I am sitting in the radiology department reception area at Mt. Sinai Hospital waiting for my name to be called. Two weeks ago, my doctor ordered a CT scan to explore some back pain she assumed would turn out to be an ovarian cyst or a stress fracture. Instead, it turned up kidney cancer.
Now, I am about to undergo a test to map out the topography and blood flow of my kidneys, which my surgeon will use to guide him to the lesion and safely remove it. When the nurse calls my name, I head up to the check-in desk.
"I'm sorry," she says as she lowers her eyes and hands me the phone.
On the other end of the line, a woman identifies herself as a "third-party intermediary" for my insurance company. She says she is calling to inform me that the procedure I am scheduled to have in just a few minutes has been approved and the facility I have selected is in network. However, my chosen provider is more expensive than other options and may result in a higher co-payment.
"You may cancel your test and reselect a cheaper provider," she tells me.
I am stunned. Then, I ask the obvious question: "If I stay, how much will it cost me?"
Her answer is that she is not authorized to give me that information and, no, she cannot tell me the price differential between staying and going somewhere else. For that, I will have to speak to my insurance company directly.
I decide to do just that. As the nurse behind the reception desk dials the number for me, she mentions how these third-party calls have been escalating in frequency.
"What do most people do?" I ask her.
"A lot of them hang up and walk out," she says.
I am disconnected from the electronic voice response system of the insurance "customer care" line twice before I finally reach a voice owned by an actual human. The representative uses a much less menacing tone than the third-party intermediary but admits he can't reveal my out-of-pocket responsibility, either. The best he can do is read from a script describing my benefits and provide an estimated average cost for the procedure. Except that my procedure isn't listed. So basically, he can't tell me anything.
State of Affairs
Welcome to the American health care system. If you're looking to sail off on a Kafkaesque journey, you've come to the right place. There is a separate rabbit hole for diagnosis, treatment, second opinions -- and above all else, cost of care. It's not like a restaurant where the prices are printed on the right hand side of the menu so you know what you're getting into. Even if you're lucky enough to have insurance -- which can cost more each month for a family of three than a mortgage -- it's virtually impossible to determine what you will pay to avail yourself of services that are necessary and, in many cases, lifesaving.
You can spend hours, as I have, trying to unravel the byzantine pricing arrangements put in place by insurance companies. A test can cost four times more when done in one hospital versus another, even when both are in network. And the same services delivered in the same facility are sometimes priced differently depending on your reason for seeking care. Recently, for example, a woman in Houston was billed $4,850 for a four-hour emergency room visit. When the hospital discovered her injuries were the result of a car accident, they jacked up the price to $20,211.
What Little You Can Do
In my experience, doctors try to help patients sort things out. But as one of my doctors admitted to me, he is having an increasingly difficult time navigating the system, himself. Just as we don't know what we are paying, your provider doesn't know what he is getting paid.
You can insist all of your providers, from your doctors to the labs who process your blood work, remain in network to help contain costs, then pray your request will be honored. (That's not always the case.)
You can repeatedly call your insurance carrier and demand answers. Ask for names to establish a modicum of accountability and, if you don't like what you hear, escalate the matter to a supervisor or hang up and call again. Trust me, the story often changes depending on who picks up the phone.
Some insurance companies have added cost predictor calculators to their websites to estimate bills. But because it's impossible to predict all of the variables, they frequently aren't accurate.
Carriers have also begun hiring on-staff advocates whose job it is to guide patients towards the best outcomes. But considering that their paychecks are signed by the insurance company, that's a bit like allowing the fox to tour the chickens through the hen house. Better to hire an independent advocate -- an expensive option, to be sure, but one that at least puts a champion in your corner and provides some peace of mind.
The Bottom Line
The advent of third-party intermediaries is a new wrinkle for health care consumers to deal with. By sucking what's left of accountability, logic and humanity out of the health care system, they will only expand the divide between patients and caregivers.
In my case, I hang up the phone, not knowing how much this procedure I need will set me back. I am forced to do a rapid analysis between cost of care and quality of care. It may be cheaper to have the test somewhere else -- no doubt the third-party intermediary believes it will be cheaper for my insurance company -- but I decide to stay where I am.
And when I get home that night, there is a letter from the very same third-party vendor telling me my test has been approved and is in network but this does not guarantee the charges will be covered.
Getting sick is scary. The uncertainty over the cost of getting sick is downright terrifying.