Should Nurses know procedural costs?

[Nolagrace1202]

I got into a discussion on Facebook regarding lack of transparency of healthcare costs. A patient was asked by a nurse to sign a form saying that if insurance does not cover the procedure/test, the patient will assume financial responsibility. He asked the nurse how much the test was and she didn't know. My question is: should the nurse know the prices of procedures and tests he/she is involved in?

[elkpark]

Advocating for the patient is actually a basic responsibility of nursing. Ensuring that a patient's questions regarding a procedure they are considering consenting to have been answered is also a basic responsibility of nursing. Nurses are free to defer patients to a more appropriate source so long as that source is available to answer their question in a timely manner. I've never worked anywhere that the billing department is open any other time than regular business hours, or about one quarter of the time, yet procedures are being ordered for patients 24/7.

When I call the billing department to ask for the billing cost of a procedure, they are looking at an excel spreadsheet that has all the prices, which I'm just as capable of looking at myself and why it's posted on our intranet for all staff to refer to when needed. All hospitals have one of these lists which is called a "chargemaster". Typically things aren't actually billed by each supply used, they are bundled prices so it doesn't matter which guidewire they're using in the angiogram, it's a set price for a diagnostic cath including supplies.

So, what exactly do you tell people? "The hospital's billing spreadsheet shows that we bill $XXXX.00 for that procedure. Of course, I have no idea whether you would get charged that amount for the procedure, because the individual insurance companies negotiate differing levels of discounts from the original hospital charge. If you don't have insurance, you would get charged the full amount, but you might qualify for the hospital's 'charity care' program, in which case you might get some level of discount that I can't tell you about because it would be based on your family's overall financial situation, which, of course, I don't know anything about, or you might get charged nothing at all if your financial situation is bad enough." Really??

We are all (at least, I am) aware that every hospital has a master list of charges for everything the hospital does. However, once all is said and done, relatively few people actually get charged the prices shown on that list, which makes it pretty meaningless. I still say that I have more than enough to do already without trying to explain how this works to the general public lying in the hospital beds. Furthermore, I almost never get asked about costs or charges. I can count on the fingers of one hand the number of times I've gotten a question about costs over the four years I've worked in my current position.

[SHGR, MSN, RN, CNS]

I think we as nurses should have some idea what costs are (ballpark) and be able to direct the person to the place to find his or her own cost. Whether that is outpatient pharmacy, billing, or what have you.

In diabetes education, yes I do know the cost of test strips and insulin, as well as which ones the major insurers prefer. In my specialty area that is a huge area of education and advocacy. I also wrote a P&P for myself to change brands for cost, and communicated with providers to get orders changed as well as doing prior auths and patient assistance forms.

If cost is a barrier to adherence, then yes we do have an obligation to be aware of these costs.

[dudette10, MSN, RN]

I'm with elkpark on this. Procedure billing has too many variables, and there are hundreds of thousands of things that have costs associated with them. This example I know about because I had to take the med. Neulasta costs about $5,000, but my insurance discounted and paid only $1500. My copay was $150, and I administered it to myself. Medicare requires patients to get it administered at an outpatient clinic, otherwise it won't pay. One drug, two insurance plans, widely varying costs and administration rules.

I'm also a little frustrated about calling it a "patient advocacy" issue, in order to drop this into a nurse's lap of obligation. I'm not going to waste my precious patient care time on tracking down a cost of a procedure that may or may not be the actual cost billed. This is a prime example of how the "scope creep" of nursing can be ridiculous.

[dudette10, MSN, RN]

I think we as nurses should have some idea what costs are (ballpark) and be able to direct the person to the place to find his or her own cost. Whether that is outpatient pharmacy, billing, or what have you.

In diabetes education, yes I do know the cost of test strips and insulin, as well as which ones the major insurers prefer. In my specialty area that is a huge area of education and advocacy. I also wrote a P&P for myself to change brands for cost, and communicated with providers to get orders changed as well as doing prior auths and patient assistance forms.

If cost is a barrier to adherence, then yes we do have an obligation to be aware of these costs.

Do you think it's your responsibility to know the cost of a Neulasta shot and all the insurance plan rules about administering it? Why or why not?

[SHGR, MSN, RN, CNS]

Hi Dudette, I'm not trying to be antagonistic. When I worked in home care, I knew and followed those rules; when I worked in an LTC that had Medicare patients, I knew and followed those rules. Did your oncology practice inform you of the rules and costs surrounding neulasta? That is what I have usually, but not always, seen in practice (for 17p injections, for instance).

[dudette10, MSN, RN]

Hi Dudette, I'm not trying to be antagonistic. When I worked in home care, I knew and followed those rules; when I worked in an LTC that had Medicare patients, I knew and followed those rules. Did your oncology practice inform you of the rules and costs surrounding neulasta? That is what I have usually, but not always, seen in practice (for 17p injections, for instance).

No, I figured it out for myself. Another patient on Medicare told me of her rules for her shot, but I'm not sure how she found out.

What one of the PP's suggested was that we should know the costs of procedures that our patients may ask about. Being a float nurse among six different units makes that list of costs and procedures quite long.

[SHGR, MSN, RN, CNS]

What one of the PP's suggested was that we should know the costs of procedures that our patients may ask about. Being a float nurse among six different units makes that list of costs and procedures quite long.

Hmmm. Well, I think patients need to be informed somehow...in a multidisciplinary environment that will possibly fall to case management, social services, pharmacy, etc. In one of my APRN classes we were taught that APRN's need to inform pts of cost of care provided. My opinion is also informed by working with a low-income, at-risk population.

But it is true that there is no way to stay up to date on everything unless you work directly with insurance or billing constantly, or if you work in a specialty with a narrow set of services.

[BrandonLPN, LPN]

Sure, I'll advocate for my patients and their financial concerns re:healthcare costs. I'll advocate them all the way to the nearest medical social worker.

[caroladybelle, BSN, RN]

I believe that nurses should know a ballpark idea of what procedures and costs of meds and supplies common to one's area are. It helps a great deal in discharge - getting prescriptions early for problem meds or services, and making alternative arrangements if those meds/services are beyond the pts means.

However, I do not believe that nurses should be quoting prices to pts. The variance from pt to pt for the "same" procedure is too great. That is for others to cover.

[Here.I.Stand, BSN, RN]

My suggestion for advocating for the pt in this instance is advise him NOT to sign the form, until he gets an answer to the cost. Then connect him to the billing dept.

Really, do we need ANOTHER person's job to do? Kitchen messes up someone's tray...get the nurse. Lab doesn't come to draw blood...get the nurse. EVS worker missed a full garbage can...tell the nurse. Now the nurse should answer billing questions?

Like a PP said, there are just way too many variables. List price, insurance write-offs (depending on which insurance the pt has), facility charge, other providers' fees (e.g. the anesthesiologist's bill), heck which hospital we're even talking about. I mean if the MD has privileges at more than one hospital; should the nurse know the bill for Hospital A and hospital B?

The billing expert isn't expected to do our job. Why should we be expected to do theirs?

[armymalenurse]

I think it should depend on where you work and the types of patients you get. Unfortunately, our country's insurance is a business. I haven't run into this issue in the US but I have in the Philippines where patients pay in cash. It was a while back so I don't know if there have been changes since then. But when I was there, if the patient did not have any money, they would put off buying medication, a procedure, or screen. We ended up suggesting cheaper ways they could get 'supplemental' treatment. It's sad but true.

[SubSippi]

People end up getting charged differently depending on what kind of insurance they have, or if they have insurance, depending on what can be negotiated. So I don't see how nurses can be expected to know prices.