Covid Relief: End to surprise medical billing?

[ua_guy]

https://www.reuters.com/article/us-health-coronavirus-usa-congress-factb/factbox-whats-in-the-u-s-covid-19-bill-unemployment-600-checks-three-martini-lunch-deduction-idUSKBN28V00R

In the list of provisions in the latest Covid relief bill, this seems pretty significant. I haven't read enough to know if it's just for treatment of covid or if it applies to broader care.

Ending surprise medical billing: Insured patients only need to pay in-network costs when an emergency or other issue forces them to use a medical provider who isn’t covered by their network.

[twix228]

https://www.reuters.com/article/us-h...-idUSKBN28V00R

Yes, right now, as far as I understand, health insurance does not cover COVID-19 cases. There is now a separate insurance that only covers COVID-19 cases. This is actually very bad. For example, in many countries, people over 60 are prohibited from visiting any banks and public places, which means that they will not be able to purchase insurance against COVID-19, thereby not protecting themselves and their health. A real-life example is my grandmother who used the Probill app, a recurring payment software, in order to pay all her bills and insurance from the comfort of her home.



[/INDENT]

Yes, now, as I understand it, health insurance does not cover cases of COVID-19. There is now a separate insurance that only covers COVID-19.

[disneysteve]

Yes, now, as I understand it, health insurance does not cover cases of COVID-19.

This is absolutely not true. Your health insurance definitely covers treatment for COVID. There’s no separate policy needed.

[LivingAlmostLarge]

https://www.reuters.com/article/us-h...-idUSKBN28V00R

In the list of provisions in the latest Covid relief bill, this seems pretty significant. I haven't read enough to know if it's just for treatment of covid or if it applies to broader care.



[/INDENT]

It is a nice first step for reform of medical billing/charting. I have to say I still think a public option for everyone is worthwhile.

[ua_guy]

It is a nice first step for reform of medical billing/charting. I have to say I still think a public option for everyone is worthwhile.

No disagreement from me. I struggle with the concept of "surprise billing" a bit because it's less of a surprise than it is a lack of knowledge. If you go to a doctor that's out of network and your insurance only covers 60% until you hit your annual out of pocket max, and you might have co-insurance after that, too... It's all spelled out with your insurance company. Maybe it takes 60 days for your claim to bill and adjudicate via the hospital's billing system, and then the hospital sends you a statement for what you owe $$$$$$. That's not your provider's fault or your hospital's fault - they have no control over the fact you have crappy insurance that doesn't pay 100% in every situation.

I'm conflicted on this one...I can see how forcing the insurer to cover it will affect their model. But I don't think it's right for the provider to eat the cost and write it off, either. They're providing the care.

[disneysteve]

No disagreement from me. I struggle with the concept of "surprise billing" a bit because it's less of a surprise than it is a lack of knowledge. If you go to a doctor that's out of network and your insurance only covers 60% until you hit your annual out of pocket max, and you might have co-insurance after that, too... It's all spelled out with your insurance company. Maybe it takes 60 days for your claim to bill and adjudicate via the hospital's billing system, and then the hospital sends you a statement for what you owe $$$$$$. That's not your provider's fault or your hospital's fault - they have no control over the fact you have crappy insurance that doesn't pay 100% in every situation.

I'm conflicted on this one...I can see how forcing the insurer to cover it will affect their model. But I don't think it's right for the provider to eat the cost and write it off, either. They're providing the care.

The problem is with cases where you really have no control. Let's say you suddenly get severe abdominal pain. You go to the ER of Hospital A because you know they are in network with your insurance. The ER doc determines the problem is your appendix. You get admitted and have emergency surgery. A day or two later, you're all fixed up and back at home. No problem, right? You did the right thing and intentionally chose the in-network hospital.

But wait. The ER is staffed by an outside contracted group of doctors who don't actually work for that hospital. Your ER visit is covered but the ER doctor's bill isn't. The surgeon is in network, so you're okay there, but the anesthesiologist is not in network so you get a bill for that, too.

There was no way for you to research all of that so you will be quite surprised when you get a bunch of bills for your care even though you went to an in network hospital. That's the sort of nonsense that needs to stop.

[amarowsky]

The problem is with cases where you really have no control. Let's say you suddenly get severe abdominal pain. You go to the ER of Hospital A because you know they are in network with your insurance. The ER doc determines the problem is your appendix. You get admitted and have emergency surgery. A day or two later, you're all fixed up and back at home. No problem, right? You did the right thing and intentionally chose the in-network hospital.

But wait. The ER is staffed by an outside contracted group of doctors who don't actually work for that hospital. Your ER visit is covered but the ER doctor's bill isn't. The surgeon is in network, so you're okay there, but the anesthesiologist is not in network so you get a bill for that, too.

There was no way for you to research all of that so you will be quite surprised when you get a bunch of bills for your care even though you went to an in network hospital. That's the sort of nonsense that needs to stop.

The above is an excellent case for why our myriad of different health care providers (our current system) is a total and complete mess of inefficiencies .

[LivingAlmostLarge]

The problem is with cases where you really have no control. Let's say you suddenly get severe abdominal pain. You go to the ER of Hospital A because you know they are in network with your insurance. The ER doc determines the problem is your appendix. You get admitted and have emergency surgery. A day or two later, you're all fixed up and back at home. No problem, right? You did the right thing and intentionally chose the in-network hospital.

But wait. The ER is staffed by an outside contracted group of doctors who don't actually work for that hospital. Your ER visit is covered but the ER doctor's bill isn't. The surgeon is in network, so you're okay there, but the anesthesiologist is not in network so you get a bill for that, too.

There was no way for you to research all of that so you will be quite surprised when you get a bunch of bills for your care even though you went to an in network hospital. That's the sort of nonsense that needs to stop.

This is why maybe a single system would be more efficient?

[disneysteve]

This is why maybe a single system would be more efficient?

Of course. A single system is outrageously more efficient for many reasons.

[TexasHusker]

The problem is with cases where you really have no control. Let's say you suddenly get severe abdominal pain. You go to the ER of Hospital A because you know they are in network with your insurance. The ER doc determines the problem is your appendix. You get admitted and have emergency surgery. A day or two later, you're all fixed up and back at home. No problem, right? You did the right thing and intentionally chose the in-network hospital.

But wait. The ER is staffed by an outside contracted group of doctors who don't actually work for that hospital. Your ER visit is covered but the ER doctor's bill isn't. The surgeon is in network, so you're okay there, but the anesthesiologist is not in network so you get a bill for that, too.

There was no way for you to research all of that so you will be quite surprised when you get a bunch of bills for your care even though you went to an in network hospital. That's the sort of nonsense that needs to stop.

Living this currently. My daughter had to be taken by ambulance to the hospital at thanksgiving. The Medic said "Which hospital?" I said "ABC...they are in-network with our plan." Of course, we hadn't met our yearly deductible so I'm 100% copay. Got the hospital bill, $4200, reduced to $2400 through my insurance contract. Paid it. Doctor bill? $1400. for CPT code 99205. 1200% of Medicare, no discount. They aren't in the network. I'm fighting it out with them now. I have offered 200% of Medicare, which I believe to be very generous, and they have refused.

[amarowsky]

Living this currently. My daughter had to be taken by ambulance to the hospital at thanksgiving. The Medic said "Which hospital?" I said "ABC...they are in-network with our plan." Of course, we hadn't met our yearly deductible so I'm 100% copay. Got the hospital bill, $4200, reduced to $2400 through my insurance contract. Paid it. Doctor bill? $1400. for CPT code 99205. 1200% of Medicare, no discount. They aren't in the network. I'm fighting it out with them now. I have offered 200% of Medicare, which I believe to be very generous, and they have refused.

So much time wasted..... And not for any good reason. It's after the health care has already been provided..... We're burning so many extra calories, dog catching bills and fighting back $$$. Wish we could spend that effort elsewhere.

Sucks both sides of establishment won't allow Medicare. Or at least ferociously attack any changes.

[LivingAlmostLarge]

Living this currently. My daughter had to be taken by ambulance to the hospital at thanksgiving. The Medic said "Which hospital?" I said "ABC...they are in-network with our plan." Of course, we hadn't met our yearly deductible so I'm 100% copay. Got the hospital bill, $4200, reduced to $2400 through my insurance contract. Paid it. Doctor bill? $1400. for CPT code 99205. 1200% of Medicare, no discount. They aren't in the network. I'm fighting it out with them now. I have offered 200% of Medicare, which I believe to be very generous, and they have refused.

Okay so TH explain to me everything. I don't get what you just wrote and I don't think many people outside of medical hospitals and offices would. The normal average person (i consider myself normal and average) would look at the bill and go okay I guess i pay $4200. I would probably call and line item and look at things, but I would not know to ask can you reduce it to $2400? Why would they if my insurance paid? Am i supposed to ask? Help because I'm flying blind and have no idea. So this is not a mocking question but a serious one about what are we supposed to do?

1. Get Bill
2. Call Hospital and say I need it reduced - they answer X, Y, Z. I didn't know this was possible with insurance. Again not mocking asking seriously.
3. Why is there a separate dr bill? Isn't it part of the hospital bill? - again never dealt with this so I am not familiar with any of this.
4. the dr bill - what is a CPT code? Why should they accept 200% of medicare? Why can't they charge you what they want? Is it at all covered by insurance? Why aren't you calling your insurance and complaining? What would you insurance say? How did they come up with this number? Doesn't your insurance company have a set and standard fee.

I am going to write something stupid and maybe not uncommon. I don't understand any of my billing. I look at my bills and think okay so my insurance pays 100% i pay a co-pay of $20. I don't pay a deductible. I don't pay portion. I don't get any of this. I do pay a premium.

But like my dental bill, I honestly see that my dentist charged $1200 to insurance for a crown. They agreed to $1200 and paid 80% which is what my plan provides for. I paid 20% = $240 per crown. I did not go back to my dentist and negotiated it down. Should I have? Should I have said that $1200 is way more than a crown should cost and I should only pay $800 and 20% of that is $160? I'm really confused. I just paid what was my share according to the dr office which looking at my running account balance appeared to be what insurance did not cover.

So how does this all work? Is this because you have private insurance? Do you not do this if you have employer provided coverage?

Anyone in medical or insurance or Disneysteve want to weigh in and explain the ins and outs. I don't think I'm completely out of the norm but maybe I am.

[disneysteve]

Okay so TH explain to me everything. I don't get what you just wrote and I don't think many people outside of medical hospitals and offices would. So how does this all work? Is this because you have private insurance? Do you not do this if you have employer provided coverage?

Anyone in medical or insurance or Disneysteve want to weigh in and explain the ins and outs. I don't think I'm completely out of the norm but maybe I am.

Think of $4,200 as the MSRP, the list price. When you walk into a car dealer, you don't see that price and write a check for that amount. You negotiate.

Your insurance company has already negotiated for you to an extent. They've signed a contract with that hospital detailing that their customers only have to pay $2,400 for what the hospital is charging $4,200 for. That's the bill that TH actually paid. He didn't mention it but I'm guessing he also reviewed the bill first to make sure it was correct. Most hospital bills contain errors. At that point, you could either pay the reduced amount or try to knock it down some more. Call the billing department and say you really can't afford that, times are tough, your income has been reduced, etc., and could they adjust it any farther if you can pay it in full right away. It may not work but it's worth a shot.

Why is there a separate doctor bill? Because the doctor doesn't work for the hospital. He/she is an independent provider. Some doctors are hospital employees but many are not. They are responsible for billing for their own services.

CPT: The Current Procedural Terminology system is the set of billing codes for services and procedures universally used by doctors, hospitals, insurance companies and other stakeholders in healthcare. Yes, the insurance company has a set fee, but TH mentioned that this doctor isn't part of his insurance company's network so isn't subject to those set fees. It's up to TH to negotiate on his own. Again, the doctor is charging MSRP but may be willing to accept a smaller amount, especially if it means getting a prompt payment in full and not having it drag out for weeks or months or having to involve a collection agency.

As for your dental question, I have no idea if what your dentist charged is a reasonable rate for a crown in your area. There is probably somewhere you could look that up. It's also a question best asked before the service is provided if it's not an emergency. How much is this going to cost? Does my insurance pay for it? What will my share be? Can you do any better than that if I pay upfront?

[disneysteve]

Let me give you a few examples, one that applied to anyone and two that were case-specific.

When our daughter got braces, the orthodontist gave us a price. He offered "free" financing but also offered a 5% discount if we paid upfront. I think I actually posted a thread about that here. We opted to skip the discount because I wasn't comfortable paying in advance for 18-24 months worth of work. If anything went wrong, we weren't satisfied, the doctor closed up unexpectedly, or whatever, we would have been stuck. So we took the payment plan. There was no negotiation needed since that offer was made freely by the practice.

One time when my wife had surgery, when she got admitted there was a set of pneumatic compression wraps in her room still sealed (used to prevent blood clots). In the OR (or in recovery probably), they put a set on her before she returned to the room. It was not the set that was sitting in her room already. After discharge, I got an itemized copy of the bill (never pay based on the summary bill you are sent). Sure enough, she was charged for two sets of compression wraps. Insurance had already paid their share of the bill. I don't recall the exact numbers but let's say our share was $2,000. I went in and pointed out the billing error, which happened to be $1,000. Since insurance had already paid, they took the full $1,000 off of our share, so I saved $1,000 by catching that mistake.

Another time after surgery, I went into the billing office to get the itemized bill. Without me even asking, the clerk said she could give me a 30% discount if I paid the bill in full. I jumped on that offer. Had I just paid based on the summary bill mailed to us, I wouldn't have gotten that discount.

[TexasHusker]

While it is a free economy and folks should be able to "get what they can get", it's a special sort of crook-ed with non-network physicians are benefitting from the hospital being in-network and all of the patient volume that follows, only to bilk the patients for 12X Medicare. Unethical, immoral, and fraudulent are the words that come to my mind.