As an experienced patient advocate—I served as medical proxy for each of my parents during their terminal hospitalizations and for my sister during a midlife curative hospitalization—I’m comfortable asking myriad questions in an effort to uncover medical and procedural facts. Since my family tries to act prudently when buying health treatment services, probing questioning is part of my day-to-day when I put on my “healthcare administrator” hat. I’m used to unearthing definitive answers (as unpleasant as some may be). The latest episode takes the cake, however: I learned that it’s impossible to make an informed advance buying decision.
We’re insured under a high-deductible plan. We have yet to meet our deductible in any plan year; essentially making us a cash customer for any treatment purchase that’s not fully covered as preventive.
A family member was prescribed, as part of her well-woman exam, a series of blood tests, a colonoscopy, bone scan, and mammography. Our plan lists these treatments as 100 percent covered if in-network. Early in a plan year on a high-deductible plan you’ll be paying the entire cost out of pocket, so careful shopping is prudent.
To verify coverage I called our insurer, Anthem Lumenos. I’d already learned, under a previous insurer who required pre-authorization for everything, that health treatment services are actually insured a la carte, like a cake billed as each ingredient, prep time, pouring, pan rental, oven charge, and a restaurant fee.
I had previously learned about colonoscopies, which carry a provider charge and a facility charge. Extrapolate that to other procedures and you learn that a mammogram is billed as the scan plus its reading by a third party. But it’s not enough to know even this much, for nowadays it’s entirely possible that the provider performing a procedure may be in-network, but the facility in which the procedure occurs may not be in-network—akin to the chef being in network but not his restaurant. (Esoteric insider clues: 1. ask if all providers and the facility bill under a common tax ID number; 2. when you cross over carpet onto linoleum you’re entering, and utilizing, a facility—too bad there’s no pay phone there to call for pre-authorization).
The Lumenos agent told me that three of the blood tests were 100 percent covered if in-network and if coded as screening (distinct from diagnostic; “screening” designates preventive investigation whereas “diagnostic” indicates investigation for a suspected condition—and if you can tell the difference between the two you’re a better advocate than I). Imagine my surprise when she advised me that three of the tests “might be” covered but she could not say with certainty. Apparently these tests are subject to some after-the-fact status interpretation. (What would cause a changed designation? What phase the moon?)
Since Lumenos couldn’t give me a guarantee of coverage even for these in-network screenings, I figured to cover myself and do a little healthcare consumer shopping. Working from the back end (often an effective strategy), I called our local hospital’s billing office. I’m already aware that facilities offer cash discounts of 40-50 percent on a “cash and carry” basis depending upon when one pays. It turns out that they refer to this as an “uninsured” transaction. The financial counseling rep advised me not to buy treatment this way. She said that she has seen—more than once—an insurer refuse to cover further testing and future treatments emanating from an insurable treatment purchase paid directly by consumers. She further said that the cost paid would not be accepted by an insurer against my annual deductible. Further still, once treatment is billed as either insured or direct pay, it cannot subsequently be redesignated.
So I asked what the costs would be for me under Lumenos versus if I were to pay directly. She could not contractually reveal the discount the hospital gives to insurers (but did cite a 30-50 percent insurer discount range in general). Back on the phone with Lumenos, the rep told me they would not reveal their discount.
In other words, it’s not possible to price all routine services before paying for them. We must choose a payment option not knowing its comparative cost. Paying an in-network provider directly could preclude future coverage and doesn’t accrue against deductible. So much for consumer choice when it becomes impossible to ascertain in advance what our coverage covers, and what procedures cost.