Jan 5, 2022
By MATTHEW HOLT
I went for an annual physical with my doctor at One Medical in December. OK it wasn’t actually annual as the last time I went was 2 & 1/2 years ago, but it was covered under the ACA, and my doc Andrew Diamond was bugging me because I’m old & fat. So in I went.
I had a general exam and great chat for about 45 minutes. Then I had blood work & labs (cholesterol, A1C, etc) and a TDAP vaccination as it had been more than 10 years since I’d had one.
Today, about one month later, I got an email asking me to pay One Medical. So being a difficult human, I thought I would go through the process and see how much a consumer can be expected to understand about what they should pay.
Here’s the email from One Medical saying, “you owe us money.”
When I clicked the “Make a Payment” button, I got this screen
It told me I owe $7 and change, and asked for my credit card. Why? Who knows?
So I clicked the “Account details” button in the corner –assuming that it would ask me to log in to One Medical’s site. But instead it sent me to a screen asking me to send myself a code. Although it did it in a messy way, saying “null null”
When I clicked on “null null” it did show me my phone number and enabled me to select it and to send myself a code. Why that step was needed I’m not sure. Security? To stop someone else paying my bill that they already showed me?
It now sends me to the actual page on a site called “Patientops” which has the details. Now it gets interesting. Or maybe not….
It showed me that I got charged for a blood draw (I know that because I can google what a Venipuncture is!). One Medical charged $15 and I owe $7.49.
But what about the billing for all those other aspects of the visit? You’d never know from One Medical’s site but of course I can go to my insurer, which happens to be Blue Cross Blue Shield of Massachusetts.
After a bit of navigation I find the claim for my appointment at One Medical. Here’s the summary
And here’s the breakdown by services.
It tells me that One Medical billed $975 and BCBS Mass nicely agreed to pay them $781 — which ain’t much of a markdown! And it does tell me that there were 4 different medical services. But there’s no way for me to know which was what. So much for online transparency
But wait. With a little bit of attention and hunting around the site, I can also download the EOB. You know, the multi page impenetrable document that health insurers send out that says THIS IS NOT A BILL on it. So I did that.
Below is a snip from the 6 page PDF of the EOB.
Just to confuse you further it tells me that BCBS Mass allowed $882 out of a total billed of $1,365 –and yes I owe $108 against my deductible which presumably was for services not mandated as preventive care under the ACA. (More on that to come). Given One Medical only billed them $975, I’m wondering where the $390 came from?
For that you need to go another 3 pages deep into the PDF of the EOB, and then you finally get some information. Yes, BCBS Mass has bundled all my health expenses for December together, including the labs generated in the visit to One Medical and a completely separate visit to my chiropractor. (My chiropractor is the most excellent Taylor Rabbetz who I highly recommend if you are in search of one in San Francisco and whose office is incidentally the next block over from One Medical’s in the Embarcadero).
Here you can see the details of all the parts of the visits.
One Medical charged $660 for the office visit for which BCBCS Mass paid $530. (Don’t worry Andrew Diamond is well worth it, but they’re still paying him a pretty decent hourly rate!). My Tdap vaccine was billed at $160 and BCBS Mass paid $153–which seems quite a lot given Goodrx will get it to you for around $55 at a pharmacy! There were “Other Medical Services” billed at $140 for which BCBS Mass paid $90 — I have no idea what those were, and there was no CPT code given so I have no way to figure it out. Finally that blood draw for the lab test was $15, for which BCBS Mass got a discount of $7.51, leaving me with a bill of $7.49. I guess lab tests and draws don’t count under “preventative care” while immunizations do. Hence that’s the $7.49 which started me off on this whole quest.
But wait there’s more. The poor chiropractor billed $120 and got a measly $57 for his efforts (which of course I paid, as it was under the deductible). Somehow BCBS is discounting that at 50% while One Medical is getting 90% of its billing. So my chiro has to see 10 times the number of patients in an hour that One Medical’s PCPs do to bring in the same amount of cash.
Then there’s the lab tests themselves–also apparently not covered under the ACA even though they are arguably the most important part of “preventative” care. I haven’t got the bill from Labcorp but now I know what is coming. Their bill was somehow broken up into 4 different tests. Again I can’t tell which was which, but I actually had CBC, lipid, A1C, uric acid and also Fecal Occult Blood (although that was a take home test which I delivered later so may not have been on this bill). But the most amazing part was that they billed $270 and only got $43. So while One Medical got about 90% of its demands and the chiro got 50%, the poor teeny lab corporation (OK, not teeny) only got about 15%. And yes I’ll have to pay them their $43 when they get round to billing me.
Which all leads me to a few conclusions:
Six years after Health 2.0 & Mad*Pow ran a challenge with ONC, AARP & RWJF called A Bill You Can Understand there is still no such thing for most of us. I mean other than a nerdy curmudgeon like me, who the hell is going to go through all the trouble I just did? And even so there’s no information like CPT codes to really track down what happened.
There seems to be no relationship between time spent or services delivered and payment. Yes my chiro spent 15 mins with me and my PCP 45 but what’s the logic in a 10 fold difference in payment?
There’s also no relationship between “charge” and “payment” — I mean that’s been known for decades. But still, why is One Medical getting 90% of charges and LabCorp only getting 15%?
There seems little logic about what is actually paid for as preventative care as mandated by the ACA. Here’s the official list of what is covered. It includes cholesterol screening yet BCBS Mass thinks I owe for that, and I also pay for the blood draw–tough to imagine getting my LDL et al checked without one! (Sorry, Elizabeth Holmes!). I should also get free diabetes screening, yet I am being charged for the A1c test. The immunization, though, is on the list and yes that was paid for in full.
The only way out of this would seem to be a uniform fee schedule. And my guess is that we’re not getting that any time soon. But otherwise the consumer has basically no chance figuring this all out. Remember this not so simple billing experience was for a routine check up! Heaven knows what it’s like for patients with complex conditions!
Oh yes, I’m off to pay One Medical their $7.49 whether or not I really owe it. Given their recent stock price, they might need it!
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Original Article: thehealthcareblog.com