The Upcharge

Dr. Hemkes and Shawn talk about why insurance doesn't make things as affordable as the insurance industry would like it to look and how DPCs are changing that.

Episode Transcript

(00:07):
Thirteen ten WIBA at full Scope withdoctor Nicole Hempkiss, Madison's direct care doctor
of whose doctor Nicole Heempkiss comes tous from Advocate, MD, a direct
primary practice with offices on the westside of Madison in Middleton, right at
Glacier Ridge Road, east side ofMadison, South Fair Oaks Avenue in Janesville,
down at Mineral Point Avenue, rightat ten twenty one Mineral Point Avenue.

(00:31):
Doctor Hempkiss, awre you doing thismorning? I'm doing well, Sean.
How are you? I'm doing great? Am I going to see you
out at Broadfest this week? Idon't. I don't think so. I'm
sure they probably have been three optionsthat I'm not usually making my way down
there. They do. They dohave a they do have a impossible brought

(00:53):
Wars on the menu. So wemay we may see you down here before
the week is over. And we'vegot important, really important things about education
and understanding. And you know,through every walk of life, you always
want to be a smart consumer.You want to be an educated consumer.
We're gonna talk this week specifically abouthow to be an educated healthcare consumer.
And doctor I still and I thinkI've told you this story maybe a couple

(01:17):
of times, but I'll tell itagain because what the heck when I remember
when I got my first I thinkfor a lot of people it's like this,
get your first full time job,you get out of high school or
college at summer job full time andoh you've got you've got insurance. You're
like, oh my gosh, everythinghas covered. Everything is good. Well,
then you learn about these things calleddeductibles and other things and how they

(01:37):
work. And sometimes we forget,like how to know what your deductible is
and all those other things, don'twe yes, you know. I think
one of the big things is thatinsurance is very complicated and it is hard
to know you know all the details, but there's it's good to know a
few of the big things. Soyou want to know what your deductible is.

(01:59):
So whether you have a one thousanddollars deductible or a ten thousand dollars
deductible, that's important to know,right because that's going to help guide you
to where you might go for things. So that would be one of the
big ones. And then things likeco pays or coinsurance. So copay is
the amount you go you pay atthe time of the visit, whether that's
a doctor's visit or a blood drawor an X ray, that would be

(02:23):
your co pay. Coinsurance is typicallya thing where once you have met your
deductible, you might still have someresponsibility. You know, for example,
you might be responsible for twenty percentof the bill and the insurance pays eighty
percent of the bill. So thosetwo things again would be good to know
because let's say you have a youknow, one hundred dollars co pay every
time you go to an urgent careclinic, or a forty dollars copay when

(02:45):
you get lab work done. Again, that might help to guide you as
to where you go for those things, and you would choose a different place.
So I think it's it's really goodto know. Even if you know
those basic things, you're deductible,your co pays, your coinsurance, that
would be good kind of a foundationto know about you know what your coverage
is. We talked this morning withdoctor Nicolehemkiss of Advocate, MD, which

(03:08):
is a direct primary care practice.One of the interesting things as we talk
about insurance, people say, well, do I do you build my insurance
or how does that work for yourprimary care? Your visit to do Advocate
MD. They are all included inyour membership. No worries about deductibles,
copays, those type of things.As a member for your primary care at
Advocate MD, you get all ofthat included with your membership. You can

(03:30):
learn more about that all online thewebsite Advocates DPC dot com. That's Advocates
DPC dot com. The telephone numberto make an appointment and become a member
at Advocate MD six O eight twosix eight sixty two eleven. That's six
O eight two six eight sixty twoeleven. Mentioned the three locations for Advocate
MD. Of course, they've gotfive doctors to see you, Doctor Nicole

(03:51):
Heempkiss, doctor Adam Balen, doctorKaren Showman, doctor Michael Augie, and
doctor Christina Quality, the newest doctorat Advocate MD. Again, you can
learn more about all the doctors,the locations of direct primary care on the
website Advocates DPC dot com. That'sAdvocates DPC dot com. And some of
that is I sometimes feel and Ithink you probably feel this way as well,

(04:13):
some of the complexity with insurance.I'm going to say it might be
intentional to uh, to make itconfusing and so people tend not to use
it in the proper ways and notreally maximize that is is it is hard
to understand sometimes, isn't it.Yes, I mean, there are so
many different types of insurance and withinthose different you know, each insurance um

(04:35):
you know, whether it's Blue Cross, Blue Shield, United At No,
there's you know, the HMOs,the PPOs, the Gold Plan, the
Bronze Plan. So it's it's soit's become such a complicated thing. I
don't know that. I don't thinkit was always this complicated, but I
feel like like everything in life,taxes, every you know, there's a
multiple layers of complication now. SoI do agree that it makes it harder

(04:56):
for the patient. And also maybethat's partial, you know, maybe that
that's true that they do that onpurpose, because then it's it's harder for
them to be able to defend ifif you know, if they get charged
for something and they didn't realize theyshould have been charged for it. But
I think you know, again,if you if you kind of know those
basic things, and that's part ofthe reason why I think that again,

(05:16):
direct primary care has gotten so popularbecause you know, in our model,
everything is very transparent, you knowthe price of things, it's it's listed
on our website. You know,we're not about hiding any prices. We're
not about making it complicated. Wewant to keep things as as straightforward as
we possibly can. That's better forus, that's better for the patient.
And if you ever have questions aboutbills or what or prior to what the

(05:39):
cost of something is, we letthe patient know that all you know right
away and so there's never a surprisebills that come in the mail. And
that's a really nice thing for patients. One of the areas too, that
I think is often surprising for ensuredpeople is you know, whether they're have
a hide a Doctorborian type of plan, is be a some is well.

(06:00):
The insurance company the prices that theynegotiate with hospitals are always the lowest,
and people are often surprised to learnthat pay is what's the old saying about
cash is king if you have likehigh deductible insurance or it's always worth a
discussion. Paying cash can can saybe a pretty substantial savings, can't it?

(06:25):
Yes? As you said, Sean, I think a lot of times
when people have insurance, you know, the idea is like, well,
I'm paying for this insurance. I'mjust gonna use my insurance card for everything
I do. Right, I'm payingthis monthly premium or you know, likely
I work for a company and theypay part of it and then I pay
the remainder of it. So whywould I not use my insurance? Why
would I pay cash when I haveinsurance? Well, the reason you might

(06:46):
decide to pay cash, and youknow, I try to pay cash for
as many things as I can isbecause what happens when you go through your
insurance is that we've talked about thisbefore, Sean, we automatically think that
the insurance has negociated as a discounton this, right. So that's part
of what insurance is for, right, because we're getting this special discount.
You know that MRI at the hospitalis three thousand dollars, but you know

(07:09):
if you if you didn't have insurance, it would be five thousand dollars.
So the insurance has negotiated that pricedown for you. Well, the reality
of the situation is you could paycash for that MRI at a different place
and it could be five hundred dollars. So it's it's it's always like it's
hard to wrap your mind around that. But what I would say about paying
cash is that you know, you'vetaken insurance out of the equation. And

(07:30):
for when you pay cash to afacility directly, the way they look at
it is they don't have to gothrough all the work and all the staffing
and the time and effort of collectingthat from the insurance company, worrying about
whether it's going to be declined orobviously the insurance doesn't pay all of it,
they pay a portion of it.So if they can get cash directly
from the patient, they like that. And it's also you know, sometimes

(07:51):
they might require you to pay acertain amount upfront. Sometimes if to get
the cash discount, you have topay the whole amount. That's not always
the case, but they will giveyou a very good discount. So systems
here in town, it could beanywhere from thirty three percent to there's a
system that gives you a fifty percentdiscount when you pay cash. So I
mean, that's a really good thing. So I would think about that.

(08:13):
You know, I would say topeople that if you have a high deductible
and that that could be five thousanddollars, that could be ten thousand dollars.
If you need something like an Xray and MRI, even a specialist
visit, urgent care visit, itmight be better for you to pay cash
for those things. The caveat beingthat that would not go towards your deductible.

(08:33):
If you're paying cash and you're notgoing through your insurance, they are
not going to count that towards yourdeductible. You cannot submit it later on
if you if you're going through likean HSA or something that that is a
kind of a different scenario. Butyou cannot pay cash for something and then
try to submit that to your insurancelater on, So you would that would
be kind of a separate thing.One thing to important important nuance there to

(08:54):
keep in mind and remember. Anddoctor I think of you know, you
have an injury, you twist yourankle, or you break a bone or
even you know, some other typeof injury that requires something like like physical
therapy and going into you know,recovery for that that that injury. Um,
there are some you've got some examplesof for example of of when when

(09:16):
you go in to see the physicaltherapists. Some things that can that can
help people understand and and and reallykeep that that bottom line and check yes,
you know. I I'll use myselfas an example. You know,
a little while ago, I hadto go to a few physical therapy sessions,
and I try to be an educatedconsumer, so I I called ahead

(09:39):
to the health system, tried tofind out what the cost was going to
be, you know, asked themabout the cash discounts. You know,
I was given a number, sofor the initial physical therapy appointments, UM,
it was going to be five hundredand fifty dollars. They were going
to discount that to three hundred dollarsUM with the cash discount UM. And
then the follow ups was going tobe uh three hundred and thirty dollars,

(10:03):
and then that was going to bediscounted to something like two hundred UM.
But the interesting part is that,you know, when I went to the
appointment and then I got the billand the mail, UM, they did
not discount. They did not giveme the cash discount, even though they
knew I was paying cash UM,and so so it still was showing that
I owed five hundred and fifty dollarsfor that first visit. So then again,
you know, this is the thisis the really frustrating part and like

(10:26):
the time consuming part. So nowI the patient have to call them and
say, hey, you know youdidn't give me this cash discount. You
know, why not can you dothat? And then you have to be
diligent and following up with it,and and a lot of people, honestly,
I mean sometimes including myself, orlike, okay, you know what,
I don't have the time for this, you know, like I can't
deal with this. I can't.I don't have time to follow up.
And so so I think a lotgets lost there. But if you can

(10:50):
kind of again make it a pointto stay on top of it, um,
you know. And again this isthe part that's that's hard because you
could be told, you know,a lot of systems now will give you
a price estimate ahead of time,including the system that I went to this
visit, and they'll give you aprice estimate, and then you know,
you could actually go in for thevisit and it could be very different than

(11:11):
the price estimate. They are requiredlegally to give you this thing called a
good faith estimate, and I can'tI don't know the legality of if it
has to be within a certain percentageof what the actual cost ends up being
but they have to give you agood faith estimate. I always find it
funny because if I'm not going throughinsurance, you should be able to tell
me what you're going to charge,right. I get that they can't maybe
determine what portion the insurance is goingto pay for because there's so many different

(11:33):
types of insurance, But if I'mgoing directly to you and you're charging the
one charging it, why can't youtell me the price? It seems a
little bit odd, But yes,that is part of it, is making
sure you know, getting the estimateahead of time if you can, and
then when they send you that bill, make sure that it did what they
said it was going to cost,and if it didn't, call them back

(11:54):
and find out why and tell themthat you had been told a different number,
and you know that eventually could getthem to lower the price. That
is it's interesting that scenario, andunfortunately, I think a lot of folks
are saying, yeah, that's notsurprising folks who have dealt that. One
of the great things about direct PrimaryCare and Advocate MD is everything is in
black and white. What's included withyour membership, And of course doctor Nicole

(12:18):
doctor Balin, doctor Augie, doctorSchulman, doctor Quality Quality. They are
all advocating for you at Advocate MD. It's an amazing model direct primary care.
If you have not explored direct primarycare for yourself, for your family,
if you're an employer or somebody lookingfor some great options for your employees
are at the workplace. And againif you're saying, well, I don't
make those decisions. Let the peopleat the office know about direct primary care

(12:41):
and Advocate MD. You can getthat information all online at Advocates DPC dot
com. That's Advocates DPC dot com. The telephone number to make an appointment
to become a member at Advocate mD six O eight two six eight sixty
two eleven. That's six O eighttwo six eight sixty two eleven. And
again the website Advocates DPC dot com. Welks into our conversation with doctor Nicolehempkiss

(13:01):
next as Full Scope with doctor NicoleWisconsin's Directcare dot continues right here on thirteen
ten WIBA, twenty four thirteen tenWIBA and full Scope with doctor Nicolehempkiss,
Wisconsin Directcare Doc. Of course,doctor Nicolehempkiss comes to us from Advocate MD,

(13:26):
a direct primary care practice. Youcan learn more about Advocate MD online
the website Advocates DPC dot com.That's Advocates DPC dot com. Talking this
week about getting educated and one ofthe great things about direct primary care and
one of the great things about AdvocateMD is there so much great information available
on the website and of course thedoctors are always there to talk and help

(13:50):
educate you as well when it comesto options. And again you can learn
more about direct primarycare on the websiteAdvocates DPC dot com. That's Advocates d
EPC dot com. Talking this morningwith doctor Nicole about the importance of being
an educated consumer and doctor. Oneof the kind of sad things is for
folks in that insured world, evena trip to urgent care or the er,

(14:13):
Wow, it can get really expensive. And of course when you're in
a position like oh, I needto I need something looked at. If
you're in that insured system, likeyou need stitch as well, I can't
wait a couple of weeks or acouple of days to see my primary care
doctor. I'm going to have togo into urgent care for something like that.
Direct primary care a little bit different. There isn't it. I would

(14:35):
say, if at all possible,avoid going into a hospital or an EAR
unless you absolutely have to. So, you know, situations being like you
think you're having a heart attack,you think you're having a stroke, you
you have a broken bone to whereit's it's you know, sticking out of
your harm or something. You know, those kind of situations you need to
go straight to an er, youknow, or call nine one one.

(14:58):
You know, of course heart attackor stroke situation, but there are many
situations in which people utilize ars,you know, for things where they could
go to an outpatient clinic. Youknow, you have a sore throat,
do you have a bad cold,you're throwing up, you have a migraine,
these sort of things. Again,maybe part of the issue is that
they can't get in to see theirdoctor, so they are told to go

(15:18):
to an urgent care and EAR.In the direct primary care clinic that we
have, we always get people infor urgent care appointments. But the other
thing, aside from the EAR thatI would just remind people is that whenever
you go into a hospital, whetherit's a an MRI, whether it's a
minor surgery, procedure, whether you'reseeing the specialist inside of that hospital,
you are being charged a higher rate, not only a higher rate for that

(15:41):
visit, but also a facility fee. So the professional services many times are
higher, but they're charging you thisadditional facility fee, which could be you
know, could be two hundred dollars, it could be eight hundred dollars.
So that's simply because of the factthat you went into a hospital. And
what they say, and this isall legal, is that they are renting

(16:02):
that space from themselves and they havea higher cost of maintaining that space because
it's located within a hospital. Soif you have the ability to see a
specialist outside of the hospital, youalso have to be very careful because there
are there are clinics outside of hospitalsthat say that they are part of the
hospital, and so they will stillcharge you the facility fee. These infuriating
things, but you know, ifthat's getting an X ray, if that's

(16:25):
seeing a specialist, or if youhave a minor procedure, you need done
do it someplace that is outside ofa hospital. And if you can choose
a private practice, choose a privatespecialist that is not owned by a hospital
system because again then you will notbe charged facility fees because, like I
mentioned, even though sometimes it's notwithin the hospital, they have this tricky
thing they do which says, thebuilding is owned by you know, hospital

(16:49):
ABC, and so we're still goingto charge you the facility fee. And
I don't it's legal, but I'mnot really quite sure how it's legal.
But so if you can go toa private doctor that is not an employee
of a hospital system, that wouldbe preferred because you know that there's not
going to be a lot of thesehidden fees and these exorbitant professional fees that

(17:10):
you get with hospital systems. It'slike going to a restaurant. They charge
you for the food you ordered,but then they charge you for the table
you sit at and be like that'soutrageous. Tragically, it goes on so
often in the medical world as well, and there's a great option for you
and your family out there. Ifyou've got an employees looking for some great
options for them as well. Whenit comes to primary care, definitely make

(17:33):
sure you are checking out direct primaryCare and Advocate MD. It is an
amazing model high quality healthcare at affordablecosts and very attainable and very the doctor's.
Great thing about Advocate MD is whenyou make an appointment with your doctor,
you'll see your doctor. They're quickto see you, the appointments last
or it's just a phenomenal model.You probably heard us talking about it.

(17:56):
If you want to learn more aboutAdvocate MD and direct Primary Care, the
website Advocates EPC dot com. That'sAdvocates DPC dot com. Looking for something
great for yourself for your family.As an employee, talk with your employer
about direct primary care again, highquality primary care and it can save them
money, which I know a lotof employers their ears kind of perk up
when they hear those words. Socheck them out online. Let your everyone

(18:17):
know about Advocate MD online Advocates DPCdot com and then telefe number six O
eight two six eight six two elevento make an appointment and become a member
at Advocate m D. Again thenumber six O eight two six eight sixty
two eleven. Doctor Nicole Heem kissyou enjoy this fantastic day and have a
great weekend. Thanks Sean you two. Certified financial planner Tracy Anton comes your

(18:37):
way next right here on thirteen ten, Wiba