This sounds about right. I've worked in the healthcare tech world for about 5 years on both sides (for providers and payors). I totally empathize with how annoying it is that essentially no one processes estimates for patients with insurance. There are some places though that do, and it tends to be small/medium size specialty practices (think orthopedics, ophthalmology, radiology) in forward thinking places (Seattle, Minneapolis, etc). I can give some technical reasons as to "why" they can't/won't give you an estimate. I'm not saying these are legitimate reasons, just stating what I've seen.
One reason they may not want to give you an estimate is because depending on what happens during your visit/procedure, the codes that get billed could change quite a bit. Because of this their initial estimate could be wildly different. In addition to the procedure codes changing, there are modifiers/adjustments that can get applied to a procedure code depending on what happens during the procedure (which adds another level of uncertainty). For example, anesthesia often bills based on time and complexity. If the procedure runs long then it will cost more, if something goes wrong and the complexity increases then it will cost more, if a nurse anesthetist (CRNA) does your anesthesia rather than an MD it will cost less, etc.
Another reason they may not want to give you an estimate is because they have no idea. This is in my experience the case most of the time. A given clinic/hospital is going to have many many contracts with many payors. There's a ton of nuance in these contracts and they are sometimes extremely complicated. I've read hundreds of these contracts and written software to try to scale price estimate tools for patients. It's really hard, happy to dive into it more if there's interest.
I often see comments on hackernews along the lines of "it's just a fee schedule, how hard is it to put it in a database and select amount from feeschedule where procedure = 99215". The big wrinkle here is the contracts. The contracts are often times super complicated, dependent on many many different fee schedules and pricing methodologies. The fee schedules/pricing methodologies may be from the payor, they may be from 3rd party vendors, they may be proprietary, they may be based on medicare, etc. Then there's a whole slew of adjustments/modifiers that can trigger depending on tons of different events and combinations of procedures codes that may appear on a claim.
Another reason they may not want to give you an estimate is because it's not straightforward to verify your insurance. There are clearinghouses that aggregate benefits data from major payors, but the data is kind of shoddy. It may return your insurance is active when it really is inactive. It may have bad data on what is covered vs not covered, what your deductible, coinsurance, etc are so given all this data is kind of unreliable then giving an estimate becomes pretty unreliable.
Anyway, these were a few reasons off the top of my head. Again, I want to emphasize I'm 100% with you on how annoying it is that we can't get estimates. I spent 3 years literally trying to solve this problem, and we actually made really good progress if it gives you any hope that things will maybe (fingers crossed) get better overtime. I just wanted to give some context / spark some conversation around these contracts and why they are challenging from a technical perspective to automate price estimates.
I had a contribution drafted, but lost it all. In summary:
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One reason they may not want to give you an estimate is because depending on what happens during your visit/procedure, the codes that get billed could change quite a bit. Because of this their initial estimate could be wildly different.
This is a common excuse given by industry. Its also BS. I want to put it out there so people know. Would you accept if an airline tried to charge you extra if because of weather they served you extra food? Or took you to a different airport ? No.
https://surgerycenterok.com/ has a price on every procedure. It never changes. How? Because they know that price changes are related to a problem doctor. You can reliably predict a problem doctor due to (a) surprise coding and (b) complications. Good doctors (and pilots) know their cases and plan accordingly.
>>>>>> Another reason they may not want to give you an estimate is because they have no idea.
This is true. They don't know because no one has bothered to translate a scheduled case into specific CPTs and/or looked up rates rates with insurer. So someone dropped the ball.
>>>>>>>>>I often see comments on hackernews along the lines of "it's just a fee schedule, how hard is it to put it in a database.
Actually, you are misinformed here. The vast majority of contracts for independent providers are simple affairs that are % of medicare rates. The only excuse they have for not putting those % rates in the open is that they have no incentive to do so. But its lazy. They could say to patients "our contract with X payor is % of medicare" and then even the patient could figure it out. They don't even do that. And patients suffer as a result. ASC and Hospitals have no excuse. Even with complex contracts, they have massive staff that can do the work.
>>>>>>>>..Another reason they may not want to give you an estimate is because it's not straightforward to verify your insurance.It may have bad data on what is covered vs not covered, what your deductible, coinsurance, etc are so given all this data is kind of unreliable then giving an estimate becomes pretty unreliable.
In my experience, some of the data fields are reliably accurate. For the rest, we are actually working on a solution. But let's not make perfect the enemy of the good. Its not hard to caveat a response like:
"Assuming all your procedures are covered by your plan, based on your remaining deductible of X and coinsurance of Y, your patient responsibility for this procedure is Z"
Its not rocket science. I do it all the time myself.
I appreciate the response, it sounds like we have some overlapping industry experiences where we've seen different things, which is interesting.
>>>>>>>>>> This is a common excuse given by industry. Its also BS.
Just to reiterate I'm not saying the reasons I gave are "good" reasons, it's more a statement of what's currently going on. I think the analogies are a little unfair but I agree with your overall point as it applies to elective procedures in certain settings. I think for emergent cases or complications the discussion gets more nuanced. The other point I'd make is that providers can't just decide to "simplify" the claim, the claim has to accurately reflect what occurred during the visit, so if things went sideways and other stuff was done then they need to document/bill for that because they are required to do so. There's also downstream reasons for this like reporting on quality/cost metrics and obviously if they bill for things that didn't occur that's fraud. Besides my anesthesia example, another clear example is an inpatient stay where you're billing an MS-DRG, you have to code in the severity of the case which is going to vary. And to reiterate, I think there are tons of clinicians that would love to move away from itemizing everything and doing something like surgerycenterok, but they are at the whim of the government (medicare/medicaid) and private insurance companies documentation requirements.
I'm aware of surgerycenterok, I'm a fan. Worth mentioning is they can't give pricing on anything done outside their purview (so imaging, labs, physical therapy, complications that send you elsewhere, etc). Definitely a step in the right direction. Side note there's quite a few places like this they just don't advertise it as openly.
>>>>>>>>>> This is true. They don't know because no one has bothered to translate a scheduled case into specific CPTs and/or looked up rates rates with insurer. So someone dropped the ball.
In my experience, payors are typically very uncooperative when making a request such as this. If you ask them any questions related to the contract/pricing they just tell you no.
>>>>>>>>>> Actually, you are misinformed here. The vast majority of contracts for independent providers are simple affairs that are % of medicare rates.
This is a tough one to swallow :) I'm going on ~5 years reading god knows how many of these contracts and writing software/doing analyses to enable practices to provide accurate pricing information. And if I didn't read the contract myself, I maintained/saw how it was implemented on the backend. This spanned small provider groups to the largest in the country, contracts from small payors to the largest in the country, and private/government contracts so I feel like my exposure is pretty well rounded to have a feel for things. But I could very well have a blindspot and we may also be talking about different things. Maybe you've mostly dealt with elective procedures at private practices where you mostly worry about professional fees? Or maybe you're alluding to the industry standard of comparing your contract to % of medicare to see if it's good or not? It's pretty common they'll say "oh we get paid 165% of medicare", but this is just in aggregate their contract may not even mention medicare.
This is interesting though because most contracts being % of medicare is the opposite of my experience. The vast majority have not been % of medicare (it may be a single component of their contract but there's much more to the terms). The handful of contracts that I saw that were truly just % of medicare were usually at smaller private practices in less competitive markets (eg some places in the Midwest). For what it's worth it's still not just % of medicare. There's an entire pricing methodology that underpins the "% of medicare" that is defined by medicare (eg depending on what else is on the claim there may be subsequent adjustments that trigger, then there's totally different rules/methods for different types of stays, etc). For example a really simple adjustment is a multiple procedure adjustment. Medicare publishes a list of procedures that qualify under this adjustment. If I get both my knees replaced and I bill for the procedure code twice I will not get paid the medicare rate times two. The second knee replacement will be adjusted 50% off. This is an extremely simple example but there's a whole slew of adjustments/nuance to the pricing methodologies, and then you add the fact that there's nothing preventing adjustments from stacking (unless the contract says they don't stack in certain situations). And I'm also just talking about the professional fee above.
All of the following were things I commonly encountered in contracts, all of which impacted the price estimates we generated: bill types like inpatient and outpatient were often very messy, handling different sites of service (clinic, asc, hospital, etc), various DRG standards, APCs, EAPGs, diagnosis codes, revenue codes, bundling agreements, modifiers, adjustments (multiple procedure, multiple radiology, multiple endoscopy, mid level provider, etc), carve outs, GPCI adjusted rates, different rules/schedules based on specialty, individual providers, location, 3rd party schedules, proprietary (meaning no one gets access / knows how it works) schedules and entire pricing methodologies that are a weird flavor of medicare pricing methodologies like 3M and optum, what quarter/year schedule is being referenced, what happens if a procedure isn't on the schedule do you grab the first time it appears in the future or the current year rates, is there a hierarchy of schedules to follow, fallback schedules, etc. To top it all off, frequently the contracts didn't outline many of the above nuances. They were assumptions made by the payor (not defined in the contract) that were only revealed until we asked them why our estimates were out of alignment.
This also doesn't even talk about the industry shift that is happening behind the scenes from fee for service to value based care. The value based care contracts I've seen only add an additional layer of complexity. How providers get reimbursed has been on a steep upward complexity curve since the 70s/80s (back when payment was based on Usual, Customary, and Reasonable charges). I would absolutely love to simplify things.
>>>>>>>>>> In my experience, some of the data fields are reliably accurate. For the rest, we are actually working on a solution. But let's not make perfect the enemy of the good.
Yeah, I would say it tended to be accurate, but when it was inaccurate and you then had a weird estimate and then an upset patient it was pretty frustrating for everyone involved. But I totally agree, that we shouldn't make perfect the enemy of the good. The other thing that was frustrating with the clearinghouses/payors was how frequently they'd have outages or the latency with someone's eligibility status if their plan changed.
One reason they may not want to give you an estimate is because depending on what happens during your visit/procedure, the codes that get billed could change quite a bit. Because of this their initial estimate could be wildly different. In addition to the procedure codes changing, there are modifiers/adjustments that can get applied to a procedure code depending on what happens during the procedure (which adds another level of uncertainty). For example, anesthesia often bills based on time and complexity. If the procedure runs long then it will cost more, if something goes wrong and the complexity increases then it will cost more, if a nurse anesthetist (CRNA) does your anesthesia rather than an MD it will cost less, etc.
Another reason they may not want to give you an estimate is because they have no idea. This is in my experience the case most of the time. A given clinic/hospital is going to have many many contracts with many payors. There's a ton of nuance in these contracts and they are sometimes extremely complicated. I've read hundreds of these contracts and written software to try to scale price estimate tools for patients. It's really hard, happy to dive into it more if there's interest.
I often see comments on hackernews along the lines of "it's just a fee schedule, how hard is it to put it in a database and select amount from feeschedule where procedure = 99215". The big wrinkle here is the contracts. The contracts are often times super complicated, dependent on many many different fee schedules and pricing methodologies. The fee schedules/pricing methodologies may be from the payor, they may be from 3rd party vendors, they may be proprietary, they may be based on medicare, etc. Then there's a whole slew of adjustments/modifiers that can trigger depending on tons of different events and combinations of procedures codes that may appear on a claim.
Another reason they may not want to give you an estimate is because it's not straightforward to verify your insurance. There are clearinghouses that aggregate benefits data from major payors, but the data is kind of shoddy. It may return your insurance is active when it really is inactive. It may have bad data on what is covered vs not covered, what your deductible, coinsurance, etc are so given all this data is kind of unreliable then giving an estimate becomes pretty unreliable.
Anyway, these were a few reasons off the top of my head. Again, I want to emphasize I'm 100% with you on how annoying it is that we can't get estimates. I spent 3 years literally trying to solve this problem, and we actually made really good progress if it gives you any hope that things will maybe (fingers crossed) get better overtime. I just wanted to give some context / spark some conversation around these contracts and why they are challenging from a technical perspective to automate price estimates.