As a patient, this is the story of an annual wellness visit served with misdirection and confusion. To the rest of the system, this was just a day in healthcare.
Each year, I visit the dermatologist for an annual wellness visit. They typically cost me nothing out-of-pocket as my insurance has always covered preventative care. Eight weeks later I was staring sideways at a stack of $800 in out-of-pocket of medical bills.
Words matter a great deal in the context of doctors, insurance, and healthcare — specifically when it comes to “coverage”. In the end, this experience was frustrating and expensive. But it also prompted a question that our team stewed on for months, and one that today sets our direction and mission for Lumedic:
In our personal healthcare journeys, who is equipped and/or incentivized to provide financial advise that truly serves the patient?
Here’s my short story.
In 2017, I went to my dermatologist for my annual wellness visit (considered preventative care). Same insurance, same doctor, same coverage as the years before. During the exam, the doctor spotted something he didn’t like, and a biopsy and phone call later he recommended a preventative procedure to remove a suspicious mole.
“Likely nothing to worry about, but I’d recommend taking care of it as a preventative measure.” — Doctor
Preventative, that’s great! My insurance card literally stated “100% Preventative Covered”. In conversation with the billing department a few days later to review insurance ahead of the procedure,
“I assume this is covered by my insurance?” — Me
“Yes, you’re all set, you’re covered” — Dermatology Billing
“Great, let’s do this” — Me
A few weeks after the procedure, bills start showing up in the mail.
- Lab Bill — initial biopsy tissue exam — $150
- Outpatient Procedure — removal of more tissue — $276 + $20 copay
- Lab Bill — Examine second tissue — $172
- Follow-up Exam — Exam + Suture Removal — $150 + $20 copay
$788 in out of pocket costs later, what happened to “100% Preventative Covered?!”
100% Preventative Covered
It turns out this meant the wellness visit; nothing more. It did not cover the subsequent preventative procedure my dermatologist recommended to remove the pesky mole, the lab bills, or the suture removal. That label on top of my insurance card meant something more along the lines of, “no cover charge for you today, but you’ll still need to pay for your drinks at the bar.” The billing department did not help clarify the actual meaning of the phase, nor did I specifically ask to confirm it. Seemed self-explanatory to an unsuspecting patient!
Confirming with my dermatologist that the procedure was ‘covered’, was too vague. The billing department later clarified that, “Yes, your insurance is going to cover this.” really meant, “Yes, your insurance is going to cover this procedure subject to deductibles and your current insurance accumulator based on your plan.”
Had I realized this was going to result in an out-of-pocket-cost (other than my co-pays), I would have asked more questions like, “how much will this actually cost me?” I followed up with the billing department and asked how to prevent this in the future. Here’s what they said:
- Step 1 — Call the dermatologist office, ask for CPT codes of the scheduled procedure prior to the appointment
- Step 2 — Call my insurance, wait on hold, provide CPT codes and dermatologist information
- Step 3 — Insurance will look up the CPT code pricing based on the agreed fee schedule with my dermatologist
- Step 4 — Insurance runs those costs against my current calendar year insurance plan
- Step 5 — Insurance determines whether I’ve hit my deductible or out-of-pocket-max (plan dependent)
- Step 6 — Insurance can then share over the phone what the estimated out-of-pocket cost should be for me
Even with this maze complete, I would have only been provided the estimate for the procedure itself, not the corresponding lab diagnostics that went with it. That’s a whole other issue with in and out of network diagnostics that I won’t get into for simplicity.
The Bottom Line
This was an elective, non-life threatening procedure. It could have waited.
In 2017 my family was relatively light on healthcare encounters, we were well below our deductible limit in November when I had the outpatient procedure. Insurance accruals and deductibles reset at end of the calendar year. And we were expecting our third child in January. That meant big healthcare costs were coming.
If we had had better information about the true cost of my elective procedure, and the knowledge needed to make a smarter financial care decision at the time, we could have delayed these elective, non-life threatening expenses by two months and saved $640. That’s because the procedure would have been subject to my 80/20 co-insurance (post baby arrival) reducing my out-of-pocket cost by $640. That’s $640 lost due to a lack of information.
With an insurance card that read: “100% preventative covered” and a dermatology billing department that confirmed the procedure was covered by my plan, I felt truly misguided as a patient. I expected to pay nothing more than a couple of co-pays in all of this. Words matter a great deal in the world of the US healthcare system, and even well-informed patients are not inherently privy to the lingo.
As a patient, I trusted my doctor to make recommendations that were in the best interest of my health. And I trusted my physician’s billing department to help me navigate the financial aspects of paying for a recommended procedure. In my case, it was a mole. But for others, it can be much worse and more difficult to manage — let alone figure out the out-of-pocket costs of treating.
No one that I’m aware of in my family’s healthcare ecosystem is equipped or incentivized to advise us on the financial considerations of our care decisions. Perhaps the reason is because the only properly incentivized actor in this situation is the patient himself. Delaying my procedure for two months would delay $800 in revenue for my dermatologist and it would shift $640 in responsibility to my insurance.
Looking back, the deck seemed stacked. And as the patient, I lost.
It’s 2018, and this was just 12 months ago at a newer Seattle dermatology clinic. I imagine the variations of this story that play out every day in our healthcare system are extensive. Yet this is the story among many that helps set our purpose as Lumedic.
It’s time to make the experience of healthcare better for patients, one wellness visit at a time.