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Demystifying How To Act As A Smart Healthcare “Consumer”

    Posted by on October 5, 2021
    4 min read

Healthcare has changed dramatically in the last decade from access and advancements to insurance and privacy. Cost transparency for the healthcare consumer has become increasingly important.  With several important healthcare changes on the 2022 horizon, we’re committed to helping our clients be educated consumers of healthcare by demystifying the process. In this first of a two-part series, are four steps you can take to be a smarter healthcare consumer.

Know the new Consumer Protections for 2022

Set to be implemented in January of 2022, the No Surprises Act is meant to prohibit many out-of-network surprise billing practices without advance notice.1

Receiving a surprise medical bill can be unsettling to say the least. To make it easier for consumers to shop and compare prices across hospitals to estimate the cost beforehand, Centers for Medicare & Medicaid Services also enacted a “Hospital Price Transparency” rule effective January 1st, 2021.2 In theory, this rule is intended to provide clear, accessible pricing information in a shoppable and consumer-friendly format so you can reasonably see what a procedure may cost you. The Health Care Cost Institute3 has compiled much of the available data from participating health systems that can shed some level of light on the range of prices charged to different payers (Medicare, Medicaid, private, etc.). Medicaid & Medicare generally pay lower rates than private insurance, but of course, cash is king. Insiders in the healthcare industry know that prices are benchmarked against what Medicare pays for procedures. While the application of new legislation is imperfect, the trend towards more consumer-friendly healthcare transparency and protections is promising.

Know your Healthcare Network

Are you in my network?

For those not on original Medicare, there may be an associated out of network separate deductible to meet in addition to your in-network deductible. You may find who is in your network by visiting your insurance company or the providers website.

What will this cost me/can you provide me an itemized bill?

After any healthcare visit, it is well within bounds for you to request an itemized bill. With the automated billing systems in place, it is all too common that mistakes are made, and charges are enhanced. You also have the right to access your health records, though it may take some persistence.

Know your Treatment

What are my options and the potential side effects?

Knowing the pros and cons of your options is a prerequisite to being a smart consumer of anything. We will discuss in our next article that the recommended treatment may vary based on your geographic location.

Is there another prescription/option available that would be cheaper on my insurance?

Practitioner’s may not know how much their treatment will cost their patients. If it is a procedure, some Physicians may be available at other more cost-effective locations. GoodRx provides a shoppable format for those prescriptions you may be able to lower your costs on.4 Be sure to run any alternative by your Physician.  

What if we wait?

Get a second opinion for significant healthcare decisions. If a second opinion on a car or home value is worth it, why isn’t one involving a major medical decision? This will help you vet, “Is this treatment necessary?”

If you are being proposed a newer treatment/medication, recognize any iceberg of side effects may be underwater still. When in doubt, favor time tested solutions. Evidence of absence of symptoms is not the same as absence of evidence.

Know what you’re signing

Patients are often presented with a payment consent form for hospital care to help ensure the provider is being compensated for the care they are providing. Award winning reporter Marshall Allen’s new book, “Never Pay the First Bill” (which would be a great supplementary resource), highlights ways we can protect ourselves in the healthcare space.

  • Beforehand- On a consent form you may write (or type if electronic/request a paper copy to write on) that you will “accept charges no more than 2 times the Medicare rate”. This point is most applicable to emergency room visits as they cannot refuse care for any reason. He refers to this as the “battlefield consent” form based on the notion that in a high stress situation, a contractually binding document may not be fully legally enforceable and an alternation can help you clarify your consent. Trying this in a non-emergency setting may not be accepted by the doctor but would serve as a layer of protection if permissible.         
  • After the fact- If you have private insurance or are self-insured, review your explanation of benefits statement along with an itemized bill if something seems off. Fairhealthconsumer.org will help you find out what a fair price is for procedures in your area.5 If you find that there are line items for procedures that did not occur or the prices are out of line, send a letter to the provider’s billing office and general counsel as a first step before going straight to paying. The lion share of claims are processed automatically leading to many cases where the bill is inappropriate.

Much of the healthcare system pays on a Fee for Service model, meaning more service/treatment, the more the healthcare organization is paid. We love our healthcare professionals and are grateful for all that they do. We recognize, however, that there is a business side to medicine. For this fundamental reason, a healthy level of skepticism of our treatments is in order.

In the next article we will discuss actions to take in advance of healthcare events to help further protect yourself a smart healthcare consumer.

References
  1. https://www.cms.gov/newsroom/press-releases/hhs-announces-rule-protect-consumers-surprise-medical-bills
  2. https://www.cms.gov/hospital-price-transparency
  3. https://healthcostinstitute.org/hcci-research/hospital-price-transparency-1
  4. https://www.goodrx.com/
  5. https://www.fairhealthconsumer.org/

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