Insurance, healthcare provider, apparent abuse, lack of transparency

Question

I'm now covered by my employer's health insurance. We're used to shopping around for health care, so we expect to spend $80 to $100 at the doctor if we're sick.

My wife has an understandable expectation that insurance is supposed to cover every visit to the doctor's office, but I made it clear to her that we get high-deductible insurance and pay out of pocket up to the deductible, and we're typically better for it financially.

She was sick, and wanted to go to the doctor, so I told her to price it and go, but prefer to stay in our insurance's network. I made it clear that I expected her to ask for the price from both the insurer and the provider, which she did. She was led to expect, based on a friendly phone conversation with an insurer representative, that she should spend no more than $80 (any poorly communicated caveats notwithstanding). She asked the doctor's office what she should expect to pay, and they refused to say, stating that the insurer would tell her.

She scheduled an appointment with the in-network doctor, and canceled her appointment at the clinic she expected to spend around $85 at.

Now we get a bill stating the total for her visit is $230. A phone call with the insurer (telling them I don't expect to pay any more than $80) revealed something about a billing code for a new patient setup fee (I'm misremembering the precise words).

My specific question is: What can I do to overcome this lack of transparency and apparent abuse, both now, and in future?

(Secondary public policy concern: how can we ever get health care costs under control if there's so little transparency? And if it's any help, I've had several insurance and securities licenses, and plenty of business school education including risk-management and insurance classes.)

Edit Good suggestion from comments (Joe): go to the doctor and ask them to remove the undisclosed charge.

Answer 1

Just as with any other service provider - vote with your wallet. Do not go back to that doctor's office, and make sure they know why.

It's unheard of that a service provider will not disclose the anticipated charges ahead of time. A service provider saying "we won't tell you how much we charge" is a huge red flag, and you shouldn't have been dealing with them to begin with.

Now you know.

how can we ever get health care costs under control if there's so little transparency?

I'm assuming you're in the US. This is not going to change, since there's no profit in not screwing the customers. As long as health-care is a for-profit industry, you should expect everyone in it being busy figuring out a way for money to move from your wallet to their. That's what capitalism is about.

Answer 2

I wouldn't classify your treatment as abuse. Medical billing has become more complex not less complex. You need to learn to ask even more questions regarding expenses, you probably need to see these price quotes in writing.

You did several things correctly. Staying in-network generally is best because many plans have two deductible limits: In-network, and out-of-network.

You need to make sure that the insurance company does credit you with having paid the new patient fee. That will qualify as an expense toward the deductible and your maximum out of pocket for the year. Some doctors offices don't send to insurance companies items that they know will not be covered, not remembering that these costs are critical under the High deductible plans with a health savings account.

Doctors offices have problems determining how much the cost to you will be. It depends not just on the insurance company but also which type of plan you have, which sub-plan you have, and are you covered by more than one plan. Not to mention individual deductibles, family deductibles, and annual out-of-pocket amount. All this is wanted prior to the doctor seeing the patient. Most doctors offices will work with you, they know that each insurance plan treats each medical billing code differently, sometimes they make a mistake. Talk to them.