Co-pays and Coinsurances are Dumb

  • by Bill Hennessey M.D.

All these do is make purchasing health care more confusing. If a health plan wants to sell more product, get rid of co-pay and coinsurance. Go ahead - adjust the deductible. Now you made it easy to understand. People buy more of what they understand. How about a health plan with a $1,500 deductible and from $1,501 onward the care is covered by insurance? Pretty easy to understand. Do not let others limit how you think. Logic is permitted.

Happy Pratterday.

A “Copy and Paste” Letter for your Medical Records courtesy of Pratter

  • by Bill Hennessey M.D.


To Whom It May Concern:

I request a full copy of my medical records, including those of the hospital and the doctor, including all of the doctor’s orders, especially blood work orders.

Once you provide these to me and I get to compare them to my itemized medical bill, I will consider payment. If I do not receive the doctor’s orders, I will request all of my medical records again. You are encouraged to be thorough and timely if you want paid in a timely manner.

I will wait to hear from you. Thank you in advance for your cooperation.


The Bull

Remember, don’t be bullied. Be the bull.

FYI: send to ATTN: medical records department

You Can't Discount a Revenue Code...

  • by Bill Hennessey M.D.

and it is causing self-insured companies to pay half of their medical bills blindly.


Revenue code:
0420 physical therapy

CPT code:
97124 massage
97110 therapeutic exercises
97116 gait training

So a revenue-coded bill comes in for 0420 for $10,200. This is happening. Which CPT code above is this a good deal for? Answer: none of them. Revenue codes skirt billing scrutiny with intentional ambiguity. 0480 means "cardiology." Was the $30K bill for a stress test or an open heart surgery? You don’t know. You just pay.

0300 means "something happened in the lab", yet we all know there are $5 and $500 lab tests. It gets this brazen when employers don't look at their medical bills before or after they pay them.

For an employer spending $100M on healthcare, chances are $50M is going out the door blindly. Who wants to be better?

Contact Mark Robinson to get your Pratter Report for your health plan spend. We diagnose and treat.

The Pratter Solution to Hospital Surprise Medical Bills

  • by Bill Hennessey M.D.

Hospitals have just sued the federal government to preserve their right to providing us all with surprise medical bills. By following the recommendations below, we get to keep more money and force their behavior change for the better. 

  1. Provide a surprise no payment. Keep your money.
  2. Keep your money for an extra year by asking the hospital for an itemized bill Yes, all 5,700 of them make you ask for one - sad, but leverage it. 
  3. Itemized bill must include each CPT billing code and full name of each test they want paid for. If not, ask again. 
  4. Next, ask for all hospital and physician medical records, including all doctor orders. You need to make certain what was ordered and performed is what was billed. Since they didn't tell you this pricing in advance, you have no choice but to not trust them. This will buy you another 3 to 6 months with your money. 
  5. With itemized medical bills and medical records, it is often easy for most lay people to see billing "mistakes." Call them out. 
  6. Never call them. Let the hospital call you. You bargain from a position of power. They want your money. Play hard to get. 

Medicare versus Commercial Health Insurance Payment Disparity

  • by Bill Hennessey M.D.

Working age people pay more for health care than those on Medicare. Commercial health insurance is more expensive than Medicare insurance due to the fact that health insurance companies pay medical providers more for the same care than Medicare. Just how much pricing variation exists by both payer and provider type has been lacking transparency.

This pricing disparity does not exist in any other sector of our economy. We can purchase the same item at the same price, whether it is online via Amazon or in a retail store like Walmart, except for healthcare. With medical cost transparency, it is believed that the same result with same and better pricing will occur. This is referred to as capitalism.

The purpose of this study was to determine the pricing disparity between Medicare and commercial insurance payments for the same care by medical provider type, such as hospitals, freestanding ambulatory surgery centers, imaging centers and blood work centers.

By understanding price points and ratios for payment of care by health insurance companies to Medicare, employers and employees can better negotiate what they pay for care and best determine where they can go to receive more affordable access to care.

Download the full white paper.


A "Copy & Paste" Letter for your Hospital Bill courtesy of Pratter

  • by Bill Hennessey M.D.


To Whom It May Concern:

I have requested an itemized medical bill with the 5 digit CPT code for each item for which you request payment. The 5 digit CPT codes were not included for each item. Please include them.

Furthermore, I am not a doctor and I do not want abbreviations. I previously requested the full medical name for each item that you want paid. You did not listen to me. I do not pay any other bill in my personal or professional life that is unitemized. I want to know what I am paying for.

Once you have provided me with each 5 digit CPT code and the full name of the medical procedure as per The AMA CPT manual, I will consider payment. Until then, you are put on notice that I will not be paying an unitemized bill.

I will wait to hear from you. I do appreciate the care but I do not appreciate the intentionally egregious medical billing practices.


The Bull

Remember, don't be bullied. Be the bull.


Medical Cost Transparency Legislation Guidelines for Medical Providers

  • by Bill Hennessey M.D.

  1. All hospitals, ambulatory surgery centers, imaging centers, urgent care centers, clinical laboratories, and physicians must provide online website access to a line item charge master for each and every medical item billed as a part of their business.
  2. The charge master fee must be within 5% of the average payment by commercial health insurance company plans receive for each care item.
  3. Medical cost data should be laid out in a “3 across” format from left to right: 1) medical test Current Procedural Terminology (CPT) code 2) medical test name and 3) medical test price rounded to the nearest dollar, each in its own cell.
  4. The five digit CPT code must be listed for each care item. The column with CPT codes must be entitled “CPT Codes.”
  5. The medical test name MUST be fully spelled out as designated in the current American Medical Association (AMA) CPT manual. Abbreviations will not be accepted.
  6. The charge masters must be in a machine learnable format, such as an Excel, .csv or Access file format. PDF files will not be accepted.
  7. The charge masters must be made available to the public via a company website. The charge master must be downloadable also.
  8. The charge masters must be updated annually by the end of the 1st quarter of the year, being March 31st.
  9. Fine. A $20,00 per day fine will be enforceable for each day the above eight (8) criteria are not provided to the public online.
  10. Jail. Hospital and medical center CEOs who refuse to provide their charge masters with the above criteria will be subject to jail time for offenses in which pricing is unavailable to the public online. Failure to comply within 30 days of this law will be associated with a likeness of 30 days in jail.

Medical Cost Transparency Legislation Guidelines for Health Insurance Companies and Health Plan Third Party Administrators (TPAs)

  1. All health insurance companies and TPAs must provide self-insured organizations all 33 cells of information on each HCFA 1500 and all … of information on a UB-04 billing form.
  2. The five digit Current Procedural Terminology (CPT) code must be listed for each care item paid. The column with CPT codes must be entitled “CPT Codes.”
  3. The electronic copy of the medical and pharmacy bills paid must be in a machine learnable format, such as an Excel, .csv or Access file format. PDF files will not be accepted.
  4. The National Provide Identification (NPI) numbers must be provided for each bill paid. Tax ID numbers will not be acceptable.
  5. CPT codes must be provided for all hospital care. Substituting four digit revenue codes for CPT codes to mask hospital pricing will not be accepted.
  6. The physical address where care occurred must be provided for all claims paid. PO Boxes used to mask the identification of better-priced care will not be accepted.
  7. The charge and the claim allowable, defined as the co-pay, coinsurance, deductible and TPA health plan payment, must be on each claim row. The omission either the charge or claim allowable will not be accepted.
  8. A complete health claims data request must be fulfilled within 30 days of the request. An email request is an accepted format. A paper request is not required.
  9. Fine. A $20,00 per day fine will be enforceable for each day the above eight (8) criteria are fulfilled with the claims data request
  10. Jail. Health insurance company and health plan TPA CEOs who refuse to provide electronic copies of the very medical bills an organization paid with the above criteria will be subject to jail time for offenses in which a data request is not fulfilled. Failure to comply within 30 days of this law will be associated with a likeness of 30 days in jail.

CEO of Pratter at White House for Signing of Executive Order

  • by Bill Hennessey M.D.

Pratter at the White HouseAs President Trump signed a medical cost and quality transparency executive order yesterday, I was honored to be there to witness history in the making. President Trump and I agree that known pricing creates competition. And with competition, the consumer wins every time with lower prices. Quality ratings will come to our platform Q3. Medical cost transparency already exists for every self-insured entity. Give Pratter one day with a copy of the very medical bills paid, and tomorrow the real prices paid are searchable for the world to view in plain sight. Our flagship offering, the Pratter Report, itemizes cost drivers by test name. 

As for medical providers, we name names. We show real pricing. 

Your Employed Physician

  • by Bill Hennessey M.D.

Most people believe their physicians send them to the best place for care. Think again. Half of the 900,000 physicians in our country are employed by hospitals where the CEO tells them where to send patients – their hospital and nowhere else. It’s worse in the Pittsburgh market where Pratter is located, where 75% of physicians are employed by hospitals. Here’s how it works. The hospital administration tells the physician where to send his or her patients. There are hospital employees paid to track where doctors send patients for care. This is also tracked by the electronic medical record (EMR). A physician is required to electronically place an order for a test, such as an MRI, in the EMR. The only option listed within a hospital EMR is the physician’s hospital MRI facility, the most expensive MRI in the region. If a hospital-employed physician chose to send a patient outside his or her hospital system for an MRI in the above example, the EMR would require the physician to answer more questions. The EMR would “red flag” this physician for referring outside the hospital system that employed him or her. Doctors can be reprimanded and even fired for sending a patient outside their place of employment. After all, why do you think the hospital bought the doctor’s practice? The answer is to control patient flow by having patients stay within their hospital system, at any cost to you, even if it bankrupts you, to enhance hospital revenue. Now that it is 2015, you are no longer a patient. You are a health care consumer with significant out-of-pocket expenses. Although you can trust your doctor with your physical health, you literally cannot afford to trust your doctor with your financial health. Use and our medical billing staff to help you understand that you have multiple excellent options for medical care (hospitals, surgery centers, imaging centers and blood work centers) when your primary care physician orders a medical test.

Shop Smart for Health Care: Imaging Studies

  • by Bill Hennessey M.D.

1. Become an educated consumer. Take ownership in your health care dollar and understand why you were referred to one place over another. Ask your doctor if he or she is required by his or her employer or financially incentivized to send you to a particular medical facility for testing.

2. Look up your imaging study on This will display your cost options and locations. If Pratter does not have results in your area yet, look up “imaging center” or “MRI centers” in your hometown.

3. Know your imaging study (e.g. x-rays, CTs and MRIs) options:
a) independent imaging centers
b) hospitals.

4. Call the imaging centers. Ask for the medical billing department or person to get charges from both hospital and non-hospital options. Ask for 1) the total cost in case you have a high deductible insurance plan and have to pay the entire amount or in case your health insurance company denies your claim and ask for 2) your out-of-pocket cost for your particular insurance plan, assuming it covers your medical test.

5. Call your health insurance company. Immediately ask for the first name, last name and case reference number of the person providing you your cost answers. This will enhance accountability and service. Ask what your expected out-of-pocket expense will be at the imaging center of your choice given your insurance coverage. Remember, you still have to call the imaging study centers for their total charges, because if your claim is denied, that total charge becomes your bill!

6. Take your prescription to the imaging study center. Ask for a copy of your image to be provided to you on a disk. This should be done at no charge to you. You can then let your doctor view the images from your disk.  Alwasy get the disk back and keep it with your health care records.

Do not accept the excuse that you “must” go to a certain imaging center in order to have your results be part of an electronic medical record. Most imaging center results can easily be integrated into the electronic medical record (EMR), and, if not, then the report can be scanned into your EMR at the doctor’s office.

*Note: This is as simple as it gets until Pratter Plus -- a health care cost consumer solution coming out later this year.  The most difficult thing to do for now is to not know the cost of your care - before you buy it - and figuring out how to deal with the sticker shock!