As of January 2019, all hospitals and healthcare systems were required to post their pricing on their websites or in some public, machine readable format. The goal of this mandate was to give patients the information needed to make informed decisions about their healthcare, from a financial standpoint. Unfortunately, what patients are being able to access may lead to more confusion rather than less. The process of determining final costs and billing for patients, especially in a hospital environment, is vastly more complex than most would think. Let’s look at a hypothetical patient entering the Emergency Department as an example.
Let’s call our patient Cathi and suppose she has abdominal pain. Entering the emergency department, she will receive a myriad of tests and, hopefully, a final diagnosis that will allow her to go home and be cured. However, depending upon her insurance, the emergency department providers may or may not be in network. This might also apply to the radiologists reading her abdominal CT. If they are in network and employed by the hospital, she is likely to receive one bill. That bill will be an adjusted bill for either a portion of her remaining yearly insurance deductible, her co-pay for the visit or some other amount as agreed upon by the insurance company and the hospital. If not in network and not employed by the hospital, she is likely to receive three bills. One for the facility fees and any testing done in the ED. One from the ED provider or the company they work for and one from the radiologist or the group they work for. If the providers are not in network, the bill will be much larger than if the providers are in network with the insurance company. If Cathi then gets admitted to the hospital, her charges will be even more complex based upon if she meets criteria to be admitted as an inpatient versus observation.
Unfortunately, this process is not any simpler for patients who are having elective surgeries or even office visits. While hospitals are posting their “charges”, this really has little to do with what the patient will actually pay in the end. While hospitals are attempting to work with insurance companies to verify coverage and deductible amounts remaining and give patients estimates for planned procedures, these estimates can still be significantly different than the final bill. Unless and until we have true interoperability and transparency between hospitals and insurers, we are unlikely to be able to offer patients more than a best guess at what their financial obligations may be.
I would love to hear your thoughts on solutions to this problem. Feel free to leave them in the comments.