Thursday, February 4, 2016

The Benjamins

Contrary to popular belief, even if you don't have a co-pay up-front, you still may end up paying a chunk of your bill. So we get calls all the time from people who don't understand the concept of a deductible or percentage of cost, angry that we had the audacity to charge them for their visit (maybe I should be angry at my landlord for charging me office rent, huh?).

Blood work is also an issue. Several insurances, especially Medicare, have a whole list of diagnoses you need to have in order for them to pay for your labs. This list is hysterically obsolete and unrealistic.

Yeah. Like those.

I'm in the middle here. If I order too many labs, Medicare will claim they weren't necessary for the condition (in spite of a crapload of medical literature saying otherwise) and the patient will get cranky because OMG THEY HAD TO PAY FOR SOME OF THEM. But if I don't order all the labs I run the risk of missing something and getting sued over it. The defense of "the insurance won't pay for the test" is legally worthless in court.

So I order what I think is appropriate. I'd rather get yelled at by patients over their bill then roasted by a lawyer for malpractice. By ordering it, I put the ball in the patient's court. If they don't want to have the test, that's their decision. But at least I tried.

So what happens when you go to the lab? Before they draw blood, you sign a form saying that you agree to pay any charges your insurance doesn't cover (for the record, you do that at my office, too. And probably every doc's office. If you didn't know that you just haven't read the fine print).

Then, if you sign it, they'll do the labs and bill your insurance. It there's any left over, they'll bill that to you.

This is where things get iffy, especially with Medicare and their outdated list of tests that will only be paid for IF you have a certain condition.

Let's say, for example, that a Medicare patient is having a neuropathy work-up, and needs a vitamin B12 level done. Most docs order a B12 level. I  do, too sometimes, but generally prefer checking methylmalonic acid (MMA). Due to its role in B12's metabolic pathway, it's actually more sensitive for B12 deficiency than B12 itself. You can see a normal serum B12 in people who are metabolically deficient in it, but the MMA nails it.

I order the MMA level. Of course, Medicare, with guidelines written during the Nixon administration, doesn't recognize it as a valid part of a neuropathy work-up. Yeah, craploads of medical research since the late 80's say otherwise, but who am I to argue with the Medicare rule book?

"Damnit, Jim, I'm a doctor, not a Medicare desk jockey."

So I order the methylmalonic acid anyway. Why? Because my job is to correctly diagnose the patient.

The bill for the MMA level gets sent to insurance, where it's screened by some of the last functioning TRS-80's left on Earth. Their programming sees "MMA level ordered for neuropathy. Test not needed per our guidelines. REJECT!"

The lab doesn't get paid for the MMA. They'll now send me a note asking for any more diagnoses that might get it covered.

So, in my 15 seconds of free time each day, I crack open the chart and fill out the form with EVERYTHING the patient has (hypertension, migraines, halitosis, genital herpes, 1948 exposure to mumps) hoping one of them will somehow get it to pass through the TRS-80's scanning on the 2nd try.

Sometimes it does, and we all live happily ever after. Other times it doesn't, the patient gets a bill, and calls my office.

Now Annie will usually take a crack at it, calling the lab and consulting a Ouija Board to see if we can find anything else going on with the patient that might get it paid for. I sign off on it, and we submit it for the 3rd go-round. I'd say this works maybe half the time. The rest of them... the patient gets another bill.

Some people recognize that healthcare isn't free, and that I'm doing my best to care for them. They pay their bill. Others, however, go apeshit and call to scream at us.

They demand I find a way to make their insurance pay it, even if it means fraudulently changing the ICD codes (nope). Or that I pay it myself (nope). Some of them even threaten me:

"Get this paid for, OR ELSE!"

"If this isn't paid, I'm complaining to the state medical board."

 "This needs to be covered, or you'll hear from my lawyer."

Because now it's MY fault that I'm trying to provide decent care.

What's really irritating is that these same people screaming about me ordering a test they now don't want to pay for... would also be the first ones in line to sue me if I didn't order it and missed the correct diagnosis. I try to be thorough, and want to figure out what's wrong with you. Plus, in the sad calculus of modern medicine, my fear of being sued trumps your wallet every time.

My office's best attempts failed. Now what happens?

The patient, like everyone else out there with bills, has to either pay them or go to collections. I did my best to help. I'm not going to practice second-rate medicine and risk missing something. They don't have to get the tests, but once they've signed off on the lab form and had them drawn, it's their responsibility. Some of these labs are hundreds to even a few thousand dollars, and they're being asked to pay for, say, $89.46 on labs that totaled $1015.58 (yeah, that's from a recent one that crossed my desk). I'm going to point out that's less than 10% of the total charge.

If you go to Target for a ginormous $900 TV, and they sold it to you for $80, you'd be thrilled. But in medicine? You go bananas that it isn't free.

"$79.99, and it wasn't even Black Friday."

Once my two appeals to get it covered have failed, I'm done. I did my best. I also remind myself that, even if I do find a way to get you out of paying for them... it means everyone else (including me) is.

My sympathy on this issue has run out. I'm tired of people demanding I care for them, then not wanting to pay their fair share of the costs. If I DIDN'T order these tests, and missed something, they'd come back and sue me. But if I do order them they whine.

My view has become it's their decision to have them or not. It's a tax deduction if they want to see it that way, but healthcare is NOT FREE. Someone is paying for it, even if it's not the patient. Everything that gets covered by insurance is passed on to the rest of us in the form of higher co-pays and premiums.

Providing competent medical care is not something you can sometimes do well and other times do a half-assed job on. You either go big or go home, so I choose to go big. The same applies to the patient. If you want an incomplete work-up, that's fine, but don't go wailing when something was missed because you refused testing. By the same token don't expect quality care to be free.

You get what you pay for.


Heidi said...

This is a perspective most patients aren't aware of.

FWIW, reading your blog gives me insight into what doctors have to deal with - and helps me be a better patient.

Anonymous said...

My 70+yo parents went to the dr. Dad is outside every day for hours, including the overcast ones. Mom walks to both the car and the mailbox. Dr orders Vit-D deficiency test for BOTH. Mom is deficient; Dad isn't. Medi-whatever won't cover Dad since it wasn't needed...

So, if you are correct in your dx, the test that proves your are right is covered. If you are 'wrong' it isn't (I use that term loosely). The pt can't know the results before the test. Now, I was not surprised by the results and I'm not sure that my parents knew the Vit-D was included in the order for Dad. And, do pts really have a line item veto at a blood lab???

My irritation comes from the fact that Mom refuses to take Vit-D because the bottle will remind Dad they were charged for the test...

The system is broken, my friends...


Packer said...

I paid a shit load of co pays , deductibles and pharmacy charges last year. I did not complain for I was sick for the first time in my 65 years,real sick not phony day off sick. I am better now. It was as they say money well spent.

Officer Cynical said...

Try explaining to a driver why his speeding ticket is so expensive.

awesomesauciness said...

I am a patient under the care of a pain management doctor. Every few months I get to pee in a cup so he can justify the medications he prescribes.

The most recent bills for this were submitted to BC/BS and I happened to see them online when I went looking for an EOB for something else. The total bill was nearly $5K. Apparently, there's gold in my urine....real gold.

The insurance denied the claim. And, now I'm waiting to get a bill so I can call and tell them to take that specimen of mine, pan the gold out of it, and sell it, because I'll be damned if I'm paying for a lab I didn't order, just so my doctor can prove I'm actually taking the medication he gives me and not selling it on the street - which, btw, I'd have to do to pay for the labs.

And, while I'm ranting, I have gold-standard insurance, and I pay for it. I've also got multiple health issues so for me the best level of coverage I can afford is a wise investment. That said, my "old" pain doctor moved to a new practice and their billing department is apparently run by rabid squirrels. In ONE month, I got billed FOUR different amounts for an office visit. My insurance is pretty clear on this one. I pay $30/visit for him, and that is it. But, the rabid squirrels can't seem to get their shit together long enough to figure it out. This, on top of the fact that I paid for the visit while I was there. So, once again, I sit and wait for the billing department and BC/BS to finish duking it out and wonder what I'll be left with. I don't mind paying, at all, I mind paying arbitrarily for items outside contract, and/or for which there's no real medical reasoning.

kjax said...

I'm glad to know there may be a 2nd shot at getting something corrected.

I had labs drawn last week after doctor's visit. AFTER it was all done, I noticed the doctor checked "dementia" (not necessarily wrong, but...) instead of the next box for "diabetes mellitus," which is what the tests were for. I figured I was about to get stuck for a lot of lab costs. I didn't know the lab might double check with the doctor's office for the diagnosis correction.

So maybe there is hope. Or maybe I'm about to pay out the ass for some lab tests that don't match the diagnosis.

Anonymous said...

As a fellow doc, I come here for humor and comic relief to get away from putting up with this crap. You have failed miserably in providing said relief. ;)

You actually expressed very well the situation we deal with daily, and it is tempting to print it out and give to patients along with the ABN to sign, but perhaps that would not be wise.

Anonymous said...

But...but...President Obama promised FREE health care! He PROMISED!

Anonymous said...

Awesomesauciness: It's a free country. If you don't want the test, it's your right not to pee in the cup. And your doc, who's following the standard of care, has the right to kick you out of is practice. Deal with it.

Loren Pechtel said...

Medicare needs to get it's act together. Back at the end of the previous century my mother had cancer. There was a spat between the oncologist and Medicare over what Medicare considered unnecessary testing looking for tumors. There's no indication of brain cancer, why are you looking there??? Yeah, there was no indication, what there was was a lack of a primary tumor--a good indication there's something hiding out.

(And Medicare didn't make the argument that it was irrelevant--the secondaries they found were aggressive and inoperable, finding the primary wouldn't change the treatment.)

Tiredveterinarian said...

Try the veterinary world: very few patients have insurance, and those who do still need to pay up front and wait for reimbursement. We're told on a nearly daily basis that if we really cared for animals we'd give care/run tests/fill meds for free or at least allow the clients to pay over time (which usually means not at all). After presenting an estimate for the recommended workup it is not uncommon for a client to ask, "What's the one test that's the most likely to get us an answer?" I even had a retired ER doc want me to choose an individual blood chemistry item rather than pay for the whole metabolic panel.

I would never want human patients, so I'm glad I'm a veterinarian. But there are many days that we wish we could install a drive-thru window to avoid dealing with the humans.

John Woolman said...

I was born 1 year before the British National Health Service started. I spent 35 years working in it, and am just coming to the end of 3.5 years of a job that amounts to investigating its disasters. I'm now going to have to rely on it for what passes for its care for the rest of my life. I read every one of Dr Grumpy's posts. And I wish I lived in New Zealand!

Mark said...

I have seven dogs, and more than a few cats, that I pay veterinary bills for. I know what (unreimbursed) vet care can cost. As an aside, I paid veterinary dental specialist for a root canal and crown for my sheltie/collie mix. When I told MY endodontist what I paid, he went sorta glassy eyed and whispered he should've become a vet.
After twenty four years enlisted time in the Air Force, I consider the wife and myself more than lucky to have Tricare, but luckier still, to have a medical group that accepts it... And takes my calls... And will be there tomorrow....
Yes, I've had to pay for unreimbursed tests. But I would much rather pay today's costs for today's care, than pay what little my great great grandparents paid for the care they were (or weren't) able to get.


Mariana said...

This kind of situation is what makes me happy to practice in a country with a National Health Service subsidized entirely by the State through taxes (no, I'm not from Cuba, but from Europe ;) ) where patients only have small co-pays to cover (a consultation costs 7,70€ and an INR test 1,10€, for example).

I am a Clinical Geneticist. I order EXPENSIVE (think 700€+) genetic tests daily. If patients had to pay for them, they all would go baloons (and probably not diagnosed).

Kathryn said...

I've never been happier to live in Australia. Two weeks ago I had a full panel blood test, and didn't pay a thing.
What I do pay is a medicare levy in my taxes, which isn't all that much, and I'm happy for it to be part of my taxes, if it means I don't have to deal with billing systems that might arbitrarily decide not to cover something.

Anonymous said...

I wonder how much less we would pay if there was no insurance, medicare, and insurance?

My gastro has a huge staff. When I have my office visit, I see him, a nurse and the receptionist. The nurse spends ten minutes with me typing the same information injto a computer that she typed in every six months for the last ten years. The doctor spends twenty to thirty minutes, and most of that is his confirming the information the computer makes him ask. We spend five minutes on are you bleeding, have any new issues, and there are no new treatments, do I schedule the scope this year or next year? When I leave, I walk past a four person office doing billing and insurance paperwork. For this, I am charged about $500, which my insurance knocks down to about $150, and between the two of us we pay (high deductible plan).

For this I pay $8200 in premiums with a $2000 deductible. If I could have the same discounts blue cross gets, I would rather just pay it direct to the doctor. Maybe he wouldn't need all the office staff? Maybe Blue Cross, Medica, and three others would not be the major employers in town, and hated by too many people?

I do not know. All I know is it is still better than any other nations care for average people. I have seen the filthy NHS Hospitals and videos of the even worse cuban hospitals. A buddytal left Cuba and he visits his parents and inlaws on the island. The hospi

Anonymous said...

One word.... CANADA
I live in CANADA, thank god.

Anonymous said...

Relating this experience reminds me of something. Hmm. Let's see. Ah, yes.

It reminds me of when I went swimming in a pool under a removable inflatable roof at the gym and the water hadn't been changed for a while because there was a cold spell with some difficulty in getting enough fresh hot water so chlorine kept getting dumped in the pool. After peering through the mist rising from the water one frigid morning, I found the edge of the pool and plunged into the deep end. I had the misfortune to take a breath, and started gasping at the chlorine fumes. No one else was there and I recall debating whether to 'pretend' (to convince myself in the panic) to hold my breath long enough to get out and run to the lobby to call an ambulance or roll around the deck to work some of the oxygen back into my lungs.

I think the 'gasping' is what I am reminded by this account. It seems as if the whole blooming thing is rigged. It's not just one detail, like the physician who undergoes years of training and experience for expertise in one aspect, but a whole behemoth has been built up around an society institution like 'education' or a 'transportation' system, except 'healthcare' is just a little higher priority.

And, yet, decades ago when I was 21, married and studying in college thousands of miles away from friends and family, and required medical and hospital care, the doctor arranged everything including the payment plan for what could be afforded. I asked for the minimum necessary, declined the pain medications and 'extras' and that was that. My husband just strung more tennis rackets when he wasn't working on homework, and I did what was necessary to recover and return to a state of health and carry on. What has happened in the meantime?

awesomesauciness said...

Hey Anon ^^^^^ - yes, and I get to pay for the people who do divert their meds, fake illness/injury, and so on by peeing in that cup.

I (mostly) didn't complain about that - that, my dear, is a whole 'nother rant.

I complained about the stupidity of a lab test costing $5K.

However, because I'm generous I'll let you have the next specimen. Because, gold.

Anonymous said...

The difference between the television scenario and what happens with medical bills is that nobody will tell me ahead of time what the medical care is supposed to cost. So I get coerced into signing off on diagnostic tests that may or may not result in life saving treatments with no idea whether I'll be charged zero dollars or all my worldly possessions. Then, several weeks or months later, I get a bill that might make sense to me but probably doesn't. Being told that the full bill was actually 5 billion dollars and I'm only being charged my first born son doesn't actually make it sound like a good deal. It makes it sound like a con job. Meanwhile, the fact that the doctors are burning themselves out doing all sorts of things behind the scenes to get the insurance companies to pay up is not obvious to me because it's happening, you know, behind the scenes. All I'm getting is that there are angry people who claim to care about my wellbeing sitting here telling me that I should stop whining and accept the bill because I've got three other kids anyway and we all have to pay our own way in this world.

Metaphorically speaking, of course.

Anonymous said...

People Probably go ape shit over the actual price of labs versus the principal of having to pay for something. For example, I require an occasional CA125 blood test. If my dr forgets to send a note with it, insurance rejects it and I get a $200 bill from the lab. For the record I DO NOT think this is the doctor's fault and I would never treat them as your patients do. I simply call them up and ask the dr to send her note on and she does and then, here is the part that pisses me off. The insurance negotiates the bill down to $17. They pay $14. I pay $3. So happy I only pay $3...but why the hell can the lab charge me $200 and insurance only $17. That means the test is only worth $17. I know this is a total rhetorical point to make but this is the problem with healthcare and i think this might be what more people get mad about. They see a $200 bill when it's only worth $17. Not all patients because obviously some people don't get it and just call you screaming but I think this is the fundamental problem with people upset about paying for their healthcare. Not that they are so entitled they have to pay something but that they have to pay jacked up price.

Anonymous said...

@Anonymous. I cannot be sure but I would say that most of those bills are worth what is being charged. It is simply the insurance company refusing to pay. My doctors' office had to discontinue giving flu shots because it was costing them to give them so for example, if the vaccine cost $20, the insurance company would only pay $11 and the patient could not be billed for the difference.

charles said...

"but healthcare is NOT FREE. Someone is paying for it, even if it's not the patient."

That is spot on Grumpy, spot on.

It never ceases to amaze me that most folks, in the US anyway, do not know the terms deductible, co-pay, charge vs. allowable, accept assignment, etc.

But, their biggest ignorance is that they all seem to think that healthcare is a "right" and that they shouldn't have to pay anything.

Further, those who live in countries that have all their healthcare "free" seem to think that they are truly getting it free. If/when the US becomes like that we will see all new innovations, new drugs, etc. disappear from the market. Only government funded medicine will be available - run just like the DMV.

And I do not mean just here in the US; it is the "free market" in the US that provides the rest of the world with medical innovations and new drugs. So, those of you outside the US who like to bash good ol' USA, just remember that it is our system that basically provides your "free" system with medical innovations and new drugs.

KJL said...

Hospitals jack up the "charges" so that they can either, put the screws to people without insurance (not so much, they will negotiate with patients) or, and much more important to them, write off the bulk of charges and claim they provided millions of dollars of "uncompensated care" to the community allowing them to remain non-profit, pay the CEO big bucks, and polish their halos in public. It's a huge con. If "charges" equaled what they really get from someone with insurance, the system would be much more transparent and fair.

Anonymous said...

At least from the pharmacy side, we know if a medication is covered or if it requires a prior authorization. Some people understand the process. Others don't. I usually says because it's expensive and insurance companies make money by not paying claims. Naturally, prior auths are put in place for a reason. If a drug was prescribed that required prior auth, most of the time the insurance company wanted to know if you tried drugs A,B, and C (cheaper alternatives). If you failed them, the prior auth is more likely to be approved. If it was prescribed because sales rep had a nice rack and provided the staff lunch, well, that probably won't be covered

Mariana said...

To Carlos:

Look, I, as a physician (and one who deals daily with patients with rare diseases), personally believe healthcare is a right to everyone. I have already understood that you do not agree with me. However, what I would like to stress is that my belief does not mean that I think healthcare is free. It isn't. It costs millions of euros (or dollars, in your case). Pharmaceutical companies will only invest in developing new drugs and laboratories will only invest in new technologies if they receive a finacial benefit. The difference between you and me is that I believe we should all, as a society, contribute to the greater good. That is to say, that money should come from the State through everyone's taxes instead of being paid individually by the citizens through insurance companies (even if it means we will all pay more taxes).

Government-funded medicine, where I come from, may have its flaws, but I think the benefits outweigh them. For example, we have one of the lowest infant mortality rates in Europe. On the other hand, USA is the country that spends more on healthcare and does not have the best rates in the world. Gives you something to think about, doesn'it it? (Or maybe no - your call).

Btw, scientific innovation is not a bastion of the USA, but that is a whole another post.

Anonymous said...

Sorry, coming from the UK I'm confused by one part:

"It's a tax deduction if they want to see it that way"

Does that mean that in the US medical costs are allowable expenses against personal income tax? Does that apply to everyone and can it be carried forward and backwards against other years?



charles said...


No, you look! My name is charles, not "Carlos"; But, it seems as if you were responding to me. If so, why did you call me by a different name?

Personally, I do not believe in taxing everyone to fund something that the free market does a better job at taking care of than government does.

By turning the money raised for medical innovation into a government, instead of free market, enterprise you end up with entrenched parties that are only interested in keeping the funding ongoing, the innovation then becomes secondary. Free markets will tend to drop something if it isn't paying off; thereby saving money instead of throwing it down the rabbit hole.

You also run the risk of voters demanding, and politicians giving them, more "free stuff." How's that working out for Greece?

As for the US infant mortality rate compared to many European rates; you are comparing apples to oranges.

The method for considering what is "infant mortality" is different in the US than in many countries in Europe. If you want to "think about it" perhaps you had best start with the method used to gather the data. As a scientist I thought you would have done so already and would have seen the difference.

Nor did I say that the US was the ONLY innovator of medicine; but, it is certainly at or near the top. Just look at the Nobel Prize for medicine. Which country comes out on top in terms of the number of recipients? Cuba? I stand by my statement that if the US goes to government funded healthcare, and no more free market, medical innovation will suffer. If you think that your drugs in Europe are NOT subsidized by the US market you need to do more research.

And again, my name is charles. But, I guess you felt it was important to change my name because you didn't agree with me? Well, bless your heart!

Please do not disrespect someone by calling them by a different name. And yes, before you decide to do more USA bashing by calling me linguistically ignorant, I am aware that "Carlos" if the Spanish version of the English "Charles"; but, to me they are different names. "Carlos" is not MY name, thank you.

charles said...


Yes, in the US medical expenses that exceed 7.5 percent (under Obamacare that number is being pushed up to 10 percent sometime soon) of your income can be deducted from US Federal income taxes. (State's income taxes may vary)

If your medical expenses all together are less than the 7.5 (or soon to be 10) percent then you cannot deduct them.

Also, you have to "itemize" which means list all your deductions by item (e.g., medical expenses, charitable gifts, property taxes, business expenses, etc.)

For US federal taxes you have two choices. Itemize or take a standard deduction. The standard deduction is a set amount while the itemized is what your individual deductions are.

Many folks want to work it both ways each year to see which will be better for them. In years when you don't have a lot of deductions the standard is better; but, if you have a lot of deductions then it makes sense to itemize. You cannot do both.

Nope, you cannot carry the expenses to other years. They are deducted for the year in which the expenses was incurred.

Word of warning though; I'm not a tax expert nor a tax advisor; but, I hope this explanation helps.

Anonymous said...

Medical costs are deductible only if they exceed 10% of your adjusted gross income. If you pay your insurance premiums with after-tax dollars that amount can be included in deductible medical expenses. If, however, your employer provides insurance and you pay a portion of the premium with pre-tax dollars, the premium amount is not deductible.

WarmSocks said...

Yes, patients can line-item veto specific tests. I've done it.

If you have a piece of paper in hand that you walk from the doctor to the lab, it's easy to see which tests were ordered. Ideally you'd discuss it with the doctor so that the questionable test didn't even show up on the lab slip. It takes a little more work if the doctor is entering orders in the computer and doesn't give you any paperwork. My last trip to the lab had the phlebotomist recruiting help in hunting for a specific tube for a special test. I stopped them and asked what was going on since I knew which tests were supposed to be run and there wasn't anything extra. Turns out that the doctor added another test in the computer (without telling me) because they lost the results from last time that test was done. The lab sent results twice (I have copies of the fax confirmation slip). The doctor still couldn't find the results so I emailed them, but they're not allowed to accept results emailed from patients -- but they are allowed to accept faxes so I then faxed the results myself. I have email from the PA in which we discuss the test results. Yet the doctor still says that they don't have any record that the test was done and wants it repeated. I told the lab that there is no chance that I am paying cash to repeat this expensive test just because the doctor's staff can't get their act together. Next time I'm in for follow-up I will hand the doctor a copy of the lab results so that she can see for herself without any staff preventing delivery of the results. And I know when I go to the lab that I have to ask which tests were ordered so that they don't slip in extras.

Moose said...

I hate Medicare. I hate Medicare. I hate Medicare. I hate Medicare.

Every time someone tells me how we need a single-payer system "just like Medicare" I tell them just how much Medicare sucks. I hate that you pay monthly for stuff that doesn't cover much. I hate that you then have to get a second insurance (more monthly payments) just for prescriptions. I hate that with those prescription plans, you have to pay out the nose for anything more than the most basic drug coverage, and even then they find ways to bone you. Need insulin to save your life? TOO BAD! Here, pay even more money for you co-pay! And just wait until you hit the [CENSORED] Donut Hole! Then we really screw you!

And one thing that really grinds my gears is that in many states, Medicaid covers more than Medicare. I had a nitwit doctor who kept prescribing based on what Medicaid covered (despite my repeatedly saying, "But I have Medicare."). That antibiotic isn't covered and is $200 for a five-day supply? Are you kidding me?!

The latest I found out is that in some states, if you have treatment-resistant depression, Medicaid will cover genetic testing to look at what your best options are. Medicare will only cover genetic testing if you're prescribed warfarin.


Mariana said...

To Charles,

Wow, chill out! I speak Portuguese and obviously slipped while writing my answer and composing a text in Portuguese at the same time. I am well aware that "Carlos" isn't the same as "Charles". Why you would think that "I felt it was important to change [your] name because [I] didn't agree with [you]" is beyond me. If I wished to insult you I would have done that more directly, I can assure you.

Anonymous said...

What is the MOST irritatingly frightening of the whole slough is there is no way to 'get off' to 'get ahead'.

It's not simple like the Water Slide, Bumper Cars, or the Teacups or Lazy River or even what you think might be a ride on the merry-go-round.

It quickly turns from a Kiddie Coaster to the Coney Island Coaster to The Beast.

When you live to tell the tale and try the Mechanical Bull, it might not seem THAT bad and if get through the Tilt-a-Whirl, Troika, Shoot the Chute, Reverse Bungee, or Pirate Ship without spilling anything, and dare attempt the Double-Shot Drop Tower (or what I think of as The Hammer), there's still the Flying Scooters, and the Tragadon and Zipper.

If you've still got your cookies, you might just have to have one more go at the Hurricane. Sometimes, it's like a Freakin' Nightmare to go from zero to fifty with just you and the outer epidermis for friction.

Anonymous said...

People will argue 'til they're blue in the face that 'healthcare' is NOT a right. ACCESS to decent services IS a civil right for EQUAL PROTECTION under the law.

I think some folks don't realize that Medicaid is whatever the State can figure out how to do with the 'money' from federal and state taxes. Medicare is a federal program off the bat. Some citizens live in states where their state government can divy up the funds MORE equally than in other states. Medicare has to answer to the feds.

Anonymous said...

My insurance will not pay for my lab work because I HAVE a diagnosis. If you get insurance through your job, do the math you are most likely better off to get major medical and cover the "small stuff" out of pocket

Mark p.s.2 said...

The drink Coke costs maybe a penny to make yet costs a dollar. Both parties are happy with the transaction.
Martin Shkreli Raised The Cost Of An HIV Drug By 5000%. The buyers and sympathetic were not happy with the cost.

What is the real cost of a lab test? No one suggests a fair price for the licensed lab, labour and materials needed.

If a carpenter or plumber does an hour of work everyone acknowledge the cost for the skill they have, the same should be for those that perform the medical analysis.

Anonymous said...

My 43 year old husband is on Medicare. He's had two cancers in the last 5 years (which rendered him disabled, hence Medicare). Medicare itself pays for jack squat so I also have both a gap plan and a prescription plan for him, which totals another $350 a month on top of the $104 for basic Medicare. Then the cherry is that he is on 50 (yes, FIFTY) meds a month. Some are cheap but most have hefty copays. And he's obviously disabled, since he's on Medicare at the age of 43, so we're living on a very very fixed income. So when you throw in a surprise bill from labs, it's a wrench in the gears. Yes, you are riding that fence between the best care you can carefully choose for your patients and getting expensive tests, but patients, especially those on Medicare, don't always have the extra cash on hand to pay for those tests.

Anonymous said...

I do consulting for a lab. To run a CBC is less than $5, but the infrastructure to do the labs is a lot. Courier services, insurance billing etc.

If you want to save money on labs, go to a doc that uses a co-op service. you pay upfront and then bill your insurance yourself. Labs cost around $10 vs going through your insurance company.

C said...

people cannot deal with unexpected expenses and the system (even in your narrative) is like rolling dice.

years ago, I needed treatment and my dr said, you need x, but your insurance will not cover that unless you have y and z first, so I have to prescribe y and z even though we both know those will not help you. So some algorithm exists that is supposed to be cost saving and it gets applied to every patient whether it is appropriate or not. here is a good Q- when was the last time an ins. co surveyed patients and doctors about their experiences? never because they know what most people would say!

Chuck Pergiel said...

Maybe someone (not me) should spend five or ten minutes with the patient and explain that the lab tests you want done are going to run 50 gazillion dollars and insurance isn't going to pay for it. But why take any preventative measures when it's so much fun to deal with the apeshit?

Anonymous said...

I think the problem is more the lack of transparency. In no other industry would I be asked to sign a blank check for an amount which could be anywhere from $0 to many thousands, yet I am asked to do exactly that at every doctors office/blood lab/medical facility I go to. The lab actually requires a credit card and for me to sign a statement that my insurance may or may not cover the tests and that I authorize the lab to go ahead and charge my card whatever amount is billed that ins won't cover. And the lab has no clue how much those tests wIll cost nor are they able to tell me ahead of time what will be covered. And just try prying that information out of Tricare! I would have no problem with paying for stuff if I knew ahead of time how much I would be on the hook for -- then I could do a rational cost/benefit analysis. As it is, I pay hundreds each month (and sometimes thousands) without having any clue what my blank check will be cashed for. And, yes, I have tried to discuss this with the doctors, nurses, admin staff, etc, but they are even more clueless than I, as there are hundreds of insurance plans out there, each with its own arcane little rule system!

Anonymous said...

Well, this one cuts both ways some times, and the whole system is just broken. Two examples.

Recently, my oldest son lacerated his finger with a brand new knife. It was a nasty cut, but one that could have probably just healed on its own. However, he was going camping with friends the next day, and I didn't want him losing his finger to tetanus or wtf because I was too lazy and stingy to take him to urgent care. Except that around here, urgent care closes at like 6:30 PM, so any medium sized boo boo after hours means a trip to the ER. We go there, meet a lot of nice nurses and a great doctor, and get him stitched up. The financial lady comes in to see how we're going to pay, because naturally the ER gets stiffed quite often. I ask what it will be with vs without insurance since sometimes if it's more or less even-steven, it's just not worth running through. In this case, they say it'll be (IIRC) $300 cash, and $250 with insurance. So I run it through insurance. It's covered. I'm happy, the hospital is happy, insurance is happy. However, when I get my benefits statement for the trip to the ER, I notice that the hospital has charged insurance $950. I'm assuming that this was all above board (and honestly, I don't care since I paid my fair share and wasn't being pestered for more) but it sure had a whiff of horseshit lingering around it.

I get the same thing with meds that aren't covered by insurance -

Pharmacy: "Yup, this here bottle of oil is $145. Insurance doesn't cover it."

Me: "Um, you know, I've never paid the same amount for this twice, but usually it's a lot closer to $100."

Pharmacy:"Oh. Hmm. Howabout $80?"

On another occasion, I was seeing a pain specialist for a consult to get an epidural for sciatica and a few tendonitis injections. I was not there seeking narcotics - not that I wasn't taking them, but my PCP was handling that side of things, and I wasn't doctor shopping or whatever. Regardless, they insisted I take a drug test. I explained that I wasn't looking for a script, and unless they were worried that I was a corticosteroid junkie I really didn't see the point. I was told that it was office policy, and the Dr insisted on testing for all new patients. So, I peed in a cup in a bathroom with no warm water and a lock on the toilet handle, and figured that was that. Nope. A month later, I'm staring at an $850 bill for the testing that "I requested" that was sent to possibly the one single lab not covered by my insanely good insurance (that I now miss very, very much). It took *months* to get that sorted out, but in the end, the lab did bill the doctors office since it was not at all voluntary, and they had not even bothered to look at my insurance to see where to send the test so it was covered.

So everyone gets screwed with. Doctors, patients, and even insurance.

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