Accountable Care: Transparency of Fees Is Mandatory

image of HIPAA form

Participatory medicine and healthcare system transparency warrior Cyndy Nayer put this up on her blog this week, and we’re re-posting it here because it’s a message that’s got to spread.

A personal account of a transaction that went very badly, and rules of Health Reform were not followed

In my surveys and seminars, physicians tell me they want responsible, accountable patients.  I’m calm, I’m rational, I’m doing my best to be proactive and ensure they get their money.  But I can’t promise an open-ended checkbook.

Accountable Care and associated transparency have not made it to Florida, at least not in this physician’s office.

I made an appt with an ENT (ear nose and throat doctor) for ear wax.  When I get there, I need to fill out 5 papers (EMRanyone??), and I’m told there is a $35.00 copay, which she says I can pay on my way out.

The 5 page HIPAA form says they can share my info with other providers who are trying to collect fees. But you only learn this, among other clauses, if you read the form that is tacked on the wall–it’s not in the form the patient signs.

image of HIPAA form

A Shortened Synopsis of The Patient Attempting to Be Responsible for Her Fees

I asked the receptionist how much the office visit is, and she said, “On your insurance there’s a $35.00 copay.” Yes, but is there an additional fee for removal of ear wax? How much? “We can’t tell you that until after the doctor sees you and marks what is done. And besides, we don’t know if you have satisfied your deductible.” I tell her I have not, but because I have to guarantee payment if the insurance company denies anything, I’d like an estimate of charges. She repeats the deductible statement and I say yes, I understand, but that’s a problem, as I haven’t satisfied my deductible so I need to know how much this will be. She tells me she will get the Office Manager (OM).

The Office Mgr (who is disguised in a clinical suit) tells me, “You have to sign this financial form before the doctor sees you because after, you will have received the services so you or the insurance company owe the money.” No problem say I, but I need an estimate, and I can’t sign a financial responsibility form that allows you to bill me if my insurance company doesn’t pay you in 45 days AND that tacks on a 30% interest fee, when I don’t know if I can afford it.

Two visits into the doctor’s lair, she comes out and says, “Dr M is more than willing to provide the services you need but he cannot be interrupted to tell you the costs of the services.” BOOM.

In my surveys and seminars, physicians tell me they want responsible, accountable patients. I’m calm, I’m rational, I’m doing my best to be proactive and ensure they get their money. But I can’t promise an open-ended checkbook, and I’m not on Medicare (which, if you read the financial form attached, seems the gateway to payment nirvana). I’m a firm believer in people being paid according to contracts and promptly upon receipt of services. But OM keeps telling me that they just don’t know what all this will cost.

So, I say, “How about if, when I get into the exam room, the doctor and I chat and then he tells me, before he does anything, what estimated costs will be billed?” Note, I’m not asking negotiated fees, even, just retail pricing.

If you know me, you know I tried every which way to get some inkling of an estimate, including sharing my dermatologist’s willingness to tell me the price of the lab review for a specimen.

OM goes back once more and comes out with this: “Dr M will gladly provide you the services you need but he is not responsible for knowing the prices of the services so he cannot provide those, and he doesn’t want to be interrupted with a patient.”

I left. What would you have done?? BTW, I’ve attached the financial guarantee with my name blacked out so you can see what I was I told to sign.


Posted in: general | policy issues





5 Responses to “Accountable Care: Transparency of Fees Is Mandatory”

  1. Jacob Reider says:

    a) I would suggest you see a family physician. Ear wax – unless incredibly difficult to remove – can be easily managed by a family doc or internist. We do this all of the time – it’s certainly in our scope of practice. A specialist will often charge you 2x what a primary care doc will charge for the same service.
    b) Ask the family doc’s Office Manager how much this will cost – and if Office Manager can’t tell you – just leave. He/she should know or should be able to figure it out. You did the right thing.

  2. I have always tried to get a “range” of the price estimate. It seems that the word “estimate” is not understood, but they certainly should know how to dig up the CPT code that equals removal of ear wax, and can quote that retail price. Until your insurance company’s discounted price is calculated–which is a big fat secret–then you have no idea what insurance will pay, or what you will pay in your 80/20 split. But they could start with that retail price. Of course, it will be ridiculously high, so that the negotiated price to the insurance company will justify your using insurance for these types of treatments.

    It would be interesting to have asked what Medicare would pay for that procedure, which will give you a sense of the baseline of the cost.

    So convoluted, and without some basic information which can be given to any patient, is there any wonder that the less confident, perhaps less educated patient does NOT use a doctor until a disaster occurs?

    • Cyndy Nayer says:

      Peggy, I tried that. I tried these: I understand that there may be multiple codes for ear wax extraction. Can you give me a range of these? Or, how about this: I’ll keep the financial paper until I meet with the doctor and BEFORE we proceed, I’ll sign and give to you? They told me no to both.

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