ 05/22/08 09:35:39 AMreport abuse

Balance billing

This is illegal in virtually all states. Providers enter into these contracts without a gun to their head. They have no complaint if the reimbursement rates aren't high enough.

By Jay Hodges @ 05/21/08 07:09:39 PMreport abuse

RE: what are we going to do about it?

Here's what I would do about it:
1) Make it illegal to shift costs from uninsured patients
2) Start prosecuting Hospital administrators and insurance company executives under the RICO statutes.

If any other business operated and kept books like a typical hospital, the FBI and FTC would be all over them for fraud, corruption, and deceptive business practices.

By Jason Telman @ 05/21/08 02:44:15 PMreport abuse

The list of fees would allow competition!

The claim that a published fees for medical procedures is "worthless" is like saying restaurant menus with prices are worthless. To the contrary, a published fee schedule would allow patients and insurance companies to take their business to medical providers with the lowest fees. Hospitals don't want to do this because it would expose the fraudulent cost-shifting that occurs when they treat uninsured or indigent patients.

By Jason Telman @ 05/21/08 02:37:45 PMreport abuse

OK, what are we going to do about it?

This system is obviously dishonest. With Insurance Co's in control of our lawmakers, what can we do about this?
I think we need to brainstorm here.

By DDM @ 05/21/08 01:27:38 PMreport abuse

Re: Why can't hospitals publish a list of fees

They could put a list of fees together but it would be worthless. The fees would be the "sticker price" and have no relation to the price you really pay except that it is 500% more. For example, a CT scan might have a "sticker price" of $6,000 in the ER but the hospital has contracted rates with each large insurer. Every insurer has a different price. So, without insurance you would be billed $6k but under a contracted health plan the bill might be $1300. And that is just for one scan. This kind of pricing system is applied to all services and billing by hospitals and most doctors. The billing means nothing. It is all phony. This also helps the hospital when they give treatments to people who have no insurance and will never pay. The hospital can now claim, and potentially write off, that they lost $6k on the CT scan from an uninsured patient rather than the $1300 they really lost.

By Benton @ 05/21/08 01:25:59 PMreport abuse

The System is Ridiculous

Q: Why can't hospitals publish a list of fees for standard procedures? A: Because they want to hide the costs they shift from non-paying/uninsured patients to the ones with the ability to pay. The insurance companies counter this cost-shifting game by paying only a fraction of the bill. If Congress made cost-shifting illegal, much of this nonsense would stop.

By Jason Telman @ 05/21/08 12:11:56 PMreport abuse

US healthcare is amazing

It is astounding that nations smaller than many US cities can offer their citizens healthcare while people in the US debate vouchers, insurance premiums, and whether providing healthcare to every human being on US soil is somehow politically, philosophically, or economically "anti-American." Amazing.

By SDD @ 05/21/08 11:49:53 AMreport abuse

I know about balance billing!

At a former employer, I was supposed to 100% health care (that job didn't last long, less than 2 years!). Of course, my employer's healthcare provider was supposed to have negotiated discounted fees, say, $75 for a test instead of $100. Well, guess who got the bill for $25? Me, and this went on for any procedure me or my family had. It took days and weeks to clear the bills and most of the time the hospitals (they were the worst) would say it was "a mistake." Right. The bills were in the thousands of dollars, most of which was for normal family healthcare. What aggravation and time this caused me! I am certain the hospitals and doctors' offices knew what they were doing. Evidently, they got a pretty good return on the inappropriate bills they were sending out. People probably weren't paying attention or didn't want to take the time to protest and would just pay the damn thing even though they didn't owe it.

What happened to America?

By Mordie @ 05/20/08 09:00:00 PMreport abuse

I agree, I pay premiums out of my paycheck. My raise suffers when my employer pays more for increasing premiums. Then I pay a copay and then finally I also receive a bill in the mail for the uncovered amount. Ughh! ...some relief please... somebody?

By Gwen in Bham @ 05/20/08 05:27:35 PMreport abuse

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May 20, 2008 -- Balance billing at center of new healthcare brouhaha

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