My wife was sick a few weekends ago so I took her to the Beth Israel Deaconess Medical Center’s urgent care clinic in Chestnut Hill, Massachusetts, where they diagnosed her with the flu. Nice, modern facility. In network. Convenient parking. You get the idea. Care was good, but slow.
Then, a few days ago, I received an explanation of benefits from my health plan.
Behavioral Health, Interoperability and eConsent: Meeting the Demands of CMS Final Rule Compliance
In a webinar on April 16 at 1pm ET, Aneesh Chopra will moderate a discussion with executives from DocuSign, Velatura, and behavioral health providers on eConsent, health information exchange and compliance with the CMS Final Rule on interoperability.
One reason to go to urgent care is that it’s more cost-effective than the emergency room. In this case BIDMC sent Blue Cross Blue Shield a bill for $1,328. Blue Cross marked it down to $365.81, subtracted our co-pay ($35) and deductible ($231.68) and sent BIDCM payment for a whopping $99.13.
In looking at the bill, I was most struck by a couple line items. “Microbiology/lab” was billed at $202 and reimbursed at $26.48, or 13 percent. And “Technical Component” (maybe for an ultrasound?) was billed at $427 and paid at $22.33, or 5 percent.
Although medical charges (i.e., what’s billed) are known to be detached from reality, I found this EOB particularly galling. How can I explain my visceral reaction, especially to the $427 charge being reimbursed at $22.33?
- If something is billed for $427 but reimbursed at just $22, it seems that BIDMC is overcharging or Blue Cross is underpaying. Or is it both?
- What happens to the poor schlub who’s out of network, or worse, lacks insurance? Is the $427 from rare patients like that – who pay 20 times what Blue Cross pays – accounting for more than 100 percent of the center’s profits?
- Is what I see on the EOB actually the economic reality behind the transaction? Or is BIDMC or my wife’s BIDMC practice being paid a capitated amount for her care and is this bill only meaningful for calculating our cost?
- What is a patient who’s interested in “transparency” and “cost effectiveness” supposed to think? Did we do the right thing by going to urgent care or not? I think it would have been a lot more useful to see a comparison between the actual urgent care visit cost and a hypothetical visit to the ER or physician office
A Deep-dive Into Specialty Pharma
A specialty drug is a class of prescription medications used to treat complex, chronic or rare medical conditions. Although this classification was originally intended to define the treatment of rare, also termed “orphan” diseases, affecting fewer than 200,000 people in the US, more recently, specialty drugs have emerged as the cornerstone of treatment for chronic and complex diseases such as cancer, autoimmune conditions, diabetes, hepatitis C, and HIV/AIDS.
OK, I’m feeling a little better now.
Photo: Bigstock
