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Covid Relief: End to surprise medical billing?

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  • TexasHusker
    replied
    Originally posted by LivingAlmostLarge View Post

    But are most dr at a hospital in network or is it common to be out of network?
    It is uncommon. Generally, a hospital requires all of its hospital-based physicians to participate in the hospital's contracted health plans, in order to avoid these very scenarios. It is a really bad look for the hospital.

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  • LivingAlmostLarge
    replied
    Originally posted by TexasHusker View Post

    Our deductible is $7000. So the insurance company isn’t paying anything. But I do get the benefit of their contractual discounts, provided that I pay promptly. The issue is, this is a group of physicians (ER) that are directly benefitting from the hospital’s status as the in-network hospital through patient volumes, and then, in my case, they bill me for 1,235% of what Medicare would allow. Yet we made a decision in good faith in selecting this hospital because it's where our insurance has a contract.

    At best, that’s unethical.
    But are most dr at a hospital in network or is it common to be out of network?

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  • TexasHusker
    replied
    Originally posted by ua_guy View Post


    The "network" is a construct of the insurance company, so it would seem that the insurance company could agree to pay the doctor as if in-network since the patient didn't have any choice in the matter. They did choose a hospital that was supposedly covered by the insurance plan.

    I'm confused...this literally has everything to do with the insurer and their coverage agreement with the patient/insured.
    Our deductible is $7000. So the insurance company isn’t paying anything. But I do get the benefit of their contractual discounts, provided that I pay promptly. The issue is, this is a group of physicians (ER) that are directly benefitting from the hospital’s status as the in-network hospital through patient volumes, and then, in my case, they bill me for 1,235% of what Medicare would allow. Yet we made a decision in good faith in selecting this hospital because it's where our insurance has a contract.

    At best, that’s unethical.
    Last edited by TexasHusker; 02-26-2021, 05:38 PM.

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  • disneysteve
    replied
    Originally posted by ua_guy View Post

    I'm talking about it from an appeals standpoint with the insurance company. If the doctor is charging $1000 and insurer only pays $600 since he's out of network, but would have paid $800 if he was in network, the insurance company could decide to pay him $800 instead of $600 since the patient had no say in the matter and tried to do the right thing to get the best coverage by going to that hospital facility. End result is the patient would owe $200 instead of $400. Or if they weren't going to cover anything out-of-network, they could elect to provide some sort of coverage because of the situation.

    I just don't see where it's the hospital or provider's responsibility to eat this.
    I see where you're going with this. Sure, the insurance company could decide to suspend their policy so it can't hurt to ask. The provider in question could also agree to accept a smaller fee. It can't hurt to ask about that either. It is nobody's responsibility to eat this charge because all parties are abiding by their contracts, but they still might make a one-off exception if you reach the right person who actually has the authority to do so.

    Bottom line is to always make the effort to negotiate. Sometimes it will work. Sometimes it won't. It works surprisingly often.

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  • ua_guy
    replied
    Originally posted by disneysteve View Post

    The out-of-network provider chose not to be a part of the network for a reason. They weren't willing to accept what the company was paying in-network providers. The problem is the whole in-network/out-of-network system. What good is ABC Hospital being "in-network" if the providers who work there aren't all in-network? I've even encountered cases where some doctors in one individual practice were in-network but others in the very same practice were not. It's insanely complicated.
    I'm talking about it from an appeals standpoint with the insurance company. If the doctor is charging $1000 and insurer only pays $600 since he's out of network, but would have paid $800 if he was in network, the insurance company could decide to pay him $800 instead of $600 since the patient had no say in the matter and tried to do the right thing to get the best coverage by going to that hospital facility. End result is the patient would owe $200 instead of $400. Or if they weren't going to cover anything out-of-network, they could elect to provide some sort of coverage because of the situation.

    I just don't see where it's the hospital or provider's responsibility to eat this.

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  • disneysteve
    replied
    Originally posted by ua_guy View Post


    The "network" is a construct of the insurance company, so it would seem that the insurance company could agree to pay the doctor as if in-network since the patient didn't have any choice in the matter.
    The out-of-network provider chose not to be a part of the network for a reason. They weren't willing to accept what the company was paying in-network providers. The problem is the whole in-network/out-of-network system. What good is ABC Hospital being "in-network" if the providers who work there aren't all in-network? I've even encountered cases where some doctors in one individual practice were in-network but others in the very same practice were not. It's insanely complicated.

    ETA: Sometimes a provider is out of network because the insurance company wouldn't admit them for some reason, like maybe they decided they already had enough surgeons on board. So there might be a surgical group that tried to join the network but couldn't.
    Last edited by disneysteve; 02-26-2021, 04:30 PM.

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  • disneysteve
    replied
    Originally posted by Snicks View Post
    It's not up to the PROVIDER to know what your insurance will or will not pay for. That is on YOU
    In most cases, it's impossible for you to find out what something will cost. Only the provider has that information. Only they know how much they will bill for a procedure or service. They know what is in the contract they have with your insurance company. You don't have direct access to that information. You need to ask your provider.

    It's difficult under the best of circumstances. It's virtually impossible in any sort of emergency situation because you don't have the time to research every piece of the care process. You don't get to pick your ER provider or your anesthesiologist or which medications are given to you in the hospital or which medical device gets implanted in the OR.

    Where I work, the fee used to not cover testing like x-rays or labs. Those were billed separately in addition to the visit itself. Insured patients didn't care but cash patients wanted to know how much the chest x-ray would be or what the charge was for a throat culture. We couldn't tell them. We didn't have that information. I asked for it numerous times and was never able to find anyone who could give me a list of charges that I could share with patients. Thankfully, they finally switched to a global fee so now one flat price covers everything. That's far simpler but it still really bothers me that I couldn't get a straight answer to a simple question.

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  • ua_guy
    replied
    Originally posted by disneysteve View Post

    He’s not fighting the hospital. He’s negotiating with the doctor who is out of network. The insurer has nothing to do with that.

    The "network" is a construct of the insurance company, so it would seem that the insurance company could agree to pay the doctor as if in-network since the patient didn't have any choice in the matter. They did choose a hospital that was supposedly covered by the insurance plan.

    I'm confused...this literally has everything to do with the insurer and their coverage agreement with the patient/insured.

    Leave a comment:


  • disneysteve
    replied
    Originally posted by ua_guy View Post

    Why are you fighting the hospital? Wouldn't it be more fruitful to fight your insurer
    He’s not fighting the hospital. He’s negotiating with the doctor who is out of network. The insurer has nothing to do with that.

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  • Snicks
    replied
    It's not up to the PROVIDER to know what your insurance will or will not pay for. That is on YOU

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  • ua_guy
    replied
    Originally posted by TexasHusker View Post


    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.
    Why are you fighting the hospital? Wouldn't it be more fruitful to fight your insurer and have them cover the professional fees as if the provider was "in-network"? You tried to do right and go to an in-network hospital but didn't have a choice in who cared for your daughter.

    I just don't see where the hospital should eat the cost or give you a discount. I'm guessing your daughter isn't a Medicare patient, so, why should they apply Medicare rates when that's not the coverage she has?

    I don't disagree that the system is broken and the cost of healthcare is astronomically high. But this is what we all deserve allowing a very free market to dictate the terms of healthcare to us.

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  • LivingAlmostLarge
    replied
    Originally posted by TexasHusker View Post
    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.
    But it's free market to allow drs right the decision to participate? And who would work in hospitals if they didn't choose? I also thought most dr worked for hospitals not private practice anymore.

    Leave a comment:


  • TexasHusker
    replied
    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.

    Leave a comment:


  • disneysteve
    replied
    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.

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  • disneysteve
    replied
    Originally posted by LivingAlmostLarge View Post

    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?


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