Finally some price transparency in cost for Medicare procedures

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cashmoney
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Finally some price transparency in cost for Medicare procedures

Post by cashmoney » Thu Nov 29, 2018 9:59 pm

Pretty cool search feature to get an idea of much procedures actually cost on medicare.Very useful to see the difference in charges between free standing facility charges vs hospital based surgical center especially if you are paying the 20% yourself.

https://www.medicare.gov/procedure-price-lookup/

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SevenBridgesRoad
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Re: Finally some price transparency in cost for Medicare procedures

Post by SevenBridgesRoad » Thu Nov 29, 2018 10:25 pm

It’s a start, a primitive start.

Procedure names and codes are extremely complicated. The average patient won’t be able to use this tool to their benefit without a lot of help.

Hopefully the Amazon/BkH/JPM entry will dramatically disrupt and simplify this for consumers. Price and quality transparency for elective procedures is important. Doesn’t really matter for true emergencies, as the patient/consumer can’t price shop. But for elective procedures, if patients have skin in the game and price transparency, that could change the game for a significant amount of health care delivery.
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staythecourse
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Re: Finally some price transparency in cost for Medicare procedures

Post by staythecourse » Thu Nov 29, 2018 10:28 pm

cashmoney wrote:
Thu Nov 29, 2018 9:59 pm
Pretty cool search feature to get an idea of much procedures actually cost on medicare.Very useful to see the difference in charges between free standing facility charges vs hospital based surgical center especially if you are paying the 20% yourself.

https://www.medicare.gov/procedure-price-lookup/
Cool feature. Bumping as I am sure this will answer MANY repeated questions that come up.

Keep in mind this looks to just be the facility fee for both surgery centers and hospital based. In that case it does NOT include professional fee cost to the physician. Also don't forget about anesthesia charges, pathology, and radiology charges where applicable. If one gets some of the smaller procedures done in an office setting it is a global charge (facility and professional fee combined) which is usually lower then the 2 charges separated in a facility (surgery center or hospital).

Good luck.
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staythecourse
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Re: Finally some price transparency in cost for Medicare procedures

Post by staythecourse » Thu Nov 29, 2018 10:31 pm

SevenBridgesRoad wrote:
Thu Nov 29, 2018 10:25 pm
Procedure names and codes are extremely complicated.
Codes are not complicated. They are CPT codes. Just find the 5 digit code for the procedure. That being said though the complicated part comes form all the additional codes that are added. For example, diagnostic colonoscopy is likely one code and biopsy is a different code. Then, of course, you have the pathology fees for the biopsy which are additional costs.

So guess you are right not so simple. :(

Good luck.
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SevenBridgesRoad
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Re: Finally some price transparency in cost for Medicare procedures

Post by SevenBridgesRoad » Mon Dec 03, 2018 11:32 pm

staythecourse wrote:
Thu Nov 29, 2018 10:31 pm
SevenBridgesRoad wrote:
Thu Nov 29, 2018 10:25 pm
Procedure names and codes are extremely complicated.
Codes are not complicated. They are CPT codes. Just find the 5 digit code for the procedure. That being said though the complicated part comes form all the additional codes that are added. For example, diagnostic colonoscopy is likely one code and biopsy is a different code. Then, of course, you have the pathology fees for the biopsy which are additional costs.

So guess you are right not so simple. :(

Good luck.
If only you were right about there being one code for diagnostic and one for screening colonoscopy. Here’s a link to a coding “tip sheet” for coding professionals, just for colonoscopy. 17 separate codes just for colonoscopy. This doesn’t include modifiers. And this doesn’t include the ICD 10 codes and modifiers.
https://www.asge.org/docs/default-sourc ... f?sfvrsn=4

If someone hasn't spent time in a medical practice billing office, it’s hard to imagine the complexity. I wish it were simpler but it’s not.
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radiowave
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Re: Finally some price transparency in cost for Medicare procedures

Post by radiowave » Mon Dec 03, 2018 11:38 pm

I looked quick and may have missed it, but I don't see if you can shop locally by provider/facility? In theory, if I had a high deductible plan and needed a routine procedure it would be interesting to shop. However this is Medicare only prices. I agree, it's one small step forward.
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Re: Finally some price transparency in cost for Medicare procedures

Post by LadyGeek » Wed Dec 05, 2018 7:36 pm

This thread is now in the Personal Finance (Not Investing) forum (insurance).
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nisiprius
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Re: Finally some price transparency in cost for Medicare procedures

Post by nisiprius » Wed Dec 05, 2018 8:35 pm

It's nonsense, because you often don't know and can't find out the procedure codes until after the procedure is complete. I don't understand the details behind this but I've tried twice, seriously, to do it and gave up both times.

Once time it was a MRI, and I was bothered because they wanted me to sign off on a paper saying I'd pay if my insurance wouldn't. (They'd already verified that my insurance would, but I guess they didn't want to take the risk that they had misunderstood). I quite honestly had no idea whether we were talking $500, $5,000, or $50,000 and wanted to know. The desk people were doing their best to humor me. They put me on the phone with the billing office. The billing office said they needed to know the procedure. I said "it's an abdominal MRI." "Yes, but what kind?" "Abdominal." "We need the procedure code." So I say to the desk people "What's the procedure code?" "Just a second, we'll call the technician."

The technician says "I don't know, because after we take the retroplanar sagittal ciguatera, the radiologist will look at it and tell us whether he wants a contrapuntal reverberating linoleum scan." "Linoleum? What's that?" "Oh, it's nothing, it's just you'll die."What did you say?" "I said, it's just a dye." Anyway, the point is that "an MRI" can be an interactive procedure; they don't know exactly what they are going to do until they do it.

Another time, I was scheduled for some surgery and wanted to verify insurance coverage, and after about six phone calls I triumphantly called my wife and told her "I did it! I got the procedure codes!" And found out that one of them was a code for the follow-up office visit after the surgery... and the other--I should have been suspicious, it was a number like "19999"--was basically a temporary placeholder, a non-specific code for "abdominal surgery with anesthesia as a hospital inpatient." No body parts specified, let alone what they would be doing to them.

A "colonoscopy?" Until they get in there, they don't know if there are polyps. So, you don't know if they are going to be doing a polypectomy or not. If prices become transparent, it will only be a matter of time before they start gaming the system, making the colonoscopy itself a loss leader but making it back on the polypectomies... "OK, so just do the colonoscopy, but if you find polyps wake me up and I'll take an Uber across town to the place with the deal on the polypectomies..."
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SevenBridgesRoad
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Re: Finally some price transparency in cost for Medicare procedures

Post by SevenBridgesRoad » Wed Dec 05, 2018 11:41 pm

And that’s just CPT codes. You can’t stop there. To get third party payment, the medical practice must also use very specific ICD 10 codes for the diagnosis. Computers match the procedure codes with the diagnostic codes, looking for reasons to reject the claim. So to get a truly accurate pre-procedure price, you would need both CPT and ICD codes.

Good luck with that.

To give you an idea of how over-the-top complex ICD 10 is, if a patient presents to the ED needing sutures due to a bird bite (it happens), the claim will be rejected if the practice provides the nonspecific W61.0 which designates an injury due to a bird. You have to provide a code for the specific bird species. Was it a parrot or macaw? For parrot, use W61.01XA. If macaw, use W61.112XA. It gets worse, but you get the idea.

The future of price transparency will require a paradigm shift in how we package and price services consistent with actual patients and actual medical practice.
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sawhorse
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Re: Finally some price transparency in cost for Medicare procedures

Post by sawhorse » Thu Dec 06, 2018 3:30 am

SevenBridgesRoad wrote:
Wed Dec 05, 2018 11:41 pm
To give you an idea of how over-the-top complex ICD 10 is, if a patient presents to the ED needing sutures due to a bird bite (it happens), the claim will be rejected if the practice provides the nonspecific W61.0 which designates an injury due to a bird. You have to provide a code for the specific bird species. Was it a parrot or macaw? For parrot, use W61.01XA. If macaw, use W61.112XA. It gets worse, but you get the idea.
:shock: That's absurd! What if they don't know what type of bird it was? Who the hell thought to divide a bird bite into all these codes?

Is the medical billing industry a big business? If so, I can understand why they deliberately try to make it harder and harder and maybe even lobby against efforts to simplify it. Sort of the way tax preparation software companies lobby against measures that make the tax code and tax filing simpler.

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SevenBridgesRoad
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Re: Finally some price transparency in cost for Medicare procedures

Post by SevenBridgesRoad » Thu Dec 06, 2018 9:58 am

sawhorse wrote:
Thu Dec 06, 2018 3:30 am

Is the medical billing industry a big business? If so, I can understand why they deliberately try to make it harder and harder and maybe even lobby against efforts to simplify it.
No, the medical billing industry is just a small part of the bigger goal: the drive to computerize/digitalization all things health care. Actually this is a worthy goal. But getting there is taking us down a lot of expensive, complex black holes, with a lot of unintended consequences.

If you are interested, there’s a ton of info out there on the challenges of computerizing the industry. The best book IMO on the subject is “Digital Doctor”, author Bob Wachter.

Back more on topic, I think we’ve established coding is complex and probably not of practical use for the average patient in the current state.
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btenny
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Re: Finally some price transparency in cost for Medicare procedures

Post by btenny » Thu Dec 06, 2018 12:00 pm

Always ask your Doctor for the surgery center option vs the hospital if you need special tests or small surgeries.
It is much cheaper. The cost will be half or less.

I did this shopping when I broke my elbow (before Medicare but on Big Corp insurance) and waited three days and then went to a orthopedic doctor. He did the Xray and said I had to have surgery. But he also said I needed to wait 5 days to let the swelling reduce. He said he could do the surgery at the local hospital as a out patient or at a surgery center about 5 miles away, my choice. He said to talk to his staff and decide and get advance approval for the procedures. The surgery center was $3Kish and the Outpatient was $8Kish for the exact same procedures. I did the surgery center and all things worked well and I personally saved about $1K due to 20% co-pays.

I also use Lab Corp for blood tests and a special MRI scan place for those tests and a special clinic for colon tests. All these places save you money and are way cheaper. But you have to ask your Doctor for those options and seek out the details. And for some procedures your Doctor may say he "prefers" the hospital out patient place. So then the decision is more difficult.

And for fun go look up kidney stones in that code list. Try to figure out what you need done and have to pay for.....

Good Luck....

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SevenBridgesRoad
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Re: Finally some price transparency in cost for Medicare procedures

Post by SevenBridgesRoad » Fri Dec 07, 2018 9:42 pm

btenny wrote:
Thu Dec 06, 2018 12:00 pm
Always ask your Doctor for the surgery center option vs the hospital if you need special tests or small surgeries.
It is much cheaper. The cost will be half or less.

I also use Lab Corp for blood tests and a special MRI scan place for those tests and a special clinic for colon tests. All these places save you money and are way cheaper.
+1
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