Today I contacted my health insurer to go over some policy changes they notified me by mail about for the upcoming year. After they answered my policy questions, I took this opportunity to ask them my standard question, “as a member of your health plan, how do I find out what my specific out-of-pocket costs are– before visiting a provider?”

Here is what I learned. This type of information is called a FORMAL PRICING REQUEST and consumers (health plan members) must obtain specific information from the provider and follow the outlined procedures below. Contact your provider’s office and find out:

1. Provider’s NPI #
2. The specific diagnosis code(s) for the procedures that will be provided (ICD-9)
3. The specific CPT code(s) for the services that will be provided
4. The amount the provider charges for these services
5. The location (place) of service. This could be lab, outpatient facility, office, hospital)

After the member has all this information from the provider, the member should contact the health plan’s benefits/claims department and be ready to answer all these questions. Within 48-72 hours after the request is made, the insurer will provide the member with a letter identifying the member’s out-of-pocket costs for the services. As a convenience, the insurance plan has offered to read the letter over the phone, rather than mail it out to the member. Contact the Benefits/claims department.

Happy New Year!

NPR ran an interesting story in November 2009 on price disparities in our health care system.

When it comes to our health care system, the basic economic rules do not apply. Prices for identical goods and services are usually the same or very close at competing businesses. That's not the case when it comes to health care — not by a long shot. In Pensacola, Florida there are huge price disparities for MRI tests. It's not a matter of greed or poor decision-making by MRI providers or a lack of consumer awareness.  For better or worse, it's the way our insurance-based health care system works.  Read the full story.

An article in the New York Times encourages consumers to shop around to find the best prices for health care services. The article recommends four steps consumers should take to comparison shop for health care:

• Check to find out if your health insurer offers tools for members
  
• Use tools like PriceDoc.com, HealthcareBlueBook.com and Outofpocket.com to look-up prices
  
• Research state transparency initiatives to look-up hospital prices in your state
  
• Call the provider to find out specific price information