Playing the Insurance Billing Game

Your insurance benefits can be difficult to navigate. Dr. Madan Kandula and Dr. Ethan Handler explain how to play the insurance billing game.
Reviewed by
Published on
February 27, 2020
Updated on
March 5, 2020

On this week's episode of ADVENTing, Dr. Madan Kandula and Dr. Ethan Handler discuss the complex insurance system and how to navigate it.

Dr. Kandula:
All right, let's talk about healthcare billing, EOBs, we'll talk about what means, I think, and just the whole situation that we're in. So, we're part of, just to kind of set the stage here, ADVENT is an independent medical practice. We're part of a larger healthcare system. Most people have health insurance, and most people who have health insurance want to use that health insurance, and so we have to play by the rules of the insurance game, which is a crazy, crazy game.Dr. Kandula:
I hear a lot of comments and chatter about how crazy it is. Why so crazy?Dr. Handler:
Yeah, the game is rigged to a certain extent. A lot of people describe it as, patients are put in the middle and don't understand the system. And sometimes, I think from an insurer's standpoint it's purposely done that way, so they can keep people not in the know and be less transparent. A lot of the reviews that we might see online ... fortunately, ADVENT gets a gazillion positive reviews. We do good things for patients, I think outcomes are good. The reviews that we see that aren't as stellar tend to be around bills. And the challenge, as a medical provider, for us, is that to explain to a patient what we have to bill based on some contract and what we collect are vastly different things.Dr. Kandula:
Correct. And I guess to boil that down, for instance, a question is, if somebody has health insurance, what does their health insurance do? What's the point? United Healthcare, Humana, Anthem, what do they do?Dr. Handler:
The insurance companies?Dr. Kandula:
Yeah. Why does everybody ... why would you buy a policy from an insurance company? What are you actually buying when you buy insurance?Dr. Handler:
You're buying negotiated rates that are less than what you would pay out of pocket, essentially.Dr. Kandula:
Correct. So point number one, you're buying into their network and they have negotiated discounted rates with their network.Dr. Handler:
Correct.Dr. Kandula:
Have you ever bought anything on sale ever? Bought a shirt, is that a shirt on sale?Dr. Handler:
I never pay a full price for a shirt.Dr. Kandula:
And neither does your insurance company.Dr. Handler:
Right.Dr. Kandula:
So how would you feel if you're paying full price for everything? How would you feel if you signed up for a sales network, we're going to get you deals on everything. I'm going to sign you up, everywhere you go, you get your nose taken care of, your ear, your lung, whatever you've got, and your kidney if you've got one. You've got two, maybe. You're going to take care of all that stuff, and I'm going to get you a deal on everything. That's what the insurance carrier, that's their proposition to you, and actually your employer.Dr. Handler:
And they hope you never utilize it.Dr. Kandula:
Yes and no. Yeah, they do. Yes, at the end of the day, they're going to sell you on, we're going to get the best docs at the best rates kind of a thing. And so, in order to get some of those deals or make it seem like they're getting a deal, they need us to have our prices at a level where we're discounting them. It's sort of this crazy, crazy game, and the numbers are crazy, but it's a game we have to play. If we want to be participants in the various insurance networks, then we've got to play that game, too, and it is crazy. I will not at all, ever, deny the fact that the whole thing is insane. I didn't set it up, but again, those are the rules that sit around us and we have to abide by those rules.Dr. Handler:
Right.Dr. Kandula:
But I think that dynamic is just sort of, it is what it is and we do what we do. At the end of the day, we provide care for people, so unlike insurance companies, we actually lay our hands on and are actually delivering care, and we need to stand up for our ability to do that, I guess is the bottom line.Dr. Handler:
And that's why when patients get this EOB. So, the first time-Dr. Kandula:
What's an EOB?Dr. Handler:
EOB is an explanation of benefits. So, that's one of these things that I had never seen one of those until I came here. Where I trained and then worked for a few years was with this kind of big box healthcare system called Kaiser Permanente, but everything was in house. So any time I went and sought care or got some bill, it was actually a bit more transparent that way. There was no EOB that came first.Dr. Handler:
Then I moved here and we started having care, and the first EOB I saw, I had no idea what it was. And I'm in healthcare, and I was confused. And the rates are astronomical on there, but of course it says, this is not a bill. And then you get a bill later on that's dramatically less. And so, that's what I think is a confusing point for patients is they think that what shows up on your EOB is what the actually surgery costs or what the actual visit costs, and it's not.Dr. Kandula:
No.Dr. Handler:
But again, it's the game that's played to show the discount.Dr. Kandula:
Right. Correct. And so, with that dynamic in play, what alternatives do we have other than to play by that game? I guess the alternative is for folks who don't want to use their insurance, they could always ... there's always an alternative pathway, which is just paying a cash price. The cash prices that we have, or self-pay pricing that we have, is not the same as what you see on an EOB. We're kind of getting into the weeds a little bit here, but the challenge is, again, trying to be sensible and make sense in a system that's insane.Dr. Handler:
Right.Dr. Kandula:
At the end of the day, as physicians, our duty is to provide care for our patients, and again, if patients want to participate in this system, then it's up to us to figure out a way to make it happen. It's challenging, though, because part of the issues we run into sometimes with insurance is that as a byproduct of those agreements that we have to make with insurance companies, it creates a level of non-transparency. We have to have all these ... it's sort of a weird, weird game that we have to play. But again, it's the world that we live in.Dr. Handler:
Right. So, to all those patients out there, we hear you. We understand your frustration. I think it's one of these things that it's not the way we want it. I think what's important to understand, and we mean this genuinely, is that we don't charge more than other people charge, also.Dr. Kandula:
Sure.Dr. Handler:
So that evidence or explanation of benefits, that is ... if you had the same thing done in the office here that you had at ADVENT, and then you did that in a hospital, at Froedtert or Aurora or somebody else, that EOB would be significantly higher.Dr. Kandula:
Yeah. Or, the same ... and I would agree. Anything you see on an EOB that we charge is typically less than what others are charging for the same thing. So, if you wanted ... one of the things that we are most known for are office based procedures. If you want to have an office based procedure done for your nose or sinuses, you're not going to be able to get those things done in big box healthcare. No healthcare system is going to allow their docs to do that in their offices, and so they kind of hide behind some of that.Dr. Kandula:
So if we do it here, because it's the right thing to do, that's why we do it. We do it here, but the charges that are there are no different than what they would be elsewhere. In fact, they typically would be less, and certainly what the insurance company is actually paying to us is definitively less than anywhere around, which is ... no doubt about that.Dr. Kandula:
So, I guess as far as trying any other angles on this insurance gig, it's a really energizing topic. We love talking about this insurance thing. It's my favorite thing to talk about in the world. It's really not, if you didn't pick that up, but it's a part of what we need to do. We need to deal with it, we need to own it, we need to acknowledge it. And we do. Bottom line on the insurance game that we have to play is it is a game, it's crazy, I'm the first to admit it. It's insanity, and all we can do is continue to try to fight forward and stake out our own place in the world. So, yeah.

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First published by ADVENT on
February 27, 2020
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Playing the Insurance Billing Game