That’s the line that stared back at me from the printout on the prescription the bag came in.

Your insurance saved you $84.99.

Did my insurance truly “save me $84.99″ I wondered.

Like most of us with private insurance, I don’t get EOBs for my prescriptions. I simply pay a prescription co-pay of $10 for generics and $35 for brand drugs. So did the pharmacy accept $84.99 less because of my insurance? That was the implication, but was it fact?

Or did my insuror pay $84.99?

Exactly how did the transaction go down?

As someone who actually pays for their insurance and does not have it provicded for me as an employee, I wondered, since when I get underwritten next year, the expense will be considered and may contribute to a rate increase. If my insurance paid $84.99, then they most certainly DID NOT save me $84.99, but they paid out $84.99 on my behalf – semantics, I know, but I don’t like being misled, and I felt I was being misled.

How do you feel about it?

I spent a lot of time in Germany – 2 years to be exact – and found Unity’s post about Health 2.0 taking off in Germany very interesting http://wisdom.blogs.com/health/2007/11/health-20-takin.html (see the original post at http://gigaom.com/2007/11/17/health-20-gaining-traction-in-germany/). Both systems have something to learn from one another, and here are some tidbits.

I got to experience the German healthcare system firsthand. It was interesting. From a customer service standpoint, it left much to be desired. Office hours were sporadic – worse than a college professor with tenure. However, there was a policy in Germany: Just go the doc during hours and take a seat. They HAVE to see you if you get there before close of office hours. From that standpoint, I can see why there might be some resistance to a ratings system. Their system just doesn’t make for the best customer service. As an ailing patient I was there for 3 or 4 hours and feel certain that I spread the love of my virus to many others.  And I felt worse when I left. But I got seen and did not have to make an appointment. Nice. Kind of like a retail based clinic.

During another stay I had a professor who took ill and wound up in the hospital for an appendectomy. When I visited, he assured me it was a very good hospital. I looked around the ward that he shared with at least 10 other men. I noted the open window and the lack of air conditioning at the height of summer. Looking back I realize it was a cultural thing. There is a greater sense of community in Europe. People convalesce and recover together, not in private isolated rooms. They breath in the fresh air, not the airtight container with windows that do not open like here (presumably to keep patients from jumping out of them due to being driven insane by being in isolation all day long).

I’m not going to pass judgement on either system, but there has to be something that we have to offer each other as we try to change this crazy notion of healthcare in the U.S.

Had the pleasure of being at the recent Health 2.0 Conference in San Francisco hosted by Matthew Holt with a big assist from Indu Subaiya, John Pluenneke and Sara Sara Walker. GREAT JOB! They really pulled off an incredible conference. My only complaint is that we needed at least one more day – oh, and we should be on the panel next time. But seriously, I think Health 2.0 went in as a movement and just may have come out of it as an industry.

During the course of the event, we got to meet quite a few people – people like us – genuinely interested in seeing our healthcare system improved. That’s a broad statement, and virtually everyone there had their own variation on the theme. One of those I found myself aligned with is that of Fard Johnmar. He triangulates in on his interests by focusing on three points: health literacy, technology, and caring for caregivers. We at change:healthcare find ourselves at the center of that very same triangle.

Another person we particularly enjoyed was Bob Coffield. Yes, he’s an attorney, but man we enjoyed hanging out with him – even though he kept us out until 2AM CST (3AM his time in all fairness). We shared alot of similar interests and no doubt will be looking for ways to work together in the future. Bob does a far better job than I can providing an overview of the H2.0 conference.

Some of the companies represented there were fantastic. PatientsLikeMe was one of the jewels of the show.

Steve Krein or Organized Wisdom was an immense pleasure. He unveiled a significant shift in their approach that was not only unique but aggressive. Krein was very “naughty” as Matthew Holt pointed out for all 550 of us in the room, but having gotten to know Steven a bit more, I think that’s just how he prefers it.

Marty Tenenbaum called for collaboration between those represented there and offered up his Commerce.net venue as a means for facilitating that opportunity. We’re already going down that path to working with some of the folks we’ve met there. Some of those I’ve listed here as well as some others who really impressed us and we’ll mention in future posts. Look for more as we move forward.

As Christopher mentioned, we’ve closed our Series A round this past week.

Never ones to slow down, we’re in San Francisco this week for the upcoming Health 2.0 conference hosted by Matthew Holt. But before we could leave, we had to squeeze in a meeting Monday AM before our flight with some new friends – a major healthcare company with multiple presences across the US.

We came early to SF catch up with a whole host of folks out here on the west coast – people like us who are interested in changing the healthcare industry for the better of the consumer. We’re finally getting to sit down with people face to face, people we’ve only been talking and e-mail with until now. It’s been great already, and the conference isn’t until Thursday!

And we’ve got great things going on while we’re away, too. Way to go Katrina, Matt, Matt, Mark, Prakash, and Jakob!

There are a lot of great people working healthcare from the technology side out here. Nashville (where we are headquartered) is the bricks and mortar of the insustry are. Clinic management companies literally spring up overnight. They are the children, grandchildren and more of HCA and its many spinoffs. Someone has to bring the technology and tangible together to make a change.

Scott Shreeve has been a great sounding board for us as we’ve rolled out MedBillManager, and we’re finally going to get to meet him in person.

We’re also going to catch up with some other people like Ben Heywood and Jeff Cole from PatientsLikeMe (a great site that focuses on helping people living with ALS, PD and MS). Since we have a partnership with MS, we obviously have some common interests.

On top of that Unity Stoakes at Organized Wisdom tells us they have big things brewing over there.

There’s more. So much more. But so little time. Off to another meeting.

OK call me naive. I thought my healthcare provider was working for me. In all fairness, it usually does, but this past incident reminds me that they do not always.

I recently had a provider’s office call me back for a follow up – some photos. Pretty simple really – they had already done it once. Problem is, the insuror said the pictures were not sufficient to determine if they would approve the procedure. So the nurse called and asked me to come back. I asked who would pay for that. The other end of the line went quiet for a moment, the nurse clearly taken off guard by the question, but she quickly understood that it was a customer service issue and said that if the pictures weren’t good enough that they would not charge me to retake them. Satisfied, I went in.

At the front desk, the woman asked for the co-pay. I explained the situation and what the nurse had told me. I had distracted the lemming from its path and now it was left to wander, “I don’t know how to do that.” She looked around as if something on her desk might explain. She made to get up and go ask, then sat down. She looked around the desk again (what the hell was she looking for?). And then she had a spark of an idea. “I know what I’ll do. I’ll make it a follow up visit with no charge.” Worked for me.

Got the photos. Went home.

Then the bill for my co-pay arrived. And an EOB arrived. They charged my insurance $33 and wanted the $20 co-pay from me. I called the provider’s business office (part of a large medical center). They put it in for review.

I got another statement. They wanted $20.

I called my insuror. I explained to the lady on the other end of the line what had happened and that either my provider was a poor photographer or my insuror was unnessecarily driving up my expenses on the matter by asking for uneccesary procedures.

Here was the basic response.

Our contract with the provider is that they bill us, and we pay them. That agreement you made was a private side agreement. We have no control over that. They bill us, and we pay them.

So I asked, “Basically what you’re telling me is that I might get my co-pay back, but you’ve sent them the $33 and they are going to keep it?”

“Yes, sir. They bill us, and we pay them.”

I think I went over her head in my understanding of things with the next part. “So you’ve paid out $33 that was not supposed to be paid out, and I’m going to be underwritten with that as an expense when it comes time to renew and establish my rate for next year?”

“Um. That’s our agreement with them.”

It’s not the amount. It’s the principle of the thing. I got them to write off the co-pay. They kept my $33 paid by my insuror.

They bill us, and we pay them.

Thanks.

We’ve all seen it – the EOB (Explanation of Benefit) with the bold lettering that proudly declares THIS IS NOT A BILL. So what is it? We called around to some insurers to find out about it and to see if they had a guide for the high math that they so often employ.

“It’s pretty easy.”

That’s what the customer service guy on the other end of the line had the audacity to say. Must be the kid from calculus class that always worked every problem at the end of the chapter. I asked him if they had a guide on how to read their EOB. They didn’t. But to his credit, he was willing to talk me through it. He started out, “It has THIS IS NOT A BILL written on it in big letters.” Thanks.

Another customer service rep said, “A guide? No we don’t have one, but you know, that’s a really good idea. We should do something like that.” His must not be so easy to read as Mr. Calculus’ or maybe he was sitting in the back of the class with me.

But there are a few insurers who put out a guide. There is even one – Humana – that publishes a guide to reading their EOB and [GASP] they have it available for download. The Humana EOB is one of the best I have seen for ease of understanding, and still it’s four pages long (And the first guy thinks people don’t need a guide? Yeah, and we didn’t need the teacher to work another problem on the board because we all got it – hah!).

Why was I doing this? Well we wanted to see how many different layouts and subtlties of semantics existed in the EOB world. So we had a small competition – see who can collect the most EOB forms from different insurors. Loser buys the coffee (Chistopher and Katrina, how do you take your java? Starbucks or Bongo Java?).

So now, in an effort to redeem myself, I am throwing it out there.

IF YOU ARE WILLING TO SHARE YOUR EOB WITH ME, POST A COMMENT.

DO NOT post your e-mail address in your comment. You have to enter it to post a comment, but it is not publicly available – it is only available to me. I’ll e-mail you with my direct e-mail address and/or fax.

You can strip off the personal data.

I don’t need to know who you are, your addess, your subscriber ID or Group ID or employer or any of your family member names. I don’t need the claim number, who you saw, what they did, the service date, how much they billed, how much your insuror discounted it, how much the insuror paid, how much was your responsibility, how much went to your deductible (OK, if you have a guide that might be helpful).

Yep. Send me your EOBs. I’m a glutton for punishment. It’s time for me to learn that high math that I thought I would never need in the real world.

Medical bills are like snowflakes in two very important ways:

• No two are exactly alike.
• They fall from the sky in flurries or in blizzards.

OK, some medical bills are alike, but it made a good analogy. Still comparing medical bills is a delicate task. Take an earlier post where I had two separate Level 1 ER visits for a child. One bill came in at $705.11 and one at $3667. Both were reimbursed a total of $358 each.

If you look at the line item detail, you can see the difference in the two bills. One had more tests, more meds, more consumables (IV, needles, etc.), and more specialists called in. The EOB said they were the same, but on close examination, they were very unique.

The issue of unique snowflakes comes in with virtually all visits. Some of the more common ailents may be  more predictable. But take a diagnosis of MS as an example. Many physicians are hesitant to reach a diagnosis of MS. It’s a devastating disease. They truly want to find some other cause for the effects. Many of the specialists in the field will tell you that the diagnosis is still a clinical one. They may arrive at the final diagnosis after a long barrage of tests including but not limited to MRIs and spinal taps. Depending on how the disease manifests itself, the MRI may be of different parts of the body. Different parts of the body have different prices for MRIs – snowflakes.

Demographics plays a role as well. A large 300 pound man may require more anesthesia that a slight 110 pound woman – snowflakes.

And there can be a variation in therapy even for the more common ailments. One doc may need a test to determine the problem, the other may be seeing the illness in a different stage and be able to readily identify it without testing and incurring the additional lab costs – snowflakes.

One doc may prescribe an antibiotic, the other may prescribe a different one and a steroid to help move things along – snowflakes.

So when the bill arrives, your insurer (if you are fortunate enough to have one) has negotiated a flat rate for the services based on the average cost (at least that’s the theory). They send an EOB that does its best to make the snowflakes all look alike. And then the provider statement arrives, and it’s really starting to snow paper now!

That’s what drives us at change:healthcare. We want to be the snowplow that helps you get through. And we want to help you look at al of your “snowflakes” to see what makes them unique and more importantly how they compare to other people’s “snowflakes.”

So when your next round of medical bills arrives – just imagine yourself standing out in the snow – try to enjoy it, and hope that global warming catches up to the healthcare industry quickly.

My three year old is a born entertainer. She has curly red hair, a personality that just grabs people and she’s a born talker. One morning on vacation recently, she and I were up before the rest of the family. I told her to be quiet so we didn’t wake anyone up. I fixed coffee, and we headed for a walk on the beach in the early morning. We got outside on the porch, and she shook her head, “Whew! Now I can talk!” She’s pretty good about letting us know how she’s doing.

Shortly before we went on that vacation, we noticed a bug bite under her right arm. Nasty little bite, but anything looks bigger and worse on a three year old. We took her to her pediatrician ($20 co-pay, $182 billed, $95.82 in network price, so $75.82 paid by insurance) and got a prescription for an antibiotic (Rx card co-pay $35, retail price $65.89 – no idea how much the insurance kicked in, but that’s another story. Three days later, she began to run a fever that spiked very quickly to 101 and within minutes to 102, we headed for the children’s hospital. It’s only 5 minutes drive from our house – a fantastic testament to the real estate mantra – location, location, location.

An IV, some acetaminophen, an additional antibiotic prescription, $100 ER Co-pay, and we were good to go again. When hospital Super Bill #1 arrived, it was for $705.11. In network discount brought it to $358 (that’s a 49% discount!). Our insurance paid the $258 balance.

Three days later, the fever was back, she was getting spots – little purple spots on her body – all over. Visited the pediatrician again ($20 co-pay, doc billed $55, but the in network discount dropped it to $34.38 so the insurer paid $14.38). If the spots get worse, go to the ER we were told.

At the ER that evening (oh yeah, the spots were worse and the fever was back), we had two IV sticks (not popular with a very loud and vocal three year old) and ultimately had to do a femoral stick to draw enough blood to check for Fifth Disease or Human Parvo Virus (not related to the dog virus). The experience was traumatic, so much so that they encouraged me to leave, but I can’t shy away from something – just not in my nature. Even the doc who did the draw was visibly shaken.

Through an alternating regimen of acetaminophen and ibuprofen, we got the fever under control, paid the $100 ER visit co-pay and went home.

The super bill for visit #2 (Super Bill 1 of 3 | Super Bill 3 of 3) came to $3,667.40. I can’t even begin to tell you what it was they charged me for. Christopher Parks took a passing glance at it. Things seemed to be as expected. I’m waiting on the EOB. I expect the in network discount to bring it down to $1600 or so, but I don’t really know. However, I am naïve. The EOB arrived before I had a chance to post this blog entry. I paid the $100 ER co-pay. My insurer paid $258. For those of you keeping count, THAT’S A WHOPPING 93% DISCOUNT!! The $258 is probably the standard negotiated rate between my insurer and this provider for a Level 1 ER visit. Still – that’s a big difference.

Alas, we wound up back at the ER with her again – maybe related, maybe not. I’ll let you know how that visit and the MRI the following day stacked up.

All told, here’s how the episode of care stacked up:

• $4,328.29 – Billed – 100.0%
• ($275.00) – My Co-Pay – 6.4%
• ($3,447.09) – Network Discount – 79.6%
• ($606.20) – Insurance Paid – 14.0%
• $0.00 – Balance – 0.0%

Imagine had I been uninsured.

My name is Robert Hendrick, one of the co-founders of change:healthcare. I have a relatively healthy family of five, a wife and three girls, seven year old twins and a three year old. I say relatively healthy because there are little things that always pop up. Like two ER visits already this year with the littlest one.

We have a major commercial health insurance plan through my wife’s employer. To be honest, our insurance is quite good. Something can always be improved, but I have little room to complain about them.

We live in one of the best areas of the country for healthcare. There are leading medical facilities including research hospitals that are first class. It doesn’t hurt that Nashville is also the home to more than its fair share of healthcare companies.

Up until a few months ago, I was one of those happy-go-lucky people who never worried about their healthcare insurance, how much it cost, whether I had coverage or if I could get in to see a doc. My wife grew up in the insurance industry – her father inherited her grandfather’s independent agency in a small West Tennessee town. She was a financial manager for the largest hospital corporation in the world (who shall remain nameless) and is an actuarial consultant who, among other things, specializes in healthcare. Guess who handled all of our healthcare insurance issues.

I got involved in MedBillManager and went on to form change:healthcare with Christopher Parks, my fellow co-founder. He tells his story better than I can, so you can read it there. When I got involved and began to understand the healthcare system and how it worked, I was amazed. I’m someone who loves to learn and the healthcare industry was deep and wide in knowledge. Now I’m up to my neck in it, and I feel compelled to share what I’ve learned and the things I continue to learn. Fair warning – you may not like everything that I’ve found out.

I’m going to be open and honest. I’m also going to reserve the right to hold back on any information that might be deemed too personal as it relates to mine and my family’s healthcare. But I’m going to put it out there. You are going to be able to see how the average American deals with the healthcare system. I won’t pull punches. I won’t cow-tow to sponsors, and if you have questions, I’ll do my best to answer them.

Welcome to change:healthcare. Less talk. More action.