Consumer Tools

8 questions to ask prior to a planned surgical procedure.

Prior to undergoing a planned procedure such as a knee replacement or gall bladder removal there are questions you can ask to help with calculating your out-of-pocket costs.

1. What is the exact name of the procedure?  Ask your doctor to clearly print the name of the procedure. Correct spelling is important and many surgery names sound similar.

2. What ICD-10 codes will be used? Your health plan pays healthcare providers based on these diagnosis codes, which the doctor’s office or hospital will provide to them. The coding system was recently updated from ICD-9 to ICD-10, which is much more detailed than ICD-9.

3. What is the CPT® code for this procedure? One or more five-digit CPT codes are the billing codes that are used by providers—usually for physician services—throughout the United States.

4. What tests will I need before the surgery? Blood tests, diagnostic imaging tests, such as a CT scan or ultrasound?  Ask for specifics about which blood tests will be ordered. Ask the doctor if you have a choice of facilities for getting these tests done. Check with your health plan before you have the test to find out where your out-of-pocket cost will be lowest.

5. Will other doctors be involved in my care and bill me for their services? A pathologist, a radiologist, and an anesthesiologist may be involved in your care. Even if your surgeon and the hospital are in your health plan’s network, other doctors involved in your hospital care may not be.

6. What kind of anesthesia will I receive? Many surgeries will involve care by an anesthesiologist and other doctors who may or may not be part of your health plan’s network.

7. After my surgery, will I go right home from the hospital? What medications and follow-up care will I need? After you are discharged from the hospital, you should be able to go directly home. After some operations, you may need care in a rehabilitation unit or skilled nursing facility for a while. Or you may need home health care. Your health plan can provide information about coverage and prices.

8. What else should I know about—such as potential complications—that might affect the cost of the procedure? For example a minimally invasive (laparoscopic) gall bladder surgery has to be changed to an “open” cholecystectomy, which may or may not be more expensive. You and your doctor should already have discussed this when you talked about the risks and benefits of the surgery. If not, be sure to ask questions about the open procedure before the day of surgery. Having a different procedure (or an additional procedure) is likely to change the cost. And if you need to stay overnight in the hospital for any reason, that is generally more expensive than an outpatient procedure.

Ultimately you may to call your insurance company (groan) or set up an online account on their web site (further groan). This may or may not give you an answer.  You could also wait for that Explanation of Benefits (EOB) statement in the mail – good luck with making sense of that document !

All of the above can entail a lot of time and effort on your part. The good news is that the whole process is a lot easier with new electronic tools that are now available. These tools do the math for you and calculate these costs. They also make your medical bills easier to read and decipher those confusing EOBs. Check to see if your employer offers these tools to their employees.

For more information on the tools offered by Obeo Health please watch the video on the home page.

Did you pick the right health insurance plan?

Selecting a health insurance plan can cause considerable angst for a consumer and his/her family. Insurance plans are complex and there is a wide variety available on the market. Let’s try to simplify the decision making process. There are basically four areas that the consumer needs to assess for each plan offering;

1. The deductible.

2. The co-payment.

3. The co-insurance.

4. Out-of-pocket spending limits.

The complexity of plan choice arises in part from wide variation among plans across these four features that determine how health costs are shared between the insurer and consumer. And so consumers are faced with a dizzying number of permutations when trying to balance these four areas.

Lack of health literacy also plays a part in the process. A study done in 2013 found that only 14% of consumers could answer four simple multiple choice questions regarding the definition of these four cost sharing features. Also when presented with a simplified plan, most respondents were unable to accurately estimate the cost of their medical services. To confuse things further employees need to know if the plan covers their medications (formulary status) and whether their physicians are in or out of network.

The Affordable Care Act (ACA) organized plans were segregated into four ‘metal’ tiers – platinum, gold, silver and bronze. One investigation of hypothetical plan choices with plan menus designed to mimic those of the exchanges found that metal labels, rather than facilitating better decisions, worsened choices compared with generic labels (eg, plan A, plan B, plan C). This study also found that alternative plan labels that encouraged consumers to forecast how much care they anticipated needing did have a modestly beneficial effect, suggesting that participants may have misinterpreted metal labels as signals of quality, or the breadth of services covered, rather than the degree of cost sharing.

To make a financially efficient choice, employees, most of whom lack extensive prior experience with insurance, have to carefully consider the complicated relationship between plan cost, cost sharing, and their expected health risk. So what can be done to help employees navigate through these complex scenarios? I would like to suggest some possible solutions;

1. Provide decision aids. These may be scenario based examples or so called “people like me” illustrations.

2. The utilization of consumer historical data (claims, pharmacy etc) to help predict future costs should be encouraged. Prescriptive analytics tools can now help perform this task.

3. A more aggressive approach may be the use of plan “defaults” or restricted menus tailored to each consumer.

4. A more long term solution would be to simplify health insurance – period. Insurance products free of the complex features that consumers are least able to understand, such as deductibles and co-insurance,would more likely help consumers make informed decisions regarding plan choice and utilization.

Offering multiple plans seems like a good idea – the typical ACA enrollee is offered an average of 47 plans. One would hope that this large number of choices would help the consumer find an appropriate plan and may stimulate competition among insurers, leading to improvements in plan price and quality. However, these benefits are unlikely to emerge if consumers are not given the right tools and education.

To sign up for a free demo of the tools on offer at Obeo Health please click here.

Can Consumers Make Affordable Care Affordable?

Eric Johnson, a Columbia business professor, led a study that found that without substantial additional assistance, a consumer’s likelihood of selecting the lowest-cost plan is no better than chance….But when study subjects were provided with a tutorial or with a calculator that revealed the full cost of each plan, or if they were placed in the lowest-cost plan by default (from which they could voluntarily switch), their chance of selecting the cheapest plan was much higher, upward of 75 percent in some experiments.

Can we make a better EOB?

If you’ve seen a doctor or been to a hospital recently, you’ll most likely have received what is called an EOB in the mail. EOB is short for “Explanation Of Benefits”. Every insurance company has a different EOB and many of them are difficult to understand.

Here’s an example of a typical EOB:

EOB_Original

Why do insurance companies send out these EOBs? An EOB is the statement insurance companies send you after your doctor sends them a bill. It tells you what the claim was for, what was covered, what you owe and why. But it’s not the actual bill.

Once you understand the purpose of an EOB, you’ll need to understand what it’s trying to tell you. This should be simple, but in today’s challenging world of healthcare pricing this can involve complicated math and unfamiliar terms. This is why Obeo Health created an EOB decoder, which provides consumers with an easy to understand breakdown of medical charges and how your benefits apply to those charges.

We start with a simple summary that includes the three most important numbers: what you were charged, what did your insurance cover, and what is your responsibility. Our tool then walks through the steps of how and why these dollar amounts were calculated, in language that is simple and easy to understand.

Finally, if there are any complicated calculations, Obeo lines up all of the charges so that you can easily understand how your total responsibilities were determined.

Here is an example of a visit to an ‘In-Network’ emergency room:

EOB_Blog

In a world where consumers are increasingly responsible for understanding the costs involved in their healthcare, Obeo Health is providing the tools necessary to make this information accessible and easy to understand.

Contact us to learn more about how Obeo Health can help your organization increase employee engagement in healthcare decisions and lower costs for everyone.