When a person who has been injured at work settles their insurance claim and receives money for their future medical care via a Medicare Set Aside, they become a cash payer in the healthcare system. Medicare mandates that they pay for their treatments with the cash they get in their MSA – but at what price? Two articles released recently by The Wall Street Journal and The New York Times draw attention to the disparity between prices for insurance companies and what an uninsured or cash payer is charged.
In their article, they shared the story of an uninsured individual who was charged some of the highest rates for abdominal, pelvic, and chest scans, compared to the price negotiated between the hospitals and insurers. For one service, he was charged $4,194 for a chest scan, which was up to $2,800 more than what an insurer was charged.
An example they provide for a procedure involving an angioplasty and stent shows the drastically different pricing that cash pay consumers may encounter on their own.
Source: Turquoise Health; Lindsay Huth/The Wall Street Journal
Last week, The New York Times released a piece on pricing transparency[ii] as well. While they caveat that the data is not complete, as many hospitals are not complying with the requirement to publish a complete list of prices, the data from those complying reveals wildly different prices depending on which insurance company a patient treats with or if they are uninsured.
The article highlights that “for an M.R.I. scan, some are paying more than 10 times what the federal government is willing to pay.” Almost always, the cash payers are being charged much more than most payers have negotiated.
Source: The New York Times
Another example within the piece shares M.R.I. costs at a specific hospital in Florida. One insurer pays $1,827, another $2,148, another $2,455, and for Medicare, $262.
What is the implication of these articles for the workers’ compensation industry and specifically individuals who are settling the future medical of their claim?
For someone that’s already gone through a life-changing injury, trying to figure out what they should be charged, and what rate they should be paying can add unnecessary stress to their life.
Today when an injured individual has an open claim, their treatment and prescriptions are being paid for by the insurance carrier or their employer. These claims are being paid at discounted rate that is negotiated through bill review companies and HMO Networks.
So, what happens to the injured individual when they settle their claim and must use their own funds to pay for future medical treatment? If an individual self-administers their medical settlement, they will likely be paying at a cash rate, which can be expensive and as the Wall Street Journal and New York Times articles showed, inconsistent. Instead, the injured individual also has the option of utilizing a company to professionally administer their funds. In fact, the Centers for Medicare and Medicaid Services (CMS) “highly recommend[s] that settlement recipients consider the use of a professional administrator for their funds” in the Workers’ Compensation Medicare Set Aside Reference Guide.
With Ametros’ professional administration service CareGuard, individuals have access to a discount network and a team of Care Advocates that review each bill looking for errors and ways to save once they settle. Our members typically save 62% on provider bills and 28% on all other medical expenses.* In our 2019 Member Impact Report, we shared that through our discounts, negotiations, and reviews, we saved Ametros members over $32 million dollars in 2019.
Transparency in healthcare is rare, but with Ametros you will be able to have insight into what you are being billed, and what we are paying on your behalf. In addition, a team of provider bill specialists helps to negotiate bills on your behalf.
If you have settled or are considering settling your insurance claim, be sure to find out how professional administration can help save you money on your treatments and prescriptions, making your funds last as long as possible!
*Disclaimer: Any potential discounts or savings for medical treatment, including but not limited to, prescription drugs, durable medical equipment and/or healthcare items and services, are not guaranteed. Ametros has made no warranties, promises, representations or guarantees whatsoever about potential cost savings or the level of potential discounts obtained on any item, service or prescription payment. There are no assurances that prior successes or past results as to cost savings will be applicable to a Member on any of Ametros’ platforms. For additional information, please see our Terms & Conditions Page.
[i] Melanie Evans, Anna Wilde Mathews, Tom McGinty. “Hospitals Often Charge Uninsured People the Highest Prices, New Data Show,” The Wall Street Journal, July 6, 2021. https://www.wsj.com/articles/hospitals-often-charge-uninsured-people-the-highest-prices-new-data-show-11625584448.
[ii] Sarah Kliff, Josh Katz. “Hospitals and Insurers Didn’t Want You to See These Prices. Here’s Why,” The Upshot, The New York Times, August 22, 2021. https://www.nytimes.com/interactive/2021/08/22/upshot/hospital-prices.html.