Turning passive patients into smart medical consumers is supposed to be one of the biggest payoffs of cost-sharing.
Harriet Gatter, a Charlotte breast cancer survivor who works in finance, gets the idea: When you pay your own bills, you’re motivated to shop for the best price. And if enough patients do that, medical practices will cut fees to stay competitive.
But when Gatter tried to compare rates for her annual breast MRI, she discovered that talk about transparency outstrips the reality of North Carolina’s medical marketplace.
Radiology offices, she says, were reluctant to quote her a price. Online cost tools that are available to the public provide averages, not specifics about what she would pay. And her insurance company acknowledges it has done a poor job of helping customers look up their negotiated fees.
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“This hasn’t been made clear enough to members,” Aetna spokesman Walt Cherniak said. “She’s actually doing exactly what we encourage customers to do: Being an informed consumer.”
Gatter, 59, switched plans when the Affordable Care Act exchange replaced North Carolina’s high-risk insurance pool in 2014. To hold her premiums down, she chose a bronze policy from Coventry Health Care of the Carolinas (owned by Aetna) that has a $6,250 deductible.
That means the annual breast imaging, which had been running $700 to $900, would come out of her pocket. When Charlotte Radiology said her 2014 MRI would cost $1,345, she started looking for a better price.
She checked HealthCareBluebook.com, which lists $915 as the fair price for imaging and reading in Charlotte. But the site includes a note: “The cost of certain in-network procedures can vary by over 400%.”
She called several offices, including some in Gastonia and Rock Hill, but says she got no firm answers on what she’d pay.
Gatter was still trying in January, when Blue Cross and Blue Shield of North Carolina made headlines by releasing public data about its payments to providers around the state. The database lists the average negotiated rate that Blue Cross pays, by procedure and provider, but warns that the numbers may not match rates negotiated by other insurance companies.
Gatter tried the cheapest listing, for a Raleigh doctor who averaged $830 from one Blue Cross plan and $1,000 from another. That office told Gatter she’d pay $1,354 under her Coventry plan.
The Observer contacted Aetna to find out why Gatter couldn’t get Coventry’s negotiated rates for radiologists in her network. After several days of trying to find an online price lookup for Coventry, which Aetna acquired in 2013, Cherniak found someone who pointed him toward it. But neither the introductory packet nor the website make it easy to find, he acknowledged.
“It does beg the question: How are folks supposed to know this? I get that,” Cherniak said.
The Coventry lookup gives a single negotiated rate – $1,515 for the MRI Gatter would have – but no details about whether any offices charge more or less.
Gatter eventually found a clinic in Augusta, Ga., that told her it’s in the Coventry network and would charge her less than $800. She says Coventry initially confirmed that. But Cherniak said that clinic is in the network for Coventry’s Georgia customers but not those in North Carolina.
“Honest to God, it’s just unbelievable,” Gatter said. “It’s so complex, and I think the people who are buying the insurance are at a loss.”