Transparency Trek: The Million EOB March

Trek (Trĕk) n.

  1. A journey or leg of a journey, especially when slow or difficult.
  2. A journey by ox wagon, especially a migration

I have been thinking alot about EOB’s. How did these anomolies of reason, this perversions of clarity, and obfuscators of objectivity come into existence? To what intent are they provided to the “beneficiary”.  Every single person I have ever spoken to goes through the same five step process when they receive an EOB:

  1. “What the heck is this?”
  2. “That office visit or procedure costs what?!”
  3. “Wait, this isn’t a bill? Why are they sending me this?”
  4. “So, how much do I owe? Doesn’t my insurance cover this? I can’t figure this out. I’ll just wait till I get the letter from collections before I pay because it usually gets reduced and they’ll forget about it anyway”
  5. “Where is that shoebox where I stuff this stuff?”

Lets take a look at a real world EOB.  It contains the price set by the provider (totally irrelevant), they also show the amount allowed (as a result of getting insurance club pricing), what the insurance pays (key data point), non-allowable fees that are removed (whatever that means),  and then what the member (“beneficiary”) owes after all the c0-pays, co-insurance, and deductibles are accounted for.  See below for an example:

This is an example of an Explanation of Benefits highlighting the various categories.

This is an example of an Explanation of Benefits highlighting the various categories.

So the providers “charged” $2,116.70, insurance says our “club price” is $1,799, and because you went to one of our in network or preferred providers, you save an additional $317.70. We, however, are only going to pay $1,259.30 and you will be responsible for the remaining $539.70 (This 70%/30% split is based on the type of plan; obviously lots of variations with this). This seems pretty straightforward, but not when you consider this is the third EOB you have received, in addition to 6 or 7 other bills from other providers who sent you a “courtesy” bill demanding full payment totallying the original $2,116.70 or additional statements form the lab, the anesthesiologist, and a wide range of people who helped on the service.

This gets repeated all over our country in every state, in every city, and nearly every home everyday. It is an unbelievably complicated mess.

Before stuffing it away, however, I would like to suggest something. Why not take 5 minutes and do something useful with it? Instead of stuffing it in the shoebox, recycle it. Or in other words, give it another shot at being useful, set it free, and post it online.

Here’s why. Those EOB’s, despite their current confused existence, are actually little gems that contain some very valuable nuggets of information. Like, the actual prices that insurance companies have negotiated with the various providers. Like, the entire propriety pricing scheme that keeps the various payers in a proverbial zero sum contest over how much value they can extract by squeezing providers while increases your rates every year. Interesting that payers have been so resistent to transparency in terms of revealing their pricing yet glibly publish it to all their members in the form of the EOB. Security (of their proprietary pricing schemes) through obscurity (widely disseminating proprietary information) is not a sustainable security scheme.

If the core competencies of the current insurance payers has been reduced to their abilty to manage Provider Networks and Administer Claims, and their profits are dependent on their ability to negotiate favorable pricing based on promised volume, then sharing “proprietary” pricing is obviously problematic. But, they are already sharing it. And the inevitable march of technology makes it possible for consumers to work together to share this information too.

So with all the talk regarding transparency, and the various pilots going on to improve transparency, why don’t we as patients band together to make this happen? Why not take these little EOB lumps of coal, distributed among thousands of us in a geographic are, and dig for the diamonds they contain?

So here is my proposition:

Lets have a nationwide Transparency Trek – lets call it the The Million EOB March. Can we get several hundred thousand consumers, to take 5 minutes to enter 7-10 key data elements readily available from their generic EOB’s*, and attempt to aggregate 1 million EOBs. Instead of all these multi-million dollar “transparency pilots” – why doesn’t someone pony up $1M to pay $1 for every legitimate EOB collected. Leverage the power of social network, real time collaboration, and the collective intelligence harness the information that is already being shared with us via our EOB’s?

The momentum from the first several thousand could inspire some self-insured companies** to contribute to the project;  analytic teams could start to expose pricing by facility, provider, and region; others could aggregate the claims by episodes of care to get to “all in pricing” specific procedures which would allow true comparisons of outcomes to occur.  Could be interesting!

Ready for a walkabout?

* Generic EOB’s only contain a fraction of the information available in the standardized electronic claims feeds that insurance companies refuse to share with individual policy holders.

** Self insured companies have access to much more detailed claims information as they are the insurance company and the traditional payers provide “Administrative Services Only”

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10 Comments

Filed under Change Agents, Innovation, Insurance, Transparency, Value

10 responses to “Transparency Trek: The Million EOB March

  1. Brilliant. Create a flickr or facebook group for folks to upload their 200×200 dpi EOBs. Tag by state or MSA and voila, pricing transparency. Will the general public join? How about just faxing the one page to a phone number that takes it in and does that processing including redacting the patient’s specifics. Wow . . . talk about disruptive innovation.

    • Stephen,

      I like the concept – lets make it easier. Provide a simple 1 – 2 – 3 website wherein you sign up for account, sign an information waver, and submit via fax, email, or direct posting to the site. The backend team validates the EOB information, verifies information is correct, tags as appropriate, and attaches the electronic EOB to the claim number for record keeping purposes. The $1M dollar sponsors pays $1 per verified EOB (50 cents to contributor/50 cents to the data team) and before you know it you are well under way to creating a disruptive solution to transparency in all regions throughout the US.

      Question is – who would sponsor this information?

  2. Beautiful concept. Would loooove to participate. The only thing I ever have done is “Medical Services” according to my EOBs. I get the same generic description for an office visit as for an outpatient surgery. But I’m with you on this. We’ll get there somehow.

    • Robert – Of course I would love Change Healthcare to serve as the platform to help this happen. Your point about “generic” (ie, worthless) information begin contained within the EOB is well taken. They dont really want you to drill down, although all the data is available from the insurer. Seems to me if you could take on the evangelical role of advocating that everybody share information in order to help each other out, and then create a simple system where they can fax, email, or send the information in somehow, you could actually aggregate a million EOB’s in relatively short order.

      The experiment would increase in value after the initial 10-20K random consumers submit their EOB’s which might interest some small self-insured businesses to do so as well (the benefit being that they get to see the shared pricing as well). We need the self insureds, as you know, because they actually get the claims data itself which has the detailed information that has the real value. It will increase again if we could get enough participation to really drill down into specific regions of the country (perhaps using the Dartmouth Health Regions) to get to relevant geographic pricing. At this point, with approximately 250-500K EOB’s, we could bring in the health analytics teams to start generating the information that would be useful to begin sharing with employers regarding the actual pricing would could fold into assist them in multiple ways.

      It would not take long from this sort of grass roots effort to accelerate the transparency trek the insurers already know they are going to have to take. Defending their proprietary pricing networks is not a long term sustainable business model, this “helps” them move up the value chain much faster. Lets talk real time to see how we can promote this “campaign” – The Million EOB March!

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  5. While I think that idea has some academic interests, I don’t think it will benefit the end user in any meaningful way.
    First there are almost as many EOB requirements as there are insurance companies. The DOL (Department of Labor) regs governing ERISA plans – which is probably most of the employer sponsored market – is the model. See http://www.medicareadvocacy.org/MedicaidandRT_ERISA.htm
    or http://www.dol.gov/ebsa/faqs/faq_claims_proc_reg.html
    But insured plans come under the jurisdiction of the 51+ state insurance departments which may or may not offer guidance in this area. (the District of Columbia has a state insurance department – I don’t know about Puerto Rico and other US territories)
    There are some fundamental flaws in the way provider reimbursement functions in the current health care market. Does it make sense that a doctor who treats a Medicaid patient should be paid thirty sense on the dollar, while the same doctor providing the same service (really?) to a private pay patient (read rich) is paid one dollar thirty on the dollar.
    In Germany, for example, providers negotiate with umbrella provider organizations and the Sickness Funds (a much better name, by the way) pay into the provider organizations. Who pays the bill is not known to the doctor. He could be working one visit and not working the next – the doctor is not affected.
    Our so called free market health system is not free, is not a system; and many argue, is not healthy.
    That is just one much more rational approach to the current system. The current system – and I do choke on the word system – drives to people to such distraction that they are forced to invent even more distractions.

    • Jim,

      Thanks for your comments . . . will be interested to see where this all goes. At a most basic level, surfacing the pricing information would be very useful as a baseline. Dealing with the disparities you describe would be an entirely different but important exercise. As long as we have 50% of our health industry pricing set by the government (totally irrationally as you point out) then we will remain in big trouble. Further compounding this is your note about the utter lack of systemness in health care – it does not exist except within some isolated pockets like Kaiser, VA, Intermountain Health, Geisinger, etc.

      Thanks for your comments. See my recent post about some transparency related news items.

  6. Scott
    More directly to you point, though. I used to work for the Pennsylvania Health Care Cost Containment Council, one of the leading state data agencies reporting on the price and outcome of health care.
    It has the legislative authority to collect and report payer specific payment data but its efforts to do so have been blocked by the insurance company lobbies.
    If your idea could gain critical mass in PA, it would be an interesting end run around some powerful interests.

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