Like the scarecrow, I lack the intelligence to fully comprehend the nature of my malady and what it holds in store as it progresses. Like the tin man, I lack the heart to emotionally prepare myself for the future. And like the cowardly lion, I undertake this odyssey and min-odyssey to UVA with no small amount of trepidation and foreboding.
I never realized, after watching the Wizard of Oz so many times over decades, that, for me, the Emerald City lies in Charlottesville, VA. This morning, Monday, November 23, 2015, Mari Jo and I embark on the Yellow Brick Road, more formally known as Interstate 81 through the Shenandoah Valley, to visit the Great Oz of LGLL. The Great Oz has a name, Dr. Thomas P. Loughran, who, without flames, smoke, curtains and other fanfare, rules the LGLL world from on high at the Emily Couric Cancer Center. Through him, I hope to find the wisdom, the heart and the courage to better prepare myself for the next 10+ years of my life as an LGLL pilgrim.
About Me
- Wayne Turner
- I was born, raised and went to school in eastern NC. Too immature at 17 to comprehend the seriousness of university life, I dropped out after two years and joined the Air Force. I spent two years of my four year military career in Germany, which I enjoyed immensely. I completed my Bachelor's Degree at Guilford College in 1985. My first career was in the computer field where I did everything short of design one. I've spent the last 30 years in the environmental field working for local governments. In December 2017 I retired from full time work. My overdeveloped sense of fairness and justice lands me on the liberal side in my political views. I think government plays a large role in social responsibility in a civilized state. I believe in the innate compassion and goodness in everyone despite the daily news reports to the contrary. My genetic predisposition for generosity in nearly all things is sometimes a source of future angst. I've been a musician and still have a deep love of music. I am naturally curious about all things especially metaphysics and science.
Health Care Economics: The Genesis of Physician Assisted Suicide
When's the last time you went into a store to buy something you really needed and proceeded to the check out not knowing how much it would cost until after you completed the purchase? More generally, when do you acquire a good or service without knowing the actual cost until after you've acquired it, also knowing in advance that there are no refunds or exchanges on the good or service? This real-world economic scenario is a mash-up of caveat emptor and que sera sera that would make drinking partners of John Keynes and Karl Marx.
The proverbial 'black box' formed by the confluence of the health care industry and the health insurance industry is the source of some of the most vexing purchase dilemmas one will ever face. The dearth of accessible information about the costs of diagnostic tests, lab work, hospital services and physician services related to health care is appalling, until after you've received the bills; at which time the bill itself is usually appalling. The time consumed attempting to discover that information is directly proportional to its importance and inversely proportional to its availability. My goal is to change this and in so doing my blog has another reason to exist. Maybe, in the not-so-distant future, some poor schmuck, when faced with the realities of dealing with medical costs and insurance, will stumble across my blog and shout "Eureka!" In some of the most extremely morbid cases, "Eureka!" may be followed by "holy shit!!", a self-inflicted fatal gunshot and a thud.
During my upcoming appointment with Dr. Loughran at UVA, I will have several diagnostic tests performed on my blood, two of which are very expensive, Flow Cytometry and Polymerase Chain Reaction (PCR). They are both important to determine exactly what type of leukemia I have. The flow cytometry test typically runs around $3,000 and the PCR around $750, according to informed sources and my own experiences. Since I am not obscenely wealthy I consider it prudent to know how much of the costs of all these services I will be responsible for paying out of pocket and how much insurance will cover before I go to this appointment. In addition to the costs for the blood tests, there will be facility charges from the UVA Medical Center and professional charges from Dr. Loughran. I have been informed that multiple claims will be filed against my insurance by several service providers.
Since the UVA Medical Center and Dr. Loughran are in-network providers under my Blue Cross Blue Shield (BCBS) health insurance plan, it is likely that a portion of the costs of all these services will be covered. My previous experience having some of these same services performed previously in July by two other in-network providers also gives me some intuition about what my share of the total costs may be. However, there are a couple of twists that muddy the waters. For one, I never received a bill from the provider that did the expensive flow cytometry test nor did I get an explanation of benefits (EOB) from BCBS showing that a claim had been filed for it. I'm not about to kick that sleeping dog and have it bite me in the ass! Caveat venditor suckas!! Second, this visit to UVA is sort of a 'second opinion' and I'm not sure if the services will be covered at the same level as they were previously. What if BCBS sends me an EOB stating that the tests were recently performed, not medically necessary and therefore the claim is denied? Under that scenario, I would be stuck with the entire bill. Given these unknowns, I set out to discover what my potential out-of-pocket costs would be for the trip to UVA. Trying to get a straight answer on exactly how much I will have to pay out-of-pocket is the portal to the black box, not unlike the entrance to hell in Dante's Inferno. "Abandon hope, all ye who enter here."
My first call was to BCBS to determine the likelihood of my worst case claim-denied scenario. Can I get a straight answer from BCBS about whether they would do this? No! In fact, when you make a call to discuss benefits or future claims, the last thing you hear from the recorded voice prior to being connected to a representative is, "Any information about benefits and eligibility provided to you during this call does not guarantee payment. Decisions about payment will be made when the claim is reviewed." Despite the specificity of the question, including providing medical procedure, current procedural terminology(CPT) codes, facility names, etc., BCBS has a blanket disclaimer that absolves them from any responsibility for paying a claim based on the conversation you have with one of their representatives. The most hopeful answer I got was "If the procedure is medically necessary as determined by your physician, then the claim should be paid based on your insurance plan's benefits." But, as the BCBS representative admitted, it all depends on how the provider's insurance and billing office codes the claim. When I asked the BCBS representative how should they code it for the particular test I was describing, she dissembled and said it is up to the provider's office. Cynically speaking, I've thought many times that provider's will code procedures to maximize their profit, which many times means insurance pays less and the patient pays more.
Next, and with no small amount of trepidation (plus the help of a BCBS insider) I did a Google search for the CPT codes for flow cytometry and voila!, I got a very useful hit that listed exactly what I needed to know. As it turns out, there are multiple CPT codes for the test, two of which are for the technical part of the test and the others for the pathologist's interpretation of the test results. For you hard-core data junkies here are the procedure codes and what they each mean.
88184 - Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; first marker
88185 - Flow cytometry, cytoplasmic, or nuclear marker, technical component only; each additional marker (List separately in addition to code for first marker)
88187 - Flow cytometry, interpretation; 2 - 8 markers
88188 - Flow cytometry, interpretation; 9 - 15 markers
88189 - Flow cytometry, interpretation; 16 or more markers
With my newfound wisdom, I referred to my EOB for the flow cytometry performed back in July and it showed a 88189 code on the claim. This means the pathologist interpreted 16 or more markers so the actual technical component of the test was for at least 16 markers. This was an exciting discovery, in a perverted sort of way. I made an assumption that my future flow test would be a combination of 88184, 88185 X 15 and 88189.
I next called the UVA Medical Center to ask how much the flow cytometry test would cost using the CPT codes I had discovered. This actually produced some intelligible results! The very nice lady, Laura, at the UVA Financial Assistance Office took down the information and said she would call me back with the cost. She also took my insurance information and said she could give me an expected out-of-pocket amount for the test. When she called back later in the day I was pleasantly surprised at the level of cost detail.
88184 = $242
88185 X 15 = $167 X 15 = $2,505
88189 = $260
Total = $3,007
Then, based on my insurance benefits and current remaining deductible, she came up with the following estimate:
Billed amount for the flow test = $3,007
BCBS allowed amount for test = $1,567
Remaining deductible = $288 (after which BCBCS will pick up 80% of costs
My out-of-pocket cost for flow = $288 + (0.2 X (1,567 - 288)) = $544.
This isn't as bad as I imagined but it's not like I have $544 laying about the house either. Throw in some other costs for more tests, facility and physician at 20% on top of that and I could easily be looking at nearly a grand for this visit, not including travel costs; none of which can be written off on taxes unless you spend at least 7.5% of your adjusted gross income on medical care. I don't think we're there for tax year 2015. The tax man taketh and the tax man taketh more!
The black box isn't as scary as it once was but I'll reserve final judgement after I receive the actual bills and EOBs from BCBS. Stay tuned!
The proverbial 'black box' formed by the confluence of the health care industry and the health insurance industry is the source of some of the most vexing purchase dilemmas one will ever face. The dearth of accessible information about the costs of diagnostic tests, lab work, hospital services and physician services related to health care is appalling, until after you've received the bills; at which time the bill itself is usually appalling. The time consumed attempting to discover that information is directly proportional to its importance and inversely proportional to its availability. My goal is to change this and in so doing my blog has another reason to exist. Maybe, in the not-so-distant future, some poor schmuck, when faced with the realities of dealing with medical costs and insurance, will stumble across my blog and shout "Eureka!" In some of the most extremely morbid cases, "Eureka!" may be followed by "holy shit!!", a self-inflicted fatal gunshot and a thud.
During my upcoming appointment with Dr. Loughran at UVA, I will have several diagnostic tests performed on my blood, two of which are very expensive, Flow Cytometry and Polymerase Chain Reaction (PCR). They are both important to determine exactly what type of leukemia I have. The flow cytometry test typically runs around $3,000 and the PCR around $750, according to informed sources and my own experiences. Since I am not obscenely wealthy I consider it prudent to know how much of the costs of all these services I will be responsible for paying out of pocket and how much insurance will cover before I go to this appointment. In addition to the costs for the blood tests, there will be facility charges from the UVA Medical Center and professional charges from Dr. Loughran. I have been informed that multiple claims will be filed against my insurance by several service providers.
Since the UVA Medical Center and Dr. Loughran are in-network providers under my Blue Cross Blue Shield (BCBS) health insurance plan, it is likely that a portion of the costs of all these services will be covered. My previous experience having some of these same services performed previously in July by two other in-network providers also gives me some intuition about what my share of the total costs may be. However, there are a couple of twists that muddy the waters. For one, I never received a bill from the provider that did the expensive flow cytometry test nor did I get an explanation of benefits (EOB) from BCBS showing that a claim had been filed for it. I'm not about to kick that sleeping dog and have it bite me in the ass! Caveat venditor suckas!! Second, this visit to UVA is sort of a 'second opinion' and I'm not sure if the services will be covered at the same level as they were previously. What if BCBS sends me an EOB stating that the tests were recently performed, not medically necessary and therefore the claim is denied? Under that scenario, I would be stuck with the entire bill. Given these unknowns, I set out to discover what my potential out-of-pocket costs would be for the trip to UVA. Trying to get a straight answer on exactly how much I will have to pay out-of-pocket is the portal to the black box, not unlike the entrance to hell in Dante's Inferno. "Abandon hope, all ye who enter here."
My first call was to BCBS to determine the likelihood of my worst case claim-denied scenario. Can I get a straight answer from BCBS about whether they would do this? No! In fact, when you make a call to discuss benefits or future claims, the last thing you hear from the recorded voice prior to being connected to a representative is, "Any information about benefits and eligibility provided to you during this call does not guarantee payment. Decisions about payment will be made when the claim is reviewed." Despite the specificity of the question, including providing medical procedure, current procedural terminology(CPT) codes, facility names, etc., BCBS has a blanket disclaimer that absolves them from any responsibility for paying a claim based on the conversation you have with one of their representatives. The most hopeful answer I got was "If the procedure is medically necessary as determined by your physician, then the claim should be paid based on your insurance plan's benefits." But, as the BCBS representative admitted, it all depends on how the provider's insurance and billing office codes the claim. When I asked the BCBS representative how should they code it for the particular test I was describing, she dissembled and said it is up to the provider's office. Cynically speaking, I've thought many times that provider's will code procedures to maximize their profit, which many times means insurance pays less and the patient pays more.
Next, and with no small amount of trepidation (plus the help of a BCBS insider) I did a Google search for the CPT codes for flow cytometry and voila!, I got a very useful hit that listed exactly what I needed to know. As it turns out, there are multiple CPT codes for the test, two of which are for the technical part of the test and the others for the pathologist's interpretation of the test results. For you hard-core data junkies here are the procedure codes and what they each mean.
88184 - Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; first marker
88185 - Flow cytometry, cytoplasmic, or nuclear marker, technical component only; each additional marker (List separately in addition to code for first marker)
88187 - Flow cytometry, interpretation; 2 - 8 markers
88188 - Flow cytometry, interpretation; 9 - 15 markers
88189 - Flow cytometry, interpretation; 16 or more markers
With my newfound wisdom, I referred to my EOB for the flow cytometry performed back in July and it showed a 88189 code on the claim. This means the pathologist interpreted 16 or more markers so the actual technical component of the test was for at least 16 markers. This was an exciting discovery, in a perverted sort of way. I made an assumption that my future flow test would be a combination of 88184, 88185 X 15 and 88189.
I next called the UVA Medical Center to ask how much the flow cytometry test would cost using the CPT codes I had discovered. This actually produced some intelligible results! The very nice lady, Laura, at the UVA Financial Assistance Office took down the information and said she would call me back with the cost. She also took my insurance information and said she could give me an expected out-of-pocket amount for the test. When she called back later in the day I was pleasantly surprised at the level of cost detail.
88184 = $242
88185 X 15 = $167 X 15 = $2,505
88189 = $260
Total = $3,007
Then, based on my insurance benefits and current remaining deductible, she came up with the following estimate:
Billed amount for the flow test = $3,007
BCBS allowed amount for test = $1,567
Remaining deductible = $288 (after which BCBCS will pick up 80% of costs
My out-of-pocket cost for flow = $288 + (0.2 X (1,567 - 288)) = $544.
This isn't as bad as I imagined but it's not like I have $544 laying about the house either. Throw in some other costs for more tests, facility and physician at 20% on top of that and I could easily be looking at nearly a grand for this visit, not including travel costs; none of which can be written off on taxes unless you spend at least 7.5% of your adjusted gross income on medical care. I don't think we're there for tax year 2015. The tax man taketh and the tax man taketh more!
The black box isn't as scary as it once was but I'll reserve final judgement after I receive the actual bills and EOBs from BCBS. Stay tuned!
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