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Pratter.us is your one-stop place to search all outpatient costs in the US. Keep up to date on the latest developments and enjoy stories from Pratter users here on our blog.

Your Employed Physician

by Bill Hennessey M.D.
Thursday, July 23, 2015

Most people believe their physicians send them to the best place for care. Think again. Half of the 900,000 physicians in our country are employed by hospitals where the CEO tells them where to send patients – their hospital and nowhere else. It’s worse in the Pittsburgh market where Pratter is located, where 75% of physicians are employed by hospitals.

Here’s how it works. The hospital administration tells the physician where to send his or her patients. There are hospital employees paid to track where doctors send patients for care. This is also tracked by the electronic medical record (EMR). A physician is required to electronically place an order for a test, such as an MRI, in the EMR. The only option listed within a hospital EMR is the physician’s hospital MRI facility, the most expensive MRI in the region.

If a hospital-employed physician chose to send a patient outside his or her hospital system for an MRI in the above example, the EMR would require the physician to answer more questions. The EMR would “red flag” this physician for referring outside the hospital system that employed him or her. Doctors can be reprimanded and even fired for sending a patient outside their place of employment. After all, why do you think the hospital bought the doctor’s practice? The answer is to control patient flow by having patients stay within their hospital system, at any cost to you, even if it bankrupts you, to enhance hospital revenue.

Now that it is 2015, you are no longer a patient. You are a health care consumer with significant out-of-pocket expenses. Although you can trust your doctor with your physical health, you literally cannot afford to trust your doctor with your financial health.

Use Pratter.us and our medical billing staff to help you understand that you have multiple excellent options for medical care (hospitals, surgery centers, imaging centers and blood work centers) when your primary care physician orders a medical test.

Shop Smart for Health Care: Blood Work

by Bill Hennessey M.D.
Thursday, February 12, 2015

1. Become an educated consumer. Take ownership in your health care dollar and understand why you were referred to one place over another. Ask your doctor if he or she is required by his or her employer or financially incentivized to send you to a particular medical facility for testing.

2. Look up your blood work test on www.pratter.us. This will display your cost options and locations. Excellent results will be nationwide will be available by April 2015. If Pratter does not have results in your area yet, look up “blood work lab” or “blood work centers” in your hometown.

3. Know your blood work lab options:
a) independent blood work centers (e.g.

  • QuestDiagnostics,
  • LabCorp
  • Med Health Services
  • Walgreens

b) hospitals.

4. Call the blood work labs.  Ask for the medical billing department or person to get charges from both hospital and non-hospital options. Ask for 1) the total cost in case you have a high deductible insurance plan and have to pay the entire amount or in case your health insurance company denies your claim and ask for 2) your out-of-pocket cost for your particular insurance plan, assuming it covers your medical test.

5. Call your health insurance company. Immediately ask for the first name, last name and case reference number of the person providing you your cost answers. This will enhance accountability and service. Ask what your expected out-of-pocket expense will be at the blood work labs of your choice given your insurance coverage. Remember, you still have to call the blood work labs for their total charges, because if your claim is denied, that total charge becomes your bill!

6. Take your prescription to the blood work lab. Ask for a copy of your blood work to be mailed to you. This should be done at no charge to you.  Your blood work results are automatically sent to your ordering doctor listed on the prescription.

Do not accept the excuse that you “must” go to a certain blood work lab in order to have your results be part of an electronic medical record.  Most blood work lab results can easily be integrated into the electronic medical record (EMR), and, if not, then scanned into your EMR at the doctor’s office.

*Note: This is as simple as it gets until Pratter Plus – a health care cost consumer solution coming out later this year. The most difficult thing to do for now is to not know the cost of your care – before you buy it – and figuring out how to deal with the sticker shock!

 

Shop Smart for Health Care: Imaging Studies

by Bill Hennessey M.D.
Tuesday, February 3, 2015

1. Become an educated consumer. Take ownership in your health care dollar and understand why you were referred to one place over another. Ask your doctor if he or she is required by his or her employer or financially incentivized to send you to a particular medical facility for testing.

2. Look up your imaging study on www.pratter.us. This will display your cost options and locations. If Pratter does not have results in your area yet, look up “imaging center” or “MRI centers” in your hometown.

3. Know your imaging study (e.g. x-rays, CTs and MRIs) options:
a) independent imaging centers
b) hospitals.

4. Call the imaging centers. Ask for the medical billing department or person to get charges from both hospital and non-hospital options. Ask for 1) the total cost in case you have a high deductible insurance plan and have to pay the entire amount or in case your health insurance company denies your claim and ask for 2) your out-of-pocket cost for your particular insurance plan, assuming it covers your medical test.

5. Call your health insurance company. Immediately ask for the first name, last name and case reference number of the person providing you your cost answers. This will enhance accountability and service. Ask what your expected out-of-pocket expense will be at the imaging center of your choice given your insurance coverage. Remember, you still have to call the imaging study centers for their total charges, because if your claim is denied, that total charge becomes your bill!

6. Take your prescription to the imaging study center. Ask for a copy of your image to be provided to you on a disk. This should be done at no charge to you. You can then let your doctor view the images from your disk.  Alwasy get the disk back and keep it with your health care records.

Do not accept the excuse that you “must” go to a certain imaging center in order to have your results be part of an electronic medical record. Most imaging center results can easily be integrated into the electronic medical record (EMR), and, if not, then the report can be scanned into your EMR at the doctor’s office.

*Note: This is as simple as it gets until Pratter Plus -- a health care cost consumer solution coming out later this year.  The most difficult thing to do for now is to not know the cost of your care - before you buy it - and figuring out how to deal with the sticker shock!

 

 

Shop Smart for Health Care: Elective Medical Procedures

by Bill Hennessey M.D.
Tuesday, February 3, 2015

Examples: Colonoscopies and carpal tunnel release surgeries

1. Become an educated consumer. Take ownership in your health care dollar and understand why you were referred to one place over another. Ask your doctor if he or she is required by his or her employer or financially incentivized to send you to a particular medical facility for testing.

2. Verify that your physician is board certified. Look up your physician to verify board certification status at http://www.certificationmatters.org.   You may also call the American Board of Medical Specialties (ABMS) Certification Verification Service toll-free at 1-866-ASK-ABMS (275-2267). Operators can assist you in confirming a physician’s certification.

3. Know your elective medical procedure location options:
a) independent ambulatory surgery centers
b) hospitals
c) hospital-owned ambulatory surgery centers

Note: Hospital-owned surgery centers charge the same amount for their medical care facility fee as hospitals. The medical facility fee is higher at hospitals.

4. Call the surgery center and hospital.  Ask if the surgery center is owned by the hospital. Ask for the medical billing department or person to get for prices from both hospital and non-hospital options. As of now, you will not be able to get a packaged fee (i.e., a price tag) for a procedure. Therefore, ask for the two easiest to get and largest expense components: 1) the physician specialist fee and 2) the medical facility fee (this one is always the highest).

For example, a colonoscopy has a gastroenterology fee, a GI surgical tray fee, an anesthesia fee, anesthesia medicine fee and a medical facility fee. As of now in 2015, hospitals and surgery centers are not providing all-inclusive pricing.  Knowing the couple highest fees will provide you with the knowledge of which medical facility costs more and which one costs less.

Ask for 1) the total cost in case you have a high deductible insurance plan and have to pay the entire amount or in case your health insurance company denies your claim and ask for 2) your out-of-pocket cost for your particular insurance plan, assuming it covers your medical test.

5. Call your health insurance company. Immediately ask for the first name, last name and case reference number of the person providing you your cost answers. This will enhance accountability and service. Ask what your expected out-of-pocket expense will be at the surgery center or hospital of your choice for 1) the physician specialist fee and 2) the medical facility fee given your insurance coverage. Remember, you still have to call the surgery centers and hospitals for their total charges, because if your claim is denied, that total charge becomes your bill!

6. Inform your primary care physician where you want your elective medical procedure. Your doctor can set up the appointment and the reason for the procedure with your doctor of choice and at your medical facility of choice once you know where you want it done.

The value you receive for your hard earned dollar means considering both cost and quality. Quality can be assessed by considering board certification status, doctor training location, years of experience, volume of procedures performed, number of published research studies, published outcomes and, of course, word of mouth recommendations like all other aspects of consumerism.

*Note: This is as simple as it gets until Pratter Plus – a health care cost consumer solution coming out later this year. The most difficult thing to do for now is to not know the cost of your care – before you buy it – and figuring out how to deal with the sticker shock!

 

Pratter Position Statements on Medical Cost Transparency

by Bill Hennessey M.D.
Wednesday, October 15, 2014

The Pratter team has heard all of the excuses as to why medical cost transparency is not possible. These excuses by some medical facilities are offered to protect their business profit model embedded in a veil of pricing secrecy. Our company’s website is living proof that not only is it possible but we have accomplished it. Pratter.us has the answers to make medical cost transparency a reality now!

First excuse: Medical cost transparency is too difficult to compare apples-to-apples because one medical institution’s heart failure and cancer patients are sicker than another medical institution’s patients with the same diagnoses. Therefore, pricing doesn’t reflect the sickness of the patient population.

Pratter.us response: 95% of medical care received in one’s lifetime is outpatient-based. This means that there are no hospitalizations. Outpatient medical care can and should be cost compared. A cholesterol level or MRI via the same medical equipment at different medical facilities should not have prices that vary across the country more than a new car – but they do. A simple outpatient procedure such as carpal tunnel surgery or a colonoscopy requires a fixed amount of time in similar medical settings and again can and should be cost compared. An unfortunate person diagnosed with cancer will quickly go through a $5,000 high deductible health insurance policy and thereby eliminate the need for medical shopping. For the majority of America looking to stay healthy, seek preventable care and treat small medical problems early, becoming a health care consumer is vital a household’s financial stability.

Second excuse: Medical facilities are not allowed to publish their medical costs because their negotiated contract rates for payment of medical services by an insurance company has a confidentiality clause.

Pratter.us response: The first half of this statement is false. The second half is true. Insurance companies do make the medical facilities that they deal with for a health care provider network sign a confidentiality clause in regard to reimbursement rates. Hospitals and surgery centers would have adverse financial and legal consequences thrust upon them if they published insurance company reimbursement rates. However, hospitals, surgery centers, imaging centers and lab centers are permitted, encouraged and should provide their medical charges for all services for their communities. According to Pratter.us, the fair market price for a medical test is the average reimbursement amount by the most common insurance carriers in the region.

For example, if a medical facility charged $2,000 for a lumbar spine MRI yet the average insurance reimbursement was $1,000 as payment in full for an individual with excellent health insurance coverage, $1,000 becomes the fair market value and a $1,000 price tag should be assigned to a lumbar spine MRI posted by that facility on Pratter.us to best serve its community. If $1,000 is considered as payment in full in this example, it should be considered as payment in full for all parties and not just insurance carriers. Individuals should not have to bear the burden of a $2,000 charge as punishment for not having an excellent insurance policy they cannot afford particularly when the medical facility’s business revenue and profit model is based off insurance company reimbursement rates.

Third excuse: It would take too long and too much effort to calculate and post medical prices online. In addition, we don’t have the medical cost and billing software expertise to do this.

Pratter.us response: Pratter.us is not asking medical providers to make public what they don’t already have in hand. All medical facilities and providers have a charge master, most often in an Excel spread sheet format. Each and every medical test has a unique five digit billing code that is standard in all 50 states. In terms of posting costs, Pratter.us has a secure portal with medical line item by line item test name with proper billing code adjacent to it. One medical biller or CFO can enter the medical test or procedure cost on each line. Cost search results would immediately be available.

Fourth excuse: Listing a medical cost for a procedure is not fair because it does not reflect the value of our service because we do it better and should be able to charge more than other medical facilities in our community.

Pratter.us response: Pratter.us is not meant to be all things to all people. Cost is a consideration in all other aspects of consumerism. Health care consumerism is here to stay as the cost burden has shifted to individuals bearing greater medical costs. If a person goes to buy a car, he or she is well aware of the good price for the desired vehicle via online searching. Quality assessment is based on other factors such as personal experience, word of mouth recommendation, review articles and consumer education by the car dealership. This process applies to all purchases and health care should be no exception.

Fifth excuse: Our medical facility has been able to charge more and get reimbursed more because we have more overhead. Therefore, if we post our medical prices online, we would lose market share.

Pratter.us response: Reduce your overhead or lose market share. Pratter.us’ mission is to provide actual medical costs to health care consumers and reward medical facilities with cost effective, quality medical care. Medical facilities that refuse to post their charges on Pratter.us have one thing to hide – high prices. We believe that the majority of medical care providers are about to tout their value based upon pricing and performance and we welcome all to our platform.