Pricing of medical procedures (tests/scans) from biz-to-biz & "rights" to go to diff provider

For those of you who have had to have medical tests and have had to pay out of pocket either for part of the test or the entire thing, you will know that the price can vary greatly from business to business and the price could be drastically different by driving 20-30 miles to a different location. Now I want to say that in this example the tests provided are of the same quality and or test for the same things using the same procedures - such as a blood test, drug test, MRI, CT scan, ultrasound, etc.

So if you are told that you need a blood test and the office you are at offers them, with the price of $150 for what you need, but other businesses across town offers the same thing for $60 - 100 depending upon where you go. Now the doctor you are at tells you to "go next door and get blood drawn" and many people would do just that. But if you are paying yourself, you may be worried about price, or if you have an insurance cap of say $4,000 per year and you know you are going to hit that amount this year for whatever reason, you may want to shop around for price. Now can the doctor demand that you go next door?

What if this is a comprehensive drug test/screen which can be very expensive in some situations some being $1,200 when testing for a mass of substances (some are 30+ different compounds), and they offer it "in house" where they take a sample, send it out and get the results. Across town the big lab where most employers send people for testing offers the same thing for $400 - 800 depending upon area. Do you have the right to go to the service that has the most competitive rates and or can the doctor demand the test be done "in office"?

Now there are some insurance plans that are much more liberal with amounts they pay for testing and don't have a cap that most people are likely to hit in a given year, unless major medical issues arise. Now if an MRI is ordered and it is going to cost $3,000 for an extensive scan at the local office, but another location in a large city (say 30-50 miles away) offers it for $1,200 - 1,600, then the person paying out of pocket would probably drive to the lower priced office, but those with insurance might not care one way or another. I've seen this type of thinking a lot and I think this is a reason that medical insurance is so high.

I've asked some people about this and I was told "well the insurance companies negotiate prices and they are pretty standard from place to place" but when I look at the explanation of benefits, which says how much the company charges the insurance company, how much the insurance company pays, I don't see a whole lot of negotiation in most cases and it may be slightly different than what the "cash" price is (in one case instead of $3,000 it may be $2,875 but no where near the $1,200 - 1,600 of other places) and if the lower priced place has "negotiated prices" then their insurance rate may be $1,095 - $1,485 (instead of the $1,200 - $1,600) - so I don't see a fixed $1,050 price at all locations or anything like that - at least I haven't for the test's I've had.

So, if the insurance company is paying for this, is there any way that they can incentivize the member to find services that offer the most competitive rate? With car insurance, I get 3 quotes for the car damage, and they often will pay the highest quote if I decide that is where I want to go, as long as it is competitive and not 2x (or more) than the others - but I can also select the shops I go to - like dealer repair locations instead of "Little Rickie's Dent Den", lol, (or some other low cost repair joint). Could something like this be done where rates are compared and the member be rewarded for using the lower cost provider? The problem would come in when this is demanded instead of rewarded and I don't know how a line could be drawn to differentiate the difference.

I just know that when I was shopping for cash prices for tests, there were some MAJOR cost differences when I looked at major metropolitan areas vs more suburban or "rural" areas. Even going out of country if needing a lot of tests (and not having insurance) can save money, prices in Canada can be much less and pricing in some Caribbean countries and SE Asia are MUCH less and even less expensive with air fare (if having a barrage of testing for whatever reason).

I want to know what people think about the "rights" or options for the patient to choose where they get tests done as explained in the blood test or the drug test (as above). Do they have the right to go to their provider of choice, or do they have to stay at the office that is asking for the test. I know some offices tend to pressure the patient to get tests done in office and don't offer any alternative or even say it is an option (like "do you want to do the test here?). I've asked what the pricing of the tests are and they haven't even been able to tell me until I get the bill or the letter from insurance which says how much they pay for and how much is owed/covered. This seems almost illegal and underhanded. It seems that the pricing should have to be clearly stated as well as the options of the patient. There are many industries where pricing, by law, has to be clear and stated. Why is this not the case for medical procedures?

They are incentivizing customers by using health savings accounts. Essentially, you lower premiums to have the basic office visit covered under the copay, and then gain access to the collective bargaining power of the insurer. Each paycheck you take the cash that you would have spent on higher premiums and put it in a health savings account (tax free contribution), usually with a match from your employer. This account is used to pay for treatment and diagnostic testing, as well as glasses and dental work (something that normal health insurance won't provide for).

To me, this is how we kill off insurance companies. If we can create a private collective bargaining platform that people can pay dues to enter into (maybe $10/year to pay for admin costs), then stop paying a health premium and instead invest in health savings accounts...that money remains yours. You aren't throwing it into the pockets of execs at UHC...it stays in your account for you to use. As you age and need more $$$ to pay for health expenses, you have this account you've paid into your whole life to help with expense.

It doesn't account for young people with extreme illness...but it does provide a way for us to break the backs of insurance companies.

some of those testing labs may be out of network for insurance purposes. That is something to consider. You might wind up paying the whole lab cost instead of a copay.

We even had our emergency room doctor at a local hospital here out of network some times. I know someone who had to pay the whole doctor cost, none was covered unless you billed for it yourself and the copay went way up in the person I know's case. The insurance company wound up paying about four hundred of the eight hundred dollar bill and still had to pay the deductible of the ER... Now they know about it and since it does not happen all the time and you have to ask, they just go to the other hospital that always has an in network doctor there who is billed through regular hospital billing. This was happening all over the country from what I saw on the news. It has not been fixed yet here, the News story did nothing to stop this practice here from what I have heard.

When I had insurance through my job at the hospital, we had certain places that were approved to go for xrays and tests as they had agreements with the insurance provider. If we chose to go elsewhere, insurance would not pay. We also had a health spending account we could pay into and use for things like dentistry and eyeglasses. That was nice.

I remember down the line, there were some changes to the health plan we had that weren't great. It got harder and harder to get the insurance to pay for anything if they deemed it unnecessary. Didn't matter if the doctor ordered it or not. If the suits at the insurance company felt it wasn't critical to your treatment, they wouldn't pay. I had to pay out of pocket for some tests the doctor ordered when I was pregnant, and insurance wouldn't pay for the private room the doctor put me in when I got a kidney infection that spread to my blood stream during that same pregnancy.

originally posted by: bigfatfurrytexan
They are incentivizing customers by using health savings accounts. Essentially, you lower premiums to have the basic office visit covered under the copay, and then gain access to the collective bargaining power of the insurer. Each paycheck you take the cash that you would have spent on higher premiums and put it in a health savings account (tax free contribution), usually with a match from your employer. This account is used to pay for treatment and diagnostic testing, as well as glasses and dental work (something that normal health insurance won't provide for).

To me, this is how we kill off insurance companies. If we can create a private collective bargaining platform that people can pay dues to enter into (maybe $10/year to pay for admin costs), then stop paying a health premium and instead invest in health savings accounts...that money remains yours. You aren't throwing it into the pockets of execs at UHC...it stays in your account for you to use. As you age and need more $$$ to pay for health expenses, you have this account you've paid into your whole life to help with expense.

It doesn't account for young people with extreme illness...but it does provide a way for us to break the backs of insurance companies.

I was brain storming some ideas about the health insurance issue some time ago and came up with an idea that I later read about that was basically a health savings account. Basically it was identical to what you described but mine differed slightly where if you put $100 per month into the account, you get that amount in the savings account, but there is a fixed percent that can never leave the company, basically a percentage that is guaranteed income for the company and that would be used to cover overages of other people (or yourself) when "real insurance" is needed. So if someone has saved $3,000 and there is a 20% hold over, they can only withdraw $2400 when they leave the plan. That 20% would be used for people who have major medical costs (like catastrophic type injury/condition) or like the younger person you described.

I've looked at my insurance and I'm wondering if it wouldn't be less expensive to pay everything out of pocket and only have something like catastrophic coverage. It gets dizzying when looking at the different plans and looking at all the terms & conditions for each plan and comparing them vs cost of different coverage.

I wonder if things might go back to employer provided doctors, where a large company might have their own doctors and contracts with hospitals/specialty providers and then smaller companies buying something like "time shares" with doctors/doctor offices and contracts with the hospitals/specialty providers as well. IIRC this type of thing was used back in the 19th century and early 20th were there was a company doctor for a lot of larger companies.

It seems that the cost of medical care started to really increase when everything was contracted out and there were layers of service providers, and large choices of providers (much of them largely the same), but the billing then became a nightmare for the individual and some providers worked only with certain groups/companies/insurance agencies/etc thus guaranteeing that the individual needed to join the insurance network to be able to get quality care when needed.

IDK how much the malpractice issue has caused this insurance mess but I remember that it was a big topic about 20 years ago where doctors said they were forced into groups to be able to afford to practice medicine and then prices went up (when they should have been lower IMO) and eventually insurance prices followed.

It's scary when the data for mis-diagnosis and other medical related injuries and death is compared to other leading causes of death as it seems the numbers shouldn't be as high as they are being what the industry is.

It's not so much a matter of your "right" to go elsewhere; it's a matter of whether your insurance will pay for it. You don't have the "right" to have your insurance pay if you decide to go "out of network." And THAT depends on how you have set yourself up. For example, I use an HMO. My optometrist is NOT a member of the HMO, i.e.: He's not authorized by my HMO. I can still go there, but they won't pay for it because they have their own optometry facilities they want me to go to just like they force me to use their own pharmacy. To complicate matters, they do NOT have advanced ophthalmology services like cataract removal, so they contract with and allow you to go "out of network" for these services with their approval.

Now, I COULD switch to a more general type of insurance that is not HMO associated. This would broaden my options and pay for all "out of network" services I mentioned above. They still have a "network," but is is much more inclusive. In fact, it includes just about everyone--except the HMO. Now why would I even put up with the situation I described? Because it costs me $28 per month for full coverage. It's a lot cheaper fr me to do that and pay for my optometrist out of my own pocket than to switch. I did the math. YMMV.