Costs for arthroscopic sx? (California) (California) (Califo

[rosellavera]

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[jonbrissman]

Good to hear you're doing fine.

Tell us more. Was your surgery done under workers' comp auspices, or was it private insurance? Was it inpatient or outpatient? Any day-of-surgery complications that could inflate the bill? Are you seeking the surgeon's fee, the facility fee, or both? What about the anesthesiologist's fee? Were you provided a sling or other DME? Did you make a co-payment? Is a PPO discount applicable? Do the provider and the carrier have a contract with pre-negotiated fees? Was a fee agreed upon when preauthorization was given?

JCB

[rosellavera]

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[jonbrissman]

Hi, Rose. PHLB was a good choice.

All the charges about which I write below are for worker's comp patients. I have little knowledge of what is paid by other health care insurers.

I don't know what procedure you had, but the OMFS allows a professional fee (for the surgeon) of $1,002.92 for a shoulder arthroscopy with limited synovectomy (CPT 29820), and $1,206.41 with complete synovectomy (29821). With partial debridement (29822), it's $1,090.13 and with extended debridement (29823) it pays $1,482.57.

The anesthesiology bill will run from $400 to $1,000 depending on the amount of time involved.

I think the OMFS for the facility fee is about $4,000 (surely someone will have a more exact figure). One large carrier has contracts with many hospitals that specifies a $8,500 flat fee for shoulder arthroscopies. Blue Cross pays pursuant to its own fee schedule for contracted providers, and that amount is less than the OMFS allows. An insurer who pays $48,700 for the facility fee would be well advised to contact PHLB and negotiate a PPO contract for future services.

JCB

[rbaird]

Glad to hear of a good result of your shoulder surgery, Rose. Big difference between Jon's quotes and the EOB's as a private patient. This does not bode well for IW's and suggests to me at least that WC reimbursement is unrealistically low and that your providers may have been overcharging. BTW, did you injure your shoulder trying to wring the necks of your children or over application of the lash? (Joking, of course).

[rosellavera]

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[stevepsca]

I don't know, but would have to assume there were OMFS in force in 2002... would stand to reason there were.

I requested a copy of the billing from my 19 day stay/surgery.
In total..hosp/medications/surgery suite, ICU, acute care, skilled nursing...no surgeon, assist, or anesth. the bill was in the neighborhood of 325K. When the carriers benefits statement came, there was a check issued for 80K on that bill.
I notified the CA regarding duplicate billing on meds to about 25K... no response. Blue Cross did the bill review, and paid per the negotiated fee schedule of the IC, not OMFS.

As I knew many of the EE's in the various dept of the hosp, much of this was verified at the time.
I am familiar with PHLB, it's a wonderful facility....if you can't get in however, take a trip to Palm Springs... Desert Hospital, or Eisenhower Medical Center, Rancho Mirage are equal to the task!

For the treatment/services provided, IMHO, the OMFS, Medicare fee schedule, and the negotiated fees are waaaaaay out of kilter.
I just don't understand why there must be so many "OMFS" ? If the guy off the street was charged the same schedule as the IC and Medicare reimbursement, wouldn't the health care system be more in line to the real world ? At least the fee-for-service would be equitable.

Sorry Rose, didn't mean to take your thread to ''health care reform''....

[jonbrissman]

Stevepsca said,

If the guy off the street was charged the same schedule as the IC and Medicare reimbursement, wouldn't the health care system be more in line to the real world ?

In a word, no. Hospitals and ambulatory surgery centers could not survive if they were paid Medicare rates for all they do. One surgery center owner told me that if he rejected every Medicare patient and sent $100 to CMS for each rejection, he would save money. Non-Medicare patients must pay more to subsidize the facilities' Medicare accounts. Many facility owners look at Medicare patients as charity accounts. Lots of physicians do not accept Medicare patients at all.

Ambulatory surgery centers sprang up in quantity in 2000, 2001 and 2002 because they were healthy profit centers under the laws and regulations existing at the time. A surgery center with only two operating rooms cost $5 million or more to establish, yet there was potential to recoup the investment in a few years. But since the 2004 workers' compensation fee schedule went into effect for outpatient surgery centers, few new facilities that cater to workers' compensation patients have opened. Plenty of existing surgery centers now are scheduling elective procedures to supplement their earnings and keep their doors open. OMFS rates, at about 120% of Medicare reimbursements, are marginal and not likely to increase substantially in the foreseeable future.

Maybe it's not equitable to charge different amounts for the same service depending on who is paying, but so what? Profit is the engine that drives industry, and Medicare reimbursements are profitless. The inequality in charges is a real-world necessity.

Excuse me for speaking in broad generalities; the above is just my sense of what's happening. I now yield my soapbox to others.

JCB

[stevepsca]

I apologize Jon... I could have phrased that differently.
I agree with you.... No one could survive with the Medicare reimbursement rates... nor the schedule with which the gov pays those bills.

My thought goes to a more level playing field. The 'guy off the street', the IC's, and yup even Medicare could be billed to an actual cost basis plus reasonable profit, market controlled rate structure much the same as any other business...ie furniture, (which carries upwards of 300% profit margins).
Maybe a system like Public Utilities Comm. would be the answer... controlled care rates. Doesn't appear electric/gas providers have any problem with profits. They are permitted to bill the end user for their infrastructure costs...and itemize on the bill they're doing it.

The IC industry has the luxury of 'negotiated fee schedule', the private/self pay patient doesn't.
In the conversation I had with the billing dept, I could certainly contract with a bill review co., and negotiate a possible 10% reduction in that bill if I were to pay in full. My alternative, at the suggestion of the Hosp., ...file BK. That's what everyone else does.

Maybe it's not equitable to charge different amounts for the same service depending on who is paying, but so what? Profit is the engine that drives industry,

In a get what you pay for world... I'll refer to Desert Hosp as that's where Im most familiar, and I would not suggest this happens everywhere... this campus is owned by Desert Hospital District, a foundation. They operated as non-profit for years. As costs increased, and Medicare reimbursements became more difficult, the facility was leased to Tenet, a for profit . As a foundation/district, it's supported by property tax dollars, and prvt/corp donations. As well as the volunteer services...'candy stripers'.
None of the freebies were forfeited when the for profit took over.
Realizing the arguement is those 'freebies' were negotiated in the lease agreement... the 'guy on the street' doesn't know about those issues when presented with a 'usual and customary' bill for private fee for services vs those the carries enjoy. Certainly have knowledge of the property tax dollars paid.

The inequality in charges is a real-world necessity.

There are 3 major hosp within 10-12 mile radius of one another, 7 (last count) ImmediateCare facilities in that same arena, and who knows the number of outpatient surgery centers... seems half the 1000+ M.D's have these in-house. Yet no 'competition'.
IC contract, Medicare just says 'thats what we pay'... you and I (as among the uninsured) don't have any recourse but to pay 'usual & customary' in a industry that is not market controlled....oh... BK.

[jobmdpsych]

<<The IC industry has the luxury of 'negotiated fee schedule', the private/self pay patient doesn't.>>

How often do people ask? I have a relative from Mexico who came to the US for surgery. It was not covered. They wanted to charge the "fantasy number". I told her to ask what the Anthem rate was for the service and she would pay 75% of that. She found out, they agreed and she saved 50K. She probably could have saved more if she wanted to be aggressive.

Even PPO contractors often bill a ridiculous fee they know they will never get paid on. Then they complain that their collection rate is below 50%. They are probably collecting 70-80% of the "real number".