Judul : Health Insurance Agent Quotes - Why Your Health Insurer Doesn’t Care About Your Big Bills
link : Health Insurance Agent Quotes - Why Your Health Insurer Doesn’t Care About Your Big Bills
Health Insurance Agent Quotes - Why Your Health Insurer Doesn’t Care About Your Big Bills
Health Insurance Agent Quotes - Why Your Health Insurer Doesn’t Care About Your Big Bills
Patients may think their insurers are fighting on their behalf for the best prices. But saving patients money is often not their top priority. Just ask Michael Frank.
Michael Frank ran his finger down his medical bill, studying the
charges and pausing in disbelief. The numbers didn’t make sense.
His recovery from a partial hip replacement had been difficult. He’d
iced and elevated his leg for weeks. He’d pushed his 49-year-old body,
limping and wincing, through more than a dozen physical therapy
sessions.
The last thing he needed was a botched bill.
His December 2015 surgery to replace the ball in his left hip joint
at NYU Langone Medical Center in New York City had been routine. One
night in the hospital and no complications.
He was even supposed to get a deal on the cost. His insurance
company, Aetna, had negotiated an in-network “member rate” for him.
That’s the discounted price insured patients get in return for paying
their premiums every month.
But Frank was startled to see that Aetna had agreed to pay NYU
Langone $70,000. That’s more than three times the Medicare rate for the
surgery and more than double the estimate of what other insurance
companies would pay for such a procedure, according to a nonprofit that tracks prices.
Fuming, Frank reached for the phone. He couldn’t see how NYU
Langone could justify these fees. And what was Aetna doing? As his
insurer, wasn’t its duty to represent him, its “member”? So why had it
agreed to pay a grossly inflated rate, one that stuck him with a $7,088
bill for his portion?
Frank wouldn’t be the first to wonder. The United States spends more
per person on health care than any other country. A lot more. As a
country, by many measures, we are not getting our money’s worth. Tens of
millions remain uninsured. And millions are in financial peril: About 1
in 5 is currently being pursued by a collection agency over medical
debt. Health care costs repeatedly top the list of consumers’ financial
concerns.
Experts frequently blame this on the high prices charged by doctors
and hospitals. But less scrutinized is the role insurance companies —
the middlemen between patients and those providers — play in boosting
our health care tab. Widely perceived as fierce guardians of health care
dollars, insurers, in many cases, aren’t. In fact, they often agree to
pay high prices, then, one way or another, pass those high prices on to
patients — all while raking in healthy profits.
ProPublica and NPR are examining the bewildering, sometimes enraging
ways the health insurance industry works, by taking an inside look at
the games, deals and incentives that often result in higher costs,
delays in care or denials of treatment. The misunderstood relationship
between insurers and hospitals is a good place to start.
Today, about half of Americans get their health care benefits through
their employers, who rely on insurance companies to manage the plans,
restrain costs and get them fair deals.
But as Frank eventually discovered, once he’d signed on for surgery, a
secretive system of pre-cut deals came into play that had little to do
with charging him a reasonable fee.
After Aetna approved the in-network payment of $70,882 (not
including the fees of the surgeon and anesthesiologist), Frank’s
coinsurance required him to pay the hospital 10 percent of the total.
When Frank called NYU Langone to question the charges, the hospital
punted him to Aetna, which told him it paid the bill according to its
negotiated rates. Neither Aetna nor the hospital would answer his
questions about the charges.
Frank found himself in a standoff familiar to many patients. The
hospital and insurance company had agreed on a price and he was required
to help pay it. It’s a three-party transaction in which only two of the
parties know how the totals are tallied.
Frank could have paid the bill and gotten on with his life. But he
was outraged by what his insurance company agreed to pay. “As bad as NYU
is,” Frank said, “Aetna is equally culpable because Aetna’s job was to
be the checks and balances and to be my advocate.”
And he also knew that Aetna and NYU Langone hadn’t double-teamed an
ordinary patient. In fact, if you imagined the perfect person to take on
insurance companies and hospitals, it might be Frank.
For three decades, Frank has worked for insurance companies like
Aetna, helping to assess how much people should pay in monthly premiums.
He is a former president of the Actuarial Society of Greater New York
and has taught actuarial science at Columbia University. He teaches
courses for insurance regulators and has even served as an expert
witness for insurance companies.
The hospital and insurance company may have expected him to shut up and pay. But Frank wasn’t going away.
Patients fund the entire health care industry through taxes,
insurance premiums and cash payments. Even the portion paid by employers
comes out of an employee’s compensation. Yet when the health care
industry refers to “payers,” it means insurance companies or government
programs like Medicare.
Patients who want to know what they’ll be paying — let alone shop
around for the best deal — usually don’t have a chance. Before Frank’s
hip operation he asked NYU Langone for an estimate. It told him to call
Aetna, which referred him back to the hospital. He never did get a
price.
Imagine if other industries treated customers this way. The price of a
flight from New York to Los Angeles would be a mystery until after the
trip. Or, while digesting a burger, you’d learn it cost 50 bucks.
A decade ago, the opacity of prices was perhaps less pressing because
medical expenses were more manageable. But now patients pay more and
more for monthly premiums, and then, when they use services, they pay
higher co-pays, deductibles and coinsurance rates.
Employers are equally captive to the rising prices. They fund
benefits for more than 150 million Americans and see health care
expenses eating up more and more of their budgets.
Richard Master, the founder and CEO of MCS Industries Inc. in Easton,
Pennsylvania, offered to share his numbers. By most measures MCS is
doing well. Its picture frames and decorative mirrors are sold at
Walmart, Target and other stores and, Master said, the company brings in
more than $200 million a year.
But the cost of health care is a growing burden for MCS and its 170
employees. A decade ago, Master said, an MCS family policy cost $1,000 a
month with no deductible. Now it’s more than $2,000 a month with a
$6,000 deductible. MCS covers 75 percent of the premium and the entire
deductible. Those rising costs eat into every employee’s take-home pay.
Economist Priyanka Anand of George Mason University said employers
nationwide are passing rising health care costs on to their workers by
asking them to absorb a larger share of higher premiums. Anand studied
Bureau of Labor Statistics data and found that every time health care
costs rose by a dollar, an employee’s overall compensation got cut by 52
cents.
Master said his company hops between insurance providers every few
years to find the best benefits at the lowest cost. But he still can’t
get a breakdown to understand what he’s actually paying for.
“You pay for everything, but you can’t see what you pay for,” he said.
Master is a CEO. If he can’t get answers from the insurance industry, what chance did Frank have?
Frank’s hospital bill and Aetna’s “explanation of benefits” arrived
at his home in Port Chester, New York, about a month after his
operation. Loaded with an off-putting array of jargon and numbers, the
documents were a natural playing field for an actuary like Frank.
Under the words, “DETAIL BILL,” Frank saw that NYU Langone’s total
charges were more than $117,000, but that was the sticker price, and
those are notoriously inflated. Insurance companies negotiate an
in-network rate for their members. But in Frank’s case at least, the
“deal” still cost $70,882.
With a practiced eye, Frank scanned the billing codes hospitals
use to get paid and immediately saw red flags: There were charges for
physical therapy sessions that never took place, and drugs he never
received. One line stood out — the cost of the implant and related
supplies. Aetna said NYU Langone paid a “member rate” of $26,068 for
“supply/implants.” But Frank didn’t see how that could be accurate. He
called and emailed Smith & Nephew, the maker of his implant, until a
representative told him the hospital would have paid about $1,500. His
NYU Langone surgeon confirmed the amount, Frank said. The device company
and surgeon did not respond to ProPublica’s requests for comment.
Frank then called and wrote Aetna multiple times, sure it would want
to know about the problems. “I believe that I am a victim of excessive
billing,” he wrote. He asked Aetna for copies of what NYU Langone
submitted so he could review it for accuracy, stressing he wanted “to
understand all costs.”
Aetna reviewed the charges and payments twice — both times standing
by its decision to pay the bills. The payment was appropriate based on
the details of the insurance plan, Aetna wrote.
Frank also repeatedly called and wrote NYU Langone to contest the
bill. In its written reply, the hospital didn’t explain the charges. It
simply noted that they “are consistent with the hospital’s pricing
methodology.”
Increasingly frustrated, Frank drew on his decades of experience to
essentially serve as an expert witness on his own case. He gathered
every piece of relevant information to understand what happened,
documenting what Medicare, the government’s insurance program for the
disabled and people over age 65, would have paid for a partial hip
replacement at NYU Langone — about $20,491 — and what FAIR Health, a New
York nonprofit that publishes pricing benchmarks, estimated as the
in-network price of the entire surgery, including the surgeon fees —
$29,162.
He guesses he spent about 300 hours meticulously detailing his battle
plan in two inches-thick binders with bills, medical records and
correspondence.
ProPublica sent the Medicare and FAIR Health estimates to Aetna and
asked why they had paid so much more. The insurance company declined an
interview and said in an emailed statement that it works with hospitals,
including NYU Langone, to negotiate the “best rates” for members. The
charges for Frank's procedure were correct given his coverage, the
billed services and the Aetna contract with NYU Langone, the insurer
wrote.
NYU Langone also declined ProPublica’s interview request. The
hospital said in an emailed statement it billed Frank according to the
contract Aetna had negotiated on his behalf. Aetna, it wrote, confirmed
the bills were correct.
After seven months, NYU Langone turned Frank’s $7,088 bill over to a
debt collector, putting his credit rating at risk. “They upped the
ante,” he said.
Frank sent a new flurry of letters to Aetna and to the debt collector
and complained to the New York State Department of Financial Services,
the insurance regulator, and to the New York State Office of the
Attorney General. He even posted his story on LinkedIn.
But no one came to the rescue. A year after he got the first bills,
NYU Langone sued him for the unpaid sum. He would have to argue his case
before a judge.
You’d think that health insurers would make money, in part, by reducing how much they spend.
Turns out, insurers don’t have to decrease spending to make money.
They just have to accurately predict how much the people they insure
will cost. That way they can set premiums to cover those costs — adding
about 20 percent for their administration and profit. If they’re right,
they make money. If they’re wrong, they lose money. But, they aren’t too
worried if they guess wrong. They can usually cover losses by raising
rates the following year.
Frank suspects he got dinged for costing Aetna too much with his
surgery. The company raised the rates on his small group policy — the
plan just includes him and his partner — by 18.75 percent the following
year.
The Affordable Care Act kept profit margins in check by requiring
companies to use at least 80 percent of the premiums for medical care.
That’s good in theory but it actually contributes to rising health care
costs. If the insurance company has accurately built high costs into the
premium, it can make more money. Here’s how: Let’s say administrative
expenses eat up about 17 percent of each premium dollar and around 3
percent is profit. Making a 3 percent profit is better if the company
spends more.
It’s like if a mom told her son he could have 3 percent of a bowl of
ice cream. A clever child would say, “Make it a bigger bowl.”
Wonks call this a “perverse incentive.”
“These insurers and providers have a symbiotic relationship,” said
Wendell Potter, who left a career as a public relations executive in the
insurance industry to become an author and patient advocate. “There’s
not a great deal of incentive on the part of any players to bring the
costs down.”
Insurance companies may also accept high prices because often
they aren’t always the ones footing the bill. Nowadays about 60 percent
of the employer benefits are “self-funded.” That means the employer pays
the bills. The insurers simply manage the benefits, processing claims
and giving employers access to their provider networks. These management
deals are often a large, and lucrative, part of a company’s business.
Aetna, for example, insured 8 million people in 2017, but provided
administrative services only to considerably more — 14 million.
To woo the self-funded plans, insurers need a strong network of
medical providers. A brand-name system like NYU Langone can demand — and
get — the highest payments, said Manuel Jimenez, a longtime negotiator
for insurers including Aetna. “They tend to be very aggressive in their
negotiations.”
On the flip side, insurers can dictate the terms to the smaller
hospitals, Jimenez said. The little guys, “get the short end of the
stick,” he said. That’s why they often merge with the bigger hospital
chains, he said, so they can also increase their rates.
Other types of horse-trading can also come into play, experts say. Insurance companies may agree to pay higher prices for some services in exchange for lower rates on others.
Patients, of course, don’t know how the behind-the-scenes haggling
affects what they pay. By keeping costs and deals secret, hospitals and
insurers dodge questions about their profits, said Dr. John Freedman, a
Massachusetts health care consultant. Cases like Frank’s “happen every
day in every town across America. Only a few of them come up for
scrutiny.”
In response, a Tennessee company is trying to expose the prices and
steer patients to the best deals. Healthcare Bluebook aims to save money
for both employers who self-pay, and their workers. Bluebook used
payment information from self-funded employers to build a searchable
online pricing database that shows the low-, medium- and high-priced
facilities for certain common procedures, like MRIs. The company, which
launched in 2008, now has more than 4,500 companies paying for its
services. Patients can get a $50 bonus for choosing the best deal.
Bluebook doesn’t have price information for Frank’s operation — a
partial hip replacement. But its price range in the New York City area
for a full hip replacement is from $28,000 to $77,000, including doctor
fees. Its “fair price” for these services tops out at about two-thirds
of what Aetna agreed to pay on Frank’s behalf.
Frank, who worked with mainstream insurers, didn’t know about
Bluebook. If he had used its data, he would have seen that there were
facilities that were both high quality and offered a fair price near his
home, including Holy Name Medical Center in Teaneck, New Jersey, and
Greenwich Hospital in Connecticut. NYU Langone is one of Bluebook’s
highest-priced, high-quality hospitals in the area for hip replacements.
Others on Bluebook’s pricey list include Montefiore New Rochelle
Hospital in New Rochelle, New York, and Hospital for Special Surgery in
Manhattan.
ProPublica contacted Hospital for Special Surgery to see if it would
provide a price for a partial hip replacement for a patient with an
Aetna small-group plan like Frank’s. The hospital declined, citing its
confidentiality agreements with insurance companies.
Frank arrived at the Manhattan courthouse on April 2 wearing a suit
and fidgeted in his seat while he waited for his hearing to begin. He
had never been sued for anything, he said. He and his attorney, Gabriel
Nugent, made quiet conversation while they waited for the judge.
In the back of the courtroom, NYU Langone’s attorney, Anton Mikofsky,
agreed to talk about the lawsuit. The case is simple, he said. “The guy
doesn’t understand how to read a bill.”
The high price of the operation made sense because NYU Langone
has to pay its staff, Mikofsky said. It also must battle with insurance
companies who are trying to keep costs down, he said. “Hospitals all
over the country are struggling,” he said.
“Aetna reviewed it twice,” Mikofsky added. “Didn’t the operation go well? He should feel blessed.”
When the hearing started, the judge gave each side about a minute to make its case, then pushed them to settle.
Mikofsky told the judge Aetna found nothing wrong with the billing
and had already taken care of most of the charges. The hospital’s
position was clear. Frank owed $7,088.
Nugent argued that the charges had not been justified and Frank felt he owed about $1,500.
The lawyers eventually agreed that Frank would pay $4,000 to settle the case.
Frank said later that he felt compelled to settle because going to
trial and losing carried too many risks. He could have been hit with
legal fees and interest. It would have also hurt his credit at a time he
needs to take out college loans for his kids.
After the hearing, Nugent said a technicality might have doomed their
case. New York defendants routinely lose in court if they have not
contested a bill in writing within 30 days, he said. Frank had contested
the bill over the phone with NYU Langone, and in writing within 30 days
with Aetna. But he did not dispute it in writing to the hospital within
30 days.
Frank paid the $4,000, but held on to his outrage. “The system,” he said, “is stacked against the consumer.”
source : https://www.propublica.org/article/why-your-health-insurer-does-not-care-about-your-big-bills
So is the article Health Insurance Agent Quotes - Why Your Health Insurer Doesn’t Care About Your Big Bills
The article Health Insurance Agent Quotes - Why Your Health Insurer Doesn’t Care About Your Big Bills This time, hopefully can give benefits to all of you. well, see you in posting other articles.
You are now reading the article Health Insurance Agent Quotes - Why Your Health Insurer Doesn’t Care About Your Big Bills with the link address https://healthinsuranceagentquatoes.blogspot.com/2018/09/health-insurance-agent-quotes-why-your.html
0 Response to "Health Insurance Agent Quotes - Why Your Health Insurer Doesn’t Care About Your Big Bills"
Post a Comment