Three Common Financial Misconceptions in the Medical World
/Understanding the complexity of various medical expenses can be overwhelming for a patient. We medical professionals are patients too! Even for us, sometimes the numbers just don’t make sense. At Impact Sports Medicine and Orthopedics, our desire is to educate patients regarding the value of these office visits and procedures and their potential out-of-pocket costs, so that they can make informed decisions regarding their health care from both a medical and economic perspective.
Here are three common misconceptions when it comes to medical expenses:
If my physician is not in-network with my insurance company, my medical expenses will be higher: until patients meet their deductibles, they typically will pay out-of-pocket for office visits, diagnostic tests and procedures. The amount a patient pays can also depend on a patient’s out-of-network provisions in their plan and/or the amount an out-of-network provider chooses to bill the patient. Often an out-of-network provider will ask the patient to pay cash, and this amount can be and often is less than the contracted amount an in-network provider has with your insurance. Example: you have Insurance X, a plan that has accepted very few in-network physicians. You have not met your deductible and you see an in-network orthopedic specialist for a consult. You have an office visit and x-rays. Insurance X allows $150 for the office visit and $50 for the x-rays. You now owe that in-network physician $200. Alternatively, you see a provider at our practice as we are in-network with most insurance plans, but not with Insurance X. We charge you $120 for the office visit and $30 for x-rays. Thus, your bill with us is $150, a $50 savings compared to the in-network provider.
If a procedure is not covered by insurance, it will cost me more in the long run: as an example, let’s use a procedure such as a platelet-rich plasma (PRP) injection. PRP has been used in orthopedics for 15 years. It has never been covered by insurance (although it should be in certain circumstances…that’s a whole different conversation). You have stubborn plantar fasciitis. You’ve done all the typical treatments, but your heel still really hurts. You consult with a foot surgeon who offers an open or endoscopic plantar fascia release surgery. Guess what, your insurance covers this procedure! However, you have a $5000 deductible, and you are nowhere near meeting this. This surgery will have charges from the surgery center, the anesthesiologist and the foot surgeon. Let’s say that your total cost for this surgery is $3000 with a 75% success rate, a 4-month recovery and some risk of additional complications. Compare this to one or two PRP injections, with each injection costing you $800. PRP, in our opinion, will have similar success rates and recovery times with fewer complications. $1600 for PRP versus $3000 for the surgery, even though the surgery is “covered by insurance.”
When it comes to an office visit or the same procedure done at different practices, insurance companies pay or allow the same amount for each physician/practice: did you know that all practices, hospitals and other medical businesses have contracted rates of payments with private insurers (non-Medicare, non-Medicaid)? If a physician is part of a bigger organization such as a hospital or a large private practice, then that group typically has greater negotiating power and can obtain higher reimbursement rates from the insurance companies. These rates have nothing to do with the quality of medical care, the training or experience level of the providers or the success rates of their interventions. So, let’s say you see a physician associated with a hospital system. You haven’t met the deductible, and you are billed for a Level 4 new patient visit. Your insurance allows $200 for that visit to that provider. Alternately, your household family member sees a physician at a smaller practice like ours, also is billed for a Level 4 new patient visit, yet the same insurance only allows for $150 for that visit, even though the same level of care was provided. So, you owe $50 more to that hospital-based practice than your family member owes to the smaller private practice. Thus, it’s important to realize that often cost really does vary based on who you are seeing, and your cost is not associated with the quality of the care.
At Impact Sports Medicine, cost education and financial transparency are very important to the physician-patient relationship. We strive to provide the highest quality of care for a reasonable out-of-pocket cost to you.
F. Clarke Holmes, M.D.