If you break your arm, broken arms are suddenly at the top of your list of least favorite subjects. But after the arm gets better, the billing process for the arm-fixing services is probably pretty high on the list.
Medical billing is something too many of us are way more familiar with than we'd like, but nonetheless will serve as an excellent first subject for this series on the business of medicine.
Let’s start by putting medical system billing in perspective.
Going to a hospital or doctor to get a service is in most ways like going to any place and getting a service.
- You’re hungry, you go to a restaurant and get a meal.
- You’re shaggy, you go to a barber or salon and get a cut.
- You’re bored, you go to a movie or show and get entertained.
- You’re bored and hungry, you go a bar with a show
- You need a book or chair or laundry detergent, you go to the appropriate store.
- For most of the above, you just go. Sometimes, when the service is popular, it pays to make a reservation. You call or do it online, and your space at the place is assured.
A pattern is clear here. When you need something, you go to the place that has, does or serves that thing and you get it. Pretty simple, and universal. Same thing with medical issues!
- You broke your leg, you go to the hospital and get it fixed.
- Your skin gets weird and painful, you go to the doctor and get it checked out.
But there’s something really important that I’ve left out of the above list; I suspect you know what it is. Let’s see if you’ve guessed what it is. I’ll wait and give you some time. Click … click … click … OK, time’s up! Did you get it? You probably did, but just in case, here’s the answer:
The billing and payment are totally different! And the scheduling/reservations are often a nightmare!
Here's how it works for nearly everything:
- For the movie, the price is posted, you pay when you enter.
- For the restaurant, salon, and retail store, you choose from a menu or list or wander around picking things, and pay when you leave based on the services/goods you got.
- For the bar with show, you pay the cover charge when you enter, and your bar tab when you’re done drinking/eating.
- For all of these, you can pay with cash or card. The card could be a credit card, which enables you to pay later or make payments.
Now, let’s look at the big exception: medical billing.
- If it’s an emergency, you might go to the ER and wait for hours.
- If not, making that “reservation” may require a “pre-auth” and a variety of other things that are often painful, and sometimes denied.
- You don’t pay when you enter.
- There are no posted prices, unlike the salon or movie. No menu. No price tags.
- Some stores let you special order things, sometimes one-of-a-kind. Before getting it, you get a price and make a payment arrangement. Not in medicine!
- There is no “check-out register” where you find out what the total comes to.
- Unlike a restaurant, where no one has any idea what food and services you’ll receive when you walk in, there is no bill at the end.
- In medicine, it’s common to leave after services have been rendered, and eventually a flurry of bills may arrive from different places and/or notices from insurance wanting information or telling you what’s been “covered” and what they’ll pay.
Go. Get services. Leave. They're all the same. Schedule it and pay for it: it's totally different in medicine!
- “I broke my leg” is like going into a car repair shop knowing you want it fixed, but not being able to do it yourself or knowing what it will cost. It’s your only car, so it’s got to get fixed.
- The car place tells you about what it will cost and you agree to pay when done. Not so at the leg fixing place!
- Bills from the ER and a couple doctors could show up over the next couple of months, with lots of fine print. The insurance company probably joins the fun with multiple pages.There's loads of stuff that has no counterpart in the real world of product and service buying.
- “I have funny skin” is like going into a salon knowing your hair and makeup just doesn't work for you, and you don't know what to do. You need a new "look" and need help and advice. After a discussion you might look at some pictures and try a couple things out. A specialist may need to be called over.
- You get your new look and pay for the products and services on the way out of the salon. Not so at the skin fixing place!
- There might be "co-pays" that you owe someone, or maybe not if they're "in network." Letters about any "coverage" some family member may or may not have. Not to mention surprise bills. Nothing that any salon of any kind would ever try if they wanted to keep their customers.
All of this is bad. Really bad. It's terrible for patients, terrible for medical people and institutions, and no fun at all for insurance companies. Believe it or not, the behind-the-scenes, underlying reality is even worse! Which is part of why it doesn't get better.
In the later posts in this series, I will go into specifics with real-life examples. In each case, while there are clearly systemic barriers to improvement, there is a clear path to improvement.
Among the issues I'll cover are these:
- The delay between the service and the bill
- Bills from different places
- The difference between provider billing and insurer paying
- What service was provided, where and by whom?
- The challenge of paying the bill
This is going to be fun!
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