For more than two months this summer, a soft-spoken grandmother in her 60s with a family history of breast cancer — whom I’ll call Diane to protect her privacy — tried to get answers to two basic questions from the government: Will Medicare cover her cancer-screening MRI this year? And if not, what will the screening cost her?
Unfortunately, she didn’t know the one thing she needed to get such basic information from the Medicare staff: the Current Procedural Terminology code for her MRI.
After years of hearing the health care industry say that better-informed consumers hold the key to controlling costs, various news publications have been reporting how difficult it is to get doctors and hospitals to reveal their often sharply different prices before patients are treated and billed. Now add Medicare to the list.
The health care industry speaks in code. Each of this country’s 9,707 medical procedures and services has a unique five-unit code of numbers or letters, plus a concise description. These CPT codes, developed and licensed by the American Medical Association over the past four decades, plus Medicare’s own set of codes, have become the nation’s shorthand for medical services and billing.
Yet doctors are not ethically bound to tell you the codes and costs upfront. And Medicare representatives are trained not to tell you the codes and not to help you without the codes, as Diane sadly learned. Medicare could — and should — change that policy immediately.
Diane has reason to fear cancer. Her mother and daughter had double mastectomies, and she has dense-tissue breasts. Her doctor, Kristen Zarfos, director of St. Francis Hospital’s Comprehensive Breast Health Center in Hartford, put her on a screening schedule years ago, alternating a mammogram and a breast MRI every six months.
Last year, her first on Medicare, the government covered both procedures. Diane didn’t pay a penny for the MRI. But in April, Diane says Dr. Zarfos’s assistant called with bad news. St. Francis’s billing department said Medicare had changed its policy and would not pay for this year’s MRI. Diane could get the MRI, the assistant added, but she’d have to pay $1,500 for it out of her own pocket. (I eventually learned that St. Francis had billed $5,548.43 for Diane’s previous MRI, but it was only paid $289.54 by Medicare.)
With nothing in writing from the hospital explaining the policy change, the bewildered family contacted the Center for Medicare Advocacy, and a person there reached out to me to do some checking with the family’s permission.
I got nowhere. No one I interviewed at cancer organizations had heard of a policy change — nor had a billing staffer at St. Francis Hospital who checked Diane’s file.
More frustrating, none of the helpers at 1-800-MEDICARE whom I phoned repeatedly could tell me anything about the MRI without the specific CPT code.
Me: The doctor did not give the patient the code. But I’ve described the procedure. Why can’t you tell me the code? Is it a secret?
Helper: No, the codes are not secret. But I’m not allowed to tell you a code. You need to get it from the doctor.
Me: What can Diane do?
Helper: Tell her doctor to call the Medicare Provider Helpline. People there can tell the doctor whether Medicare is likely to cover her MRI.
Me: You’re telling me there’s a Medicare phone line with the answers, but only doctors can call it? Does that sound fair to you?
Helper: Can I help you with anything else?
Catch 22. No CPT code. No answers. No MRI for Diane.
Donald Berwick, who ran the Centers for Medicare & Medicaid Services two years ago and is running for governor of Massachusetts, was surprised to hear about the helpline’s answer. “Wow, they can’t help you without the code?” he said. “I wasn’t aware of that problem. I would have tried to fix it.”
Bruce Vladeck, a former head of the Healthcare Financing Administration, was blunt. “If beneficiaries can describe services in plain English and still can’t get basic information without a code,” he said, “then, of course, the hotline is not doing its job.”
But Vladeck, a hospital efficiency expert at the consulting firm Nexera, also argued strongly that it is “a fool’s errand” to ask people to master a system that can have 15 highly specific codes for one procedure. “What kind of a society forces people to learn complex codes to get medical services?” he asked.
Unfortunately, it’s this society.
Obviously, in emergencies, few people have the time or inclination to get codes and ask about prices. But most of the time, if you choose to consume health care without an idea of your treatment’s CPT codes, you may as well eat in restaurants with no prices on the menus. Our doctors, hospitals, and health insurers should at least make the most common procedure codes readily available, along with cost estimates. And Medicare should go first with full information on preventive services and cancer screenings.