President Obama’s Affordable Care Act, the health care overhaul law passed in 2010, tries to make some improvements (though the Supreme Court is expected to rule whether all or some of the law is constitutional this month). But while the law’s changes help you shop around for insurance policies — specifically through its new HealthCare.gov Web site, a one-stop shop that lists all of your insurance options in one place — it’s still unclear how effective the law will be for anyone comparing medical services.
Still, there are a handful of provisions that will help consumers on these issues. Starting in September, health insurers and group health plans must provide consumers a comprehensive summary of their plan’s benefits and coverage in plain language. It also provides grants to help states start or improve services, known as Consumer Assistance Programs, aimed at assisting people who have questions or problems about their health coverage. These programs, like Connecticut’s Office of the Healthcare Advocate, help people understand their plans, find coverage as well as assist with billing issues. Additionally, the new law gives patients the right to appeal their insurers’ decisions after they are denied payment, for “plan or policy years” starting after July 1, 2011.
But one of the overarching ideas behind the law, according to Mike Hash, acting director of the Center for Consumer Information and Insurance Oversight, is to eventually encourage insurance plans to provide detailed information on, say, the quality of care and how much your share of the costs will be if you choose to have your knee surgery, for instance, at one provider versus another. He also expects more clarity on out-of-pocket costs, which will be capped at reduced amounts for people who buy insurance through the state-run insurance exchanges and meet certain income requirements. But other out-of-pocket limits will apply to other people who buy plans inside and many plans outside the exchanges, experts said.
Resoures, Tools for Reading Medical Bills
For now, there are some other helpful resources that exist, many of which can provide you with a rough idea of what some services might cost in a specific area, while some insurers offer tools to its customers as well.
As for the 68-year-old patient, Ms. Poole’s detective work ultimately reduced his out-of-pocket costs by more than $22,000, which left him responsible for about $3,915. Since the couple didn’t have long-term care insurance, he was also responsible for the nursing home’s charges of $65,000, which Ms. Poole said Medicare covered for only a short period of time. (Ms. Poole, a former emergency room nurse, who later received an M.B.A., generally charges about 25 percent of the savings found.)
She uncovered the savings in various places — there were charges for brand medications when the patient ordered generic, services that were double-billed, as well as charges for a private room that the patient did not request; he was only there because no other rooms were available. In another instance, a surgeon belatedly submitted his $4,400 bill to the insurance company, so the claim was denied. That wasn’t the patient’s fault, but he was billed anyway. She lobbied the billing department to drop the charges, and they did.
Then, when the $132,000 hospital bill came, the patient was told he owed $9,200 and it had to be paid in 10 days. As it turns out, only one of the insurers had paid its share, which was hard to decipher from the bill. Ultimately, the patient only owed $164.99. “There were three explanation of benefits from Blue Cross Blue Shield, each with an different amount due,” she said, ranging from about $164 to $81,900. “How’s that for confusion?”
All told, Ms. Poole spent about 96 hours dissecting each bill, line by line, comparing it with the providers’ medical records and keeping track of it all in a complex spreadsheet.
“It's a broken system,” she said.