Salinas Valley Memorial Hospital - Imaging...
This is a case where a hospital was paid $3677 for a 3 minute CT scan.
That 3 minute scan is paid out from Medicare and Medicaid at $85-150.
Most insurances pay out under $200 for the service.
If I had wanted to pay cash for it, without insurance it's in the $450 range. Which is really screwed up too if you think about it. A cash price that is 2-3x more than a price where the provider has to bill insurance, wait for money and then bill a patient? Why wouldn't that price be the same or less than the insurance reimbursement price?
Oh. Wait a minute. I forgot. I'm in the USA, where all commercial logic stopped working decades ago. Swapped out for an illusion and none seem any the wiser.
Sadly, Blue Shield did pay $3647 and they mandated that I had to chip in $30...
And sadly, according to all involved other than me, everything with the payment is "ok", even though the auth was for a different cpt code outside of a hosptial setting...
Let's roll this back a bit, see what happened, get educated and then see if this makes any more sense...
I needed a CT scan of my right hip.
- A simple 3 minute scan.
- It's really just a bunch of x-rays taken in rapid fire form that can create a 3-D imagine for review.
- I was referred to a hospital instead of the far more affordable imaging center next to my doctors office (which is now owned by the Hospital)
- The hospital got reimbursed $3677.38 for the 3 minute procedure.
- cool video here of what it looks like when it spins..
- https://www.shutterstock.com/video/clip-1018886323-ct-scan-image-pelvic-bone--hip
We've all heard these stories.
- Chase CEO Jamie Dimon even referenced this or something very much like it on a TV interview the other day. Who heard that? Anyone? He thinks he and a good team of a few are going to "tackle this"? Hummmm...
- I'd imagine it went in and out of most ears.
- He did a nice job of playing down the over billing as a "minor problem"
- I've yet to hear him address the 2 Billion in cocaine found on a Chase own frigget, have you? No wonder their transportation fund has been doing so well...
- If we wait for those making BIG BANK on all this to 'fix it', we'll be waiting a long time since they've had the 'fix on it' for decades. Anything now from these folks is but a distraction. Sadly.
This story is so straight forward, I thought I'd put this one in writing to see if the people who are sustaining this game with their own life energy are ready to wake-up (yet).
I'm going to include a backstory in here about Hospital Billing versus non Hospital billing to set the stage.
This backstory may disappear or shift elsewhere with time, as it's a story in and of itself, but for now, this is where it will reside.
Backstory about Hospital Billing versus non-hospital facility billing...
In late 2013, I finally got diagnosed with mal formed hips (aka FAI, aka Pincer and/or Cam Hip Impingement).
I had been suffering for over 15 years with no proper diagnosis, which only took a $45 x-ray once someone figured out where to look for my lower back, upper back and leg pain.
Just prior to the diagnosis, I was at the point where I viewed my future with only two options. 1) ask the doctors to severe my hamstrings and live my life out that way in hopes of reducing the pain or 2) blow my head off.
The daily torture with no understanding of source had gotten to be too much. All therapy was fleeting and almost any motion caused flare ups. Some people with these only experience minor issues. Others like me get nearly paralyzed by pain.
The "fix" was an arthroscopic procedure that involved cutting a groove in my hip bone to eliminate interference between it and my sacrum.
From a carpenter's perspective, this is pretty simple stuff once it was diagnosed properly
Tiny incisions are made. They stick tools and cameras through the holes and they grind away the impingement(s).
They know they got it close by moving you all around while you're passed out...
I had had about 10 surgeries prior to that round of 6.
Most had been orthopedic, and arguably, most were likely needed or a result of navigating around the dysfunction of the hips.
I was extremely familiar with the US Corporate Store as it pertained to our health insurance system in general. I was turned down for insurance when I was 22 and there's little more terrifying than realizing that beast early on in the dream.
I was extremely familiar with over billing of insurance by billers on one hand, and the over billing of patients by billers on the other. They prey on both sides of the money pit and most of you fail to acknowledge their existence as people yet (smh).
Due to 10 prior surgeries, mostly at surgical centers vs hospitals, I was extremely familiar with the cost of surgical procedures at surgical centers vs hospitals.
For the first surgery in 2014, my hip surgeon asked me if I preferred the hospital or surgical center for procedures. He indicated he liked the local surgery center for easier access and I said that was fine.
Unfortunately, he called back to say my insurance company at that time, Blue Cross, would not allow surgery at the surgery center. They required the surgery be done in the hospital.
He told me how illogical it was, and that he was aware the facility fee for the work was double to triple, but it was what it was. He told me he saw that regularly from a few insurance companies, with Blue Cross being one of them.
Why would an insurance company force a procedure in a facility that was going to charge double or triple the rate for an already overpriced 8k facility fee? Great question. In my opinion it's all about inside relationships and cash burn.
I had four surgeries in the hospital that year, with facilities charges in the $17k to $27k range as I recall. Those fees are for a 4 to 5 hour outpatient visit, beginning to end. They cover a bed in preop. A nurse inserting an IV. An operating room rental fee stocked with a few nurses and assistants. A bed in post op and a nurse in post op. Now that's some lucrative property management work with a few contract laborers tossed.
In a strange change up, on the 5th and final surgery that year, which was in November or so, Blue Cross allowed for the final procedure (which was a redo of one done just months prior) in the surgery center vs the hospital. That facility charge was in the 8k range, vs the $17-27k range, as was paid to the hospital numerous times prior that year for the same types of procedures.
From my perspective, it seems Blue Cross had completed their necessary cash burn for the year and thus they were ready to manage money for the final month or so before starting their game anew.
Just like troops and contractors in Iraq burned equipment so they can ask for new stuff the following year, the insurance company seems to do the same. They simply burn cash, and nobody gets it. Everyone wants to blame the poor people and the people who have issues that we should all care about (smh).
Some baseline reimbursement fees for outpatient surgery for foundational education...
For what it's worth, there are typically three fees associated with an outpatient surgery.
- A surgeon fee
- An anesthesiologist fee and
- A facilities fee.
It's pretty simple and straight forward stuff. Three items on three different bills from the three "vendors" involved. Note, if the procedure is done in a hospital, they will typically add more line items to their bill instead of just bundling it into one line item, just because they can. It's hard to justify all that work under a single number I guess.
For what it's worth, this is the typical range of pay for an outpatient surgery.
- Surgeons get about $1200 to $1500 for a 1 hour outpatient surgery
- Anesthesiologists get about $1000 to $1200 for a 1 hour outpatient surgery .
- Surgery Centers get about $6-10k for a 1 hour outpatient surgery. Hospitals get $16-30k for renting space for the same surgery.
I realize we've gotten a little off track with regards to this gross CT scan billing thingy, BUT it's important you look at this example as just a clean example of things that are in fact far larger and far more problematic too.
ON TO THE STORY!!
I live in the Monterey Bay area.
I live in between Santa Cruz and Monterey a few miles inland. A handful of miles north of Salinas.
We are about 100 miles south of San Francisco and about 50 miles south of San Jose.
Not everyone is rich in this area.
There are really rich people, kind of rich people, normal people, poor people, really poor people and the illegal immigrants who farm $6 Billion worth of food annually from this area, keeping the rich and powerful people around here in the money and everyone who eats US grown greens in the chemical bath that is non-organic food.
Jimmy Panetta is the Congressman for the area I live in. I met him once in his office. He seemed like a very nice person. His staff was very nice too. They kept us on schedule.
Those of you who read and liked "My Day at a Hillary Clinton Rally", you'll probably like this one too. It's been written in a similar style.
The doctors I go to are mostly in the Salinas area.
I've been to one or two in the Monterey Pacific /Grove area and one or two in the Carmel Valley area too.
My preferred "doctor" is a Licensed Acupuncturist who works in Monterey and Prunedale. He's not a Dr because he only took three years of schooling to get a masters in Acupuncture. There are Dr's of it. They take 4 years. The label is far less relevant than their experience and their own Chi. His ability to reform bone and repair tears is slower than I prefer, although likely pretty good if I had the patients for it. (<< a fun play on words!).
Salinas has a population of 157,596 people.
This is that place John Steinbeck is known for.
It's a small town, surrounded by Big Ag.
The hospital and most of the medical offices and such are on the south side of town, generally in the red circle.
The green circle was where I tried to see Hillary Clinton when she was in town.
What a strange event and strange experience that was. You really should read that story too. It went viral during the campaign for about 36 hours before it got pulled from all the FB feeds. Alas, it was my short time in the spotlight as a writer, but it was really fun while it lasted.
Most things medically related are within a mile or so of each other.
Salinas Valley Memorial Hospital (SVMH) is the hub of all things medical.
SVMH recently bought out the Precision Orthopedic folks. Their clinic is now called Salinas Valley Memorial Clinic (SVMC). It has a dozen or so orthopedics in it and there is an MRI facility with one machine in the same building that is lower cost and convenient. They don't have any Radiologists who read there. They take MRIs and send out to folks in the Bay area to read (folks who bill like the devil it seems).
Salinas Valley Imaging (SVI) is right across a side street from SVMC. They are owned by Radiologists. They have a lot of imaging machines (MRIs, CT, and other). They do the imaging reads for SVMH, but oddly they do NOT do the reads for the MRIs coming through SVMC right next door and owned by the hospital. That seems odd to me. Why would the hospital send them the high fee reads and not the lower ones?
The private surgery center at the bottom of the image, Monterey Peninsula Surgery Center, use to be independent. It was recently purchased by the Monterey Peninsula Surgery Center group.
And finally, speaking of "odd", be sure to check out the "Independence Order of Odd Fellows Cemetery". << ???? It's right behind "Denny's" (the only foody landmark google applied to this map by default?)
All my orthopedic medical healing stuff that requires an MD typically starts with the SVMC Ortho clinic at 611 Abbott Street.
The staff at the front desk works very hard. Everyone does a good job of keeping a smile on their face. The supervisor of those folks is available and accessible. It's cool.
The MRI machine is out the front door an into the door to the right. The two offices are connected on the inside for employees. It's really the same facility, but patients only go in and out the front doors.
https://www.svmh.com/Locations/SVMC-Orthopedics-Podiatry-Spine-Sports-Medicine.aspx
MRI machines and CT Machines
The machine to the right is an MRI machine.
It uses magnets and electricity to create images of soft tissue and bone. You lay down on the bed and they slide you in until the body part is inside the donut.
A scan for body part extremity typically consists of multiple scans. (you can here the machine start and stop and the person running it will talk to you through a speaker). When it turns on, there are very loud vibrating and humming noises. Nothing sounds like it's going round and round even though it's a round shape. It sounds kind of like the sounds when they buzz to open and close jail cell doors.
The entire process from the time you lay down until you get up might be 25-40 minutes. You wear ear protection because it's loud.
The lower end of reimbursements from insurance to the facility for a scan with this machine is in the $180 range. That is just for the scan.
A radiologist, who can be located anywhere in the world, has to read that and write up a short report. They get paid about $80 for that job. It only takes about 10 minutes and they get $80 or so.
The machine to the right is a CT scanner (aka cat scanner).
Conceptually, it operates similar but different to an MRI machine. It's around and smaller and simpler. This is older technology. It is basically a round x-ray machine. It takes a bunch of x-rays like slices through the body and then they compile those into a 3d model. It's good for modeling broken bones and such but does nothing for documenting soft tissue issues. There is a lot of radiation associated with this machine that does not exist with the MRI.
Like the MRI machine, you lay on the table, they put the body part into the donut that needs scanning, and then they scan. When this is turned on, something starts going round and round like from star trek. It sounds like a soft motor going round. No ear protection required (as I recall).
My scan on my right hip only took 3 minutes (vs an MRI for my right hip which took 30-40).
A reimbursement from Medicaid and Medicare for a 3 minute CT scan is typically in the $75 to $150 range. (compared to an MRI which is 160 or so).
Just like with the MRI, a radiologist, who can be located anywhere in the world, has to read that scan and write up a short report. They gets paid about $60 for that job. It only takes about 10 minutes and they get $60 or so.
As we can all see, a CT scanner is a simpler machine that can do very fast work. Reimbursement for its use is typically lower than that of an MRI machine. The processes look very similar, but the technology itself is in fact quite different and it produces a different output. CT is only typically used for mapping bone issues, and MRI's are good for both bone issues as well as soft tissue.
The authorization process for an MRI or CT scan is similar, and there's a murky twist in here that's worth a look-see...
A doctor writes an order and/or a prescription on a piece of paper.
If no insurance is involved, the patient would be on their own to find an imaging center and negotiate fees.
Cash fees for MRIs and CT scans run in the $450 to 800 range. You have to see if that includes or excludes the read.
That compares to $75-150 fees they get for insurance patients for CT scans and $160 fees they get for MRIs which exclude a $60 to 80 read fee.
Question -- Why do doctors charge MORE for a service when someone is standing there with cash? Shouldn't they charge less, or at very least an equal amount? They have to do a LOT more to collect from insurance. Collecting cash is a lot easier. Something seems very, very broken here...
Assuming insurance is involved, that authorization paper/prescription actually goes to someone in his/her office that calls the insurance company to get approval for the scan.
This is odd to me. It makes more sense to take that script to an imaging center where they would call.
But there is something else odd about this that is more disconcerting... (and it seems like part of this process has now been fully hijacked).
When the doctor's office calls for authorization, the authorization that is given is not only given for a given procedure, the authorization is only given for a single, specific facility that the Doctor's office had to specify at the time of the call...
Yep. The call from the Doctor has to not only ask for permission for the service, but the doctor has to specify a facility before checking on availability at the facility...
Strangely enough, when the patient gets a copy of an authorization letter in the mail, the implication is that the procedure was approved and they could go where they wanted, with warnings about in-network and out-of-network providers
This entire letter presents a fully false narrative.
I could only go to the provider that was authorized, and that information is NOT on the authorization document and the opposite is implied.
In speaking with folks in my docs office, this is industry standard, not isolated to Blue Shield.
If I had wanted to go to a certain place, I needed to specify that before the authorization.
What if the place they authorize has a 3 week wait? What if the one across the street which is also in network has immediate availability? One would think I could take this auth in and they could use it right? NOPE.
I have to get my docs' office involved again to start the auth process over. Make that make sense...
Basically, the doctor's offices have now been put in charge of directing all aspects of imaging ordering. If a greedy business person or company wants to control who gets imaging business in a town, they have to now control the doctors offices, or at very least the employees making the authorization calls...
If I owned an independant imaging facility, this would bother me. It sounds to me like as an imaging facility, you either now have to get in with the doctors offices and be their first choice, or you may be out of business.
Or wait... maybe it works this way, in Salinas anyway... As an imaging center owner, you are either forced to sell out to the hospital who has bought up all the doctors offices or you go out of business?
It kind of looks like all previously free MDs, are either becoming an employee of a bigger fish or they may be running out of luck...
The EOB...
The hospital that did the CT scan submitted an EOB to Blue Shield on 4/30/2019. That was turned around in a day. Nice work!
The Blue Shield authorization letter indicated cpt code 73700 was approved for the CT scan .
The code Blue Shield paid out on was 0350.
Odd.
Wouldn't you think they'd track authorizations and approvals?
We saw Blue Shield turn down an MRI read bill from Advanced Imaging for an auth code to billing code mismatch? Given that, how does this mismatch happen?
HINT: by design.
For all those that think Blue Shield should care about overpaying by $3500 for a 3 minute service, ask yourself why?
Blue Shield and all insurance companies are basically going to pay themselves on a portion of everything paid out. If they pay out more this year, they get to increase premiums next.
It's such a huge sham you should be ashamed you keep pointing at "un-insurable" ones for the blame.
Sparrow Health Care
So, where did I get the medicare and medicaid reimbursement rates for this expose?
That little tip came in from one bird to another. I googled some cpt codes and some magic words and poof. There was a document of my dreams. (an upload at www.sparrow.org . See if you can find it if you'd like your very own copy of all pricing for all radiology codes. Google will take you there. No hacking required)
NOTE: The "Sparrow Price" here is irrelevant. This insurance pricing system in general is far more confusing and far more terrifying than used car dealers. They can list any price they want on any document they want. They could claim this 3 minute procedure was $10,000 with no repercussions. It's an airy fairy number. Just focus on the "reimbursement" rates. According to this, health insurance typically pays 751 for this. When I asked around, that was not the case at all. Health insurance was reimbursing more inline with the cash price noted here ($150).
Salinas Valley Memorial Hospital
According to Wikipedia, Salinas Valley Memorial Hospital has 269 hospital beds and 2132 employees.
Wow. That's almost 10 employees for every bed?! Gheez. That seems like a lot, doesn't it?
Supposedly, in the late 2000's or so, the Salinas Hospital was near bankruptcy. They now get 3.5M a year from Salinas tax payers, and now they are making HUGE bank (like in the $50 Million per year in profits range...).
It seems SVMH stopped updating their website with financial disclosures in 2017. At that time it looks like they were making about 50 M per year in profits.
https://www.svmh.com/About-Us/Healthcare-District-Information-Reports/Financial-Disclosures.aspxHUH?
50,000,000 / 2132 employees = > That's $215,000 in profits per employee!? That's outrageous...
50,000,000 / 158,000 residents =>> That's $316 in profit from every citizen in Salinas. One report indicates they operate on a 10% profit margin, meaning every person in Salinas would have had to require $3160 in medical services in a single year to net SVMH this small fortune. How many people do you know that required $3160 in medical procedures last year?
And NASA too?
Can you think of any reason why the Salinas Valley Memorial hospital was one of a group of hospitals to work with NASA, along with the likes of Stanford and the Cleveland Clinic? Could Leon Panetta have influenced that? I mean really... how does a small community hospital get that type of connection? https://en.wikipedia.org/wiki/Salinas_Valley_Memorial_Hospital
Conveniently I JUST found this video online by accident. No kidding. I had no idea this was out there until I started writing up this summary. Truth is stranger than fiction sometimes.
PS: It looks like the hospital has bought up every major medical provider in and around Salinas. It sure looks a lot like a big company store at this point.. https://www.svmh.com/Locations.aspx
Blue Shield?
As for Blue Shield?
If I had to guess, they are the ones who own or have a major stake in the Hospital Systems. Maybe not directly, but look high enough and you'll likely find the same owners.
My insurance premiums have gone from 150/year to 1100/year in the last 10 years.
- It's not from the demand uninsured folks put on the system.
- It's from the collaboration of groups of individuals that we should all just refer to as the "medical mafia".
Nobody has wanted to address this for decades.
- I see no reason why anyone will really care now either, but I thought I'd at least give everyone the opportunity to see things for what they really are.
- A population fully drugged and numbed to the point they behave like prisoners in a cell with no bars more so than a group of beings here for a short spin around the earth school.
- It's too bad. There's a lot to see and do. I just need to untangle myself from this damn medical system!!
- I'll bet many in the medical mafia really enjoy their vacations, time off and benefits.
- Maybe I ought to switch sides. At least they set commercial goals and achieve them.
- Nah. I can't really consider it. My cats would dis-own me, and I simply can't bear that thought.
