One of the big complaints about health care services is not knowing or being surprised by the cost of medical treatment. Blue Shield of California has taken a modest step toward helping plan members determine the cost of health care services with their new treatment cost estimator tool. Initial reports from clients suggest the new treatment cost estimator application is better than the assistance they get from either Blue Shield or their doctor’s office.
Blue Shield helps estimate health care costs
It was coincidental that at the same time Blue Shield sent me an email on their new Treatment Cost Estimator tool I got a call from an exasperated client trying to figure out the cost of her colonoscopy. My client had called both Blue Shield and her doctor’s office to get an estimated quote for the colonoscopy and both told to call the other. Even the Blue Shield customer service representatives didn’t mention the new treatment cost estimator tool.
Bundled treatment cost estimates
After logging into her account my client was able to use the new health care services estimating link and received an estimate of $1,200 to $1,800 for the colonoscopy. Even though Blue Shield states the cost is a bundled estimate for all the services involved, there are still lingering questions about receiving care from providers who might not be in the Blue Shield network. However, just having a ballpark estimate for a cost was far better than the poor customer service and knowledge of Blue Shield, the doctor or the colonoscopy facility.
Doctors fail to provide any estimates
Another significant point about the treatment estimator tool is that it shows that it can be done. The glaring hole in health care reform is price transparency because of all the secret deals the health plans cut with the providers. Blue Shield is taking their secret negotiated rates for services and developing estimates of different health care services from their network providers. From my perspective, physicians performing elective health care services should have to provide a cost estimate just like when a mechanic works on your car. The downside to the Blue Shield treatment cost estimator is that the cost will dissuade individuals from getting care. How do I know this? My client decided against the physician recommended colonoscopy because of the cost.
Below is specific information provided by Blue Shield of California on their treatment cost estimator tool. Files for download and link to video introducing the estimator tool at end of post
Things You Should Know When Using the Treatment Cost Estimator
Whether you’re a patient or caregiver, we’ve made it easier for members with a PPO plan to make decisions about your health care costs with the Treatment Cost Estimator. Use this tool to research estimated cost ranges for various health care services, including high-cost or elective services. You can also use the tool to research the differences in the estimated costs of a particular service based on the facility where the services are provided, such as a doctor’s office, hospital, imaging center or ambulatory surgery center. We get these estimates exclusively from 12 months of PPO health benefit claims data. Your out-of-pocket costs will differ, based on your specific benefit and coverage information, as well as the specific services you receive.
The information provided by this tool is not a guarantee of coverage, a guarantee of payment or an authorization for a particular service. The estimates provided by this tool are not an exact calculation of your actual costs and do not reflect all of the terms, conditions, limitations and exclusions that may apply to your coverage. Your actual costs will vary depending upon the specifics of your benefit plan and the particular services and supplies you receive.
The Treatment Cost Estimator is intended to be a reference tool and is not a substitute for medical decision-making. Your health is an important priority, so do not avoid getting health care based on the cost estimates on this website. Use this information when you talk to your provider or physician, only you and your doctor can decide which medical decision is best for you. Be sure to consult with your own physician about your particular medical condition and discuss treatment and facility options. The information in the tool is not a recommendation or endorsement of any particular health care facility or its services and doesn’t guarantee services will be available or will be of any particular quality or cost.
Costs for the same health care service can vary a great deal by location and health care provider; the Treatment Cost Estimator can help you stretch your health care dollars by allowing you to compare what it may cost to have your desired service performed at various facilities.
The information available within this tool is developed using 12 months of PPO health benefit claims data, and provides members with an estimate of the range of costs for a specific health care service at a specific facility before your benefits are applied. For example, the typical cost for a knee replacement may range from around $11,000 to $13,000 at one facility, and may range from around $36,000 to $40,000 at another facility.
The range of costs reported by the tool represents only the typical costs for services supplied by facilities and professional health care providers (e.g., physicians) that are related to the primary health care service you selected. In addition, there may be costs for other services provided in addition to the primary medical treatment that are not reflected in the cost estimate, such as medications, lab tests, x-rays, etc., as well as additional costs for related services received at other facilities. In some cases these additional costs can be high, and you could be responsible for those costs depending on your benefit plan. Your actual costs will vary based on the specific services you receive, your benefits for that health care service and your progress towards meeting your annual deductible and copay maximum.
What’s Not Included in the Typical Costs Estimate
Estimates do not take into account certain types of claims and services, such as:
- Medicare claims
- Claims paid after a primary health plan has paid (secondary coverage)
- Emergency cases, transplant cases
- Claims that include numerous complications
- Your specific benefit and coverage information
In addition, typical cost ranges for hospitals and facilities that do not have enough claims information for your selected health care service are excluded from the results.
The information about the facilities presented in this tool is for reference only and may have changed since this tool was last updated. Be sure to confirm with the facility the facility’s address, phone number, specialty, and participation (in-network) status before making an appointment.
If you find that a particular facility is not listed for a certain type of health care service, it may be that the facility is not a participating provider in the Blue Shield network, that we do not have enough claims information to be able to provide a useful estimate of the cost of the selected health care service at such facility and/or the that the facility does not provide the service.
About Health Care Services
Most health care services involve a particular bundle of related services, tests and visits. We’ve developed a standard bundle that’s typical for this service based on averages from 12 months of PPO health benefit claims data. Each cost range includes the typical cost range for this type of care’s standard bundle of related services including facility, physician and other services, such as typical lab tests and x-rays. This gives you the total estimated cost of the standard bundle of service. Whether your estimate falls within the range depends on which of these related services your doctor recommends or prescribes for your care, your own condition, as well as your benefits. Remember, the costs displayed are estimates and your actual cost will vary. Health care services listed in the tool were selected because they are not emergency services and can be performed by a variety of health providers, allowing you to ‘shop’ for your health care in advance.
About Missing Providers
The information available in the tool is developed using 12 months of PPO health benefit claims data. Some providers may not be displayed for one of the following reasons:
• Blue Shield does not have enough claims information from a particular facility for a particular health care service
• Blue Shield’s contractual arrangement with the provider prohibits the disclosure of the provider’s cost information through the Treatment Cost Estimator
If you find that a particular provider is not listed for a certain type of health care service, you may contact your provider directly about typical cost ranges for your service of interest.
About Out-of-Pocket Costs
The Treatment Cost Estimator uses your current overall medical spending to estimate your out-of-pocket cost.
Pending claims that have not yet been processed by Blue Shield are not included in your overall medical spend. Once these claims are processed, your balance towards deductible and out-of-pocket maximum may change. Your actual out-of-pocket cost may change from those estimated in the tool.
If your benefits include service type specific deductibles or limits (e.g. for chiropractic or acupuncture), your actual out-of-pocket cost may be different from the one in the Treatment Cost Estimator.
Your final out-of-pocket cost may be influenced by many other factors such as the mix of services, past performed services to a specific category, and other factors affecting individual treatments.
Individual hospitals may disagree with the methodology used to define the cost ranges, the cost data or quality measures. Many factors may influence cost or quality, including, but not limited to, the cost of uninsured and charity care, the type and severity of procedures, the case mix of a hospital, special services such as trauma centers, burn units, medical and other educational programs, research, transplant services, technology, payer mix, and other factors affecting individual hospitals.