Cost comparison of brain MRI

I called Advanced Medical Imaging (AMI) in May 2014 to get a prior authorization for a brain MRI with and without contrast.

This is for a woman under 65 who is having short term memory problems. We are looking for treatable causes of short term memory loss. The blood work is negative. Next is the MRI.

Her MRI is already scheduled at the local hospital where I worked for nine years. It is the only hospital because we are a small county.

The AMI representative suggested that the patient get the MRI in Everett.

“The cost there is $917.00. It would be cheaper. It is only 29 miles away.”

“Yes, but Everett is across the sound. She’d have to drive around or take a ferry. What is the cost in Bremerton?” I asked. “At the radiology providers there?”

“The cost there is $967.00.”

“And where she is scheduled?” My local hospital has a “Rural Hospital” designation. Medicare will pay them more than other hospitals.

“$4585.00.”

I squeaked. “For the same MRI?”

“Yes.”

“Um. You should tell the patient.” Except that, is the patient willing to drive to Bremerton? And is the cost to the patient the same? And do they care?

“Do you want the prior authorization for that site.”

“Can it be changed if I talk to the patient?”

“Yes, she can call us.”

The prior authorizations are now site specific. That is, I’m getting approval for the MRI at a specific place. I have no idea why.* Seems stupid. Seems like just another hoop to remember to jump through and if we get it wrong the insurance can say, “Oh, ha, ha, ha, we don’t have to pay for that. You do.” Chalk up some more profit for the investors. Mission accomplished, money made.

I called the woman and explained. She was willing to go to Bremerton and said that she would call AMI. I asked her to call us back if she had any trouble.

The cost really matters to my medicare patients and any patient that has to pay a percentage of the cost. If they only have medicare part B, with no secondary, they pay 20% of the bill. 20% of 4500.00 is a lot more than 20% of $900. But some of my frailest most elderly most confused don’t really have a choice. Going 29 miles might as well be going to the moon.

And this is a woman with memory loss, remember? She wrote down the instructions and repeated them back to me three times.

Every phone call to insurance is like this, and makes me wonder about our culture.

* Actually, the authorizations are site specific because some places are “out of network” and the insurance won’t cover anything done there. Though I think the whole point of health insurance in the US is to try to remove money from people and avoid paying for care.

This was first posted at everything2 on Friday May 9, 2014. The woman died last month.

Comparison of cost of abdominal CT with and without contrast

I keep reading that the US Health System should be a “free market” with competition.

To have an free market, one needs to be able to check the prices. I want to compare price tags. I have a patient who needs a CT scan of the abdomen and pelvis with and without contrast. So can I, as a doctor, find out the price?

I start making phone calls:

I call AIM Specialty Health, a procedure clearing house hired by many insurers here, to get prior authorization for the CT of the abdomen and pelvis with and without contrast. They ask for the usual identifying information: my name, tax id, NPI number, patient name, insurance number, check my address, phone number, fax number. They ask for theICD-9 codes — codes for the diagnosis. I know those. They ask for the CPT code, which is the procedure code for the test. I have to scramble to find the book and look it up: 74178. With the brain MRI the other day they volunteered site specific charges. Not this time. The representative said they didn’t know. I asked for prior authorization in Poulsbo, since that was most reasonable for the brain MRI. I asked what the patient’s copay is: AIM does not know.

Call to Premara Blue Cross, which is the patient’s insurance company. They can tell me that the patient has a $10,500 deductible each year. She will have to pay that much before the insurance pays anything. I ask them what it will cost at different sites. They say they can’t give me that information.

Next I call 5 different sites to get the price for that CPT code/proceedure.
Call to my local hospital: Charged amount is $4200.00
Call to a free standing radiology clinic in Poulsbo: Charged amount $1416.00
Call to the hospital in Bremerton, south of us: $8958.00.
Call to a free standing radiology clinic further south in Silverdale:$1526.00 + $20.00 for contrast.
Call to the hospital in Port Angeles, north of us: $ 3101.70 for the facility fee. Gave me Radia’s number for the physician fee.
Call to Radia and left message.
Left message with patient.

Radia called back and the fee is $346.80, so that would be added to the $3101.70 at Olympic Medical Center.

Now I know the amount BILLED at five sites. However, that is not the amount my patient will PAY.

If the site is “in network” then the site has a contract with Premara Blue Cross, which states the amount that Premara is going to pay. The patient will get an EOB, an explanation of benefits, from the insurance. “Benefits” is an interesting choice of words. The patient has paid for the insurance so that they will cover the bills. Is that a “benefit”?

On the EOB, it will state the amount that was billed for the service. Next it will state the amount “allowed”. “Allowed” is misleading. To me it implies that the insurance has held the cost down. But the insurance “allowed” the site to be “in network” because the doctor/site signed a contract. So this is a contracted price or agreed upon price.

I want to know the allowed/contracted/agreed upon price.

Call to the WA State Office of the Insurance Commissioner. The office says that the patient should be able to request the allowed cost for a specific site. Each site has a separate contract with the health insurance, so the allowed cost could be different at each site.

Call to Premara Blue Cross. This time they say that it’s not that they refused the information, it’s that it was not available. Now the representative says that they need the “units or minutes billed.” I don’t know what that is, but I will find out. I ask if that is the only other thing that I need. They say yes, but I cannot contact the same rep directly. I have to go through the rigamarole each time: my name, my tax id, patient’s name, patient’s insurance identification number, my clinic address, fax number, phone number, sometimes the patient phone number. Usually I have to punch 4 or five of these into the automated system and then have to repeat it all when I reach a human being.

Call to Poulsbo. The units refer to 100 units of contrast. Some patients will need more, up to 200 units.

Call to Premara Blue Cross again. I go over everything with representative Hailey, who then wants to know the amount that Poulsbo is billing. Explained that I was told only the units were needed. She put me on hold and checked with Poulsbo. She is quoted the same price.

Continuing with call to Premara Blue Cross. Hailey has entered everything and doesn’t get a result. She says she doesn’t know. I explain that they have a contract with Poulsbo that names an actual amount. She transfers me to another department after 25 minutes. The representative there says that she can give the allowed amount information to the provider doing the test, that is, to Poulsbo. I explained that the WA State Office of the Insurance Commissioner says that a patient can indeed request that information. I asked if they are refusing it to the patient. Rep repeats that she can give it to that provider but not me. I offer to have the patient in for a visit and get them on speaker phone and again request the information. Without the information, I will strongly consider filing a complaint with the state insurance commission. She decides to transfer me. That’s at 30 min and I am again put on hold.

The call to Premara Blue Cross ended after 45 min and 37 seconds and the third representative in the provider relations department states that if they get a call from Poulsbo that they could tell THEM the contracted allowable amount. Again stated that the insurance commissioner’s office says that the patient can request the amount. Are they and will they refuse it to the patient? Representative Whitney says that she has access only to provider accounts and that the contract with Poulsbo is proprietary information*. I say that I think health insurance is also a contract between the patient and the insurance and surely the patient can ask what it will cost in advance. I stated that I would be calling the patient and the state insurance commissioner’s office again.

I talk to the patient. She will now call the insurance and ask the “allowed” amount for this site. I give her the diagnosis code, CPT code and units billed.

She calls back. Premara says “around $600.00”.

I call Poulsbo and ask if they will check the contracted amount. They call Premara. They call me back.

If she only has 100 units of contrast, the CT of the abdomen and pelvis with and without contrast will cost her $641.00, as the “allowed” amount by contract between her insurance and the radiology site.

I still do not know the “allowed”/contracted amount for the other four sites, so I have failed in my attempt at comparing price tags. I only know the amount the sites would bill. The “allowed”/contracted amount for each site could be different. The hospitals bill more because they have a “facility” fee. I think this means that they are allowed to factor in various hospital costs. Even so, it seems outrageous that one hospital bills twice as much as the other two and more than six times as much as the least expensive site, but the allowed amount might be lower then the billed amount.

I don’t think this is a free market. I think it is an obscured market. And this is just one procedure and one single charge. Think of a hospital stay.
AIM Specialty Health http://aimspecialtyhealth.com/about-aim/guidelines
Washington State Office of the Insurance Commissioner is at http://www.insurance.wa.gov/
Premara Blue Cross https://www.premera.com/wa/visitor/

* When I called about the head MRI, why wasn’t the information about what is billed at different sites proprietary then?

This was initially posted on everything2 on Friday, May 16, 2014.

Mad as Hell Doctors in California: October 5, 2010

October 5, 2010

Today I rejoined the Mad as Hell Doctors (http://madashelldoctors.com/) on the road trip, this time in California. This day was a mix of planes, trains, cars, single payer health care, social justice and neoprene.

The Mad as Hell Doctors have been two weeks on the road in California, doing town halls for single payer. Some doctors are there for the entire trip, some have come for a week at a time, many local chapters of Physicians for a National Health Program (PNHP http://www.pnhp.org/) have local speakers and local providers join us at the events. Each event is different, with a mix of our team and the local team. One more week to go, ending in Chico, California on October 12th. I am leaving my practice and my children for one week, the last week of the trip.

The previous trip was from Portland, OR to Washington DC, 26 cities and more than 30 town halls, a road trip across the United States. I joined the Mad as Hell Doctors in Seattle and participated for a week. I flew home from Colorado and then rejoined them for the last 5 days, ending in a rally across the street from the White House.

Up at 3 am and quick finishing my packing, left at 3:40 after kissing the kids. Drove from home to Sea Tac, about two hours, down through Bremerton and across the Tacoma Narrows Bridge as the sky is starting to lighten and then north on I5. I5 luckily not busy and not backed up. Left the car with some company on International Boulevard and rode the van to the airport. At the scanner after I checked one bag, security found a jackknife in my carry on. Rats. I did not have time to go back around and mail it home. I wonder what really happens to all the confiscated knives. On to the gate and the flight was boarding. Nice flight down to San Diego. We left at 6:50 am and arrived at around 9 am. I felt disoriented as soon as I stepped outside: the sun was too high in the sky and those palm trees are just wrong. The air is so dry after the Pacific Northwest.

I checked on a van to go meet my Mad as Hell Doctor compatriots, but it would cost $170. “No? How about $150? How much can you afford?” The 3 pm train was $17.00 so I waited for that. I checked my bag at the train station and wandered around San Diego for a while, had breakfast.

At 3:00, the train moved out. San Clemente Pier was the third stop. The disembodied train speaker said “You should be going down the stairs and be ready at the doors: this is a very short stop.” I was ready and the only one to get off. I rolled my bag along as the train pulled away. No one was there. Then I heard my name and from the ocean side a man was running, sort of, in a black shortie wetsuit with one yellow flipper in his hand and the other on his right foot. I must be insane, I thought, and got a very wet oceany neoprene hug from Dr. Mike Huntington.

I changed into my swimsuit and joined Drs. Huntington and Sapir (http://madashelldoctors.com/2010/10/05/california-road-trip-day-14-san-clemente/) in the ocean, my suitcase tucked up on the lifeguard tower. No lifeguard. The water was at a crisp 68, which is better than the usual Pacific Northwest 56 degrees. I bodysurfed for half an hour until I couldn’t feel my toes and my hands were turning bloodless and white. Changed back into clothes and we played frisbee on the beach, me with enthusiasm but little skill. Mark Sapir said, “First chance to exercise in two weeks. I went running today and now everything hurts, so now we’re letting waves pound us in to the sand.”

We trooped back to the houses where they were staying and I met our hosts. Dinner with 14 people, kind and gracious hosts. Much discussion of medicine and politics. This was a day off for most of the [What I learned from my first Mad as Hell Doctors week|Mad as Hell Doctors], though Dr. Paul Hochfeld was at a talk given by a Physicians for A National Health Program California Chapter Fellow to medical students. He was back for dinner, reporting on the event.

This trip is streamlined. Currently there are eight of us. The trip is still 3 weeks, but with a little recovery time built in. Instead of staying in motels, we have stays arranged with PNHP members along the way. Phillip Kauffman is with us, saying that this trip is both easier and harder than the one last year. We have less paid support crew so more duties have fallen on him, but it is also a smaller group of people to coordinate. Dr. Hochfeld called him a “butterfly herder” in his blog yesterday, but I still think we’re more like cats. I don’t think of butterflies as having the same sort of egos or defense weapons as cats. And I am delighted to return to the group. They are incredibly dedicated and stubborn and willing to go on fighting for single payer. They, or we, are ignoring the people that say, “Why work on this? The health care bill passed. You won’t get another for years and years.” They might be right: but social change and social justice is not attained by sitting back, being apathetic or giving up. It takes dedicated people continuing stubborn work. I feel closer to these people after less than two weeks last year then some physicians that I have worked with for ten years: to be back on the road with the Mad as Hell Doctors is like coming home.