Medicare, ABN, and Highway Robbery

If you are American and have, or someday plan to have, Medicare, this is required reading. If you live elsewhere, count your blessings, at least when it comes to medical services pricing.abn-bag_of_money

We believe in testing. We do not believe in enriching the test centers by encouraging people to get tests that may be absurdly priced. Hence, we are going to run a series of posts that cover some of the sleaze going on out there.

Let’s start with Medicare ABN, one of the more egregious examples.

From the Medicare site

Your costs in Original Medicare

You pay nothing for Medicare-approved covered clinical diagnostic laboratory services.

[so far so good, but then…]

Note

Your doctor or other health care provider may recommend you get services more often than Medicare covers. Or, they may recommend services that Medicare doesn’t cover. If this happens, you may have to pay some or all of the costs. It’s important to ask questions so you understand why your doctor is recommending certain services and whether Medicare will pay for them.

[uh oh, what sorts of costs are we talking about here?

Surf…Surf….Surf… hmmm…hard to find…

…later that same day, on another government site:]

A physician is required to give you an ABN if either of these are true

  1. He believes Medicare may not pay for an item or service;
  2. Medicare usually covers the item or service; but, Medicare may not consider the item or service medically reasonable and necessary for this patient in this particular instance. (For instance, if Medicare considers the test is ordered too frequently.)

ABN stands for Advance Beneficiary Notice, and is intended to protect Medicare from unnecessary procedures, and the patient, you, from unpleasant surprise charges. However, abn-formthe charges will still be unpleasant, just not a surprise.

Now then, what happens if you sign the form? Well basically the blood draw people will charge you some rather unspecified price. They do NOT charge you the cheap Medicare price. Who ordered that? The usual suspects, we suppose. It would have been a rather simple matter for Medicare to add “…must be billed at the Medicare rate,”  at the appropriate spot.

And what do we suppose that price might be? Well, this is a little hard to find out. In fact, quite hard. But then, a precise medical money-extraction procedure like this couldn’t be left to individual blood centers, could it? There had to be guidelines that the laboratory companies issued to their own people. Right? We searched and searched, but no such information was to be found. Finally we stumbled onto at least one lab that had put their procedures and prices on-line, so let’s make the assumption that they are typical, and dare to compare the ABN prices to three priced-up-front alternatives:.

Test ABN Price:“Welcome To My Parlor” Labs Walk in Labs:LabCorp Retail New Century Labs: Quest Retail
Fasting Glucose $44 $27 $10
PSA $130 $35 $17
Triglycerides $77 $27 $15
Hemoglobin A1C $68 $27 $14
HDL Cholesterol $87 Included with triglyceride test included with triglyceride test

Do you see a trend here? Which prices would you prefer to pay? By the way, these aren’t fly-by-night back alley outfits. New Century Labs is a retail front for Quest Diagnostics, #1 blood draw, and Walk In Labs sends you to LabCorp, #2. You pay, they send you a blood draw requisition, you go to the nearest Quest or Labcorp. They take your blood, but no more money. And there is always a nearby one. Combined, they operate almost 4000 centers.

ABN is a form you have to sign, and it is required to contain pricing information. You physician is supposed to have you sign it. DON’T SIGN IT. It is a license for the blood draw company to steal. A license for the blood draw company to charge you whatever they want..

Instead get your doc to do one of these three things:

  • abn-doctor_consultationWrite down the tests he wants you to get and go get it retail via Walk In Labs or New Century Labs.
  • Get a test requisition from your doctor. Take it to Quest or LabCorp, or any other, and say, no insurance, tell me in advance the cash price, or your cheapest price. Wheedle and whine. Discover your inner Arab Carpet Merchant. They will give you a good price. If they don’t, walk out. If they haven’t already taken your blood, you have choices.

Medicare people: If you didn’t sign an ABN, and they take your blood, you don’t pay. Your physician could possibly be on the hook for this though. He knows this, and will be reluctant to request a test for which Medicare may not pay. However, if the two of you agree that you are going to get the Medicare tests that are safely covered, he can write a requisition for that, and a second one for the other tests. No sticker shock here, and all bottoms covered.

How is it that this outrageous ABN pricing is allowed? A simple change to the law would fix it all: “Prices for ABN services must cost the same as Medicare covered services.” Want to save the senior citizenry a bundle? Write your congressperson. Write AARP. Yell out the window “I’m as mad as hell, and I’m not going to take this anymore!”  How much of this thievery are we expected to tolerate?

Note. We talk a lot about Walk In Labs and New Century Labs, because a quick and informal survey found them to be the cheapest. However, there appear to be several dozen others, most of them sending you to either Quest or LabCorp. There may be cheaper ones out there. Let us know what you find. Also, watch out for sales. It’s retail after all. Remember, a test by Quest or LabCorp is the same test whether you paid $11 for it or $200.

  2 comments for “Medicare, ABN, and Highway Robbery

  1. Dan
    May 22, 2016 at 6:59 am

    You might update this, given all the negative news surrounding Theranos…

    • May 23, 2016 at 8:29 am

      Dan, I know. I still find it hard to believe that Theranos was started as a criminal enterprise. They were going to be a major disruptor of current lab economics and thus had a very large target on their backs. I also know that regulators were motivated – yes, they are on the status quo’s side in all disputes – to find fault. At this point I simply do not know what to think except they won’t be the price disruptor as soon as I had hoped; or perhaps they will never be. Someone will, as the current multiple-tiered price-model is corrupt. Watching and waiting… Thank you for your input, Dr. Mike

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