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Old 08-24-09, 03:52 PM   #26
Kmical
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Re: What is the best way to negotiate a Medical, ER Bill?

Unlike many people, I'm actually happy with my medical coverage from my employer:

I have a high-deductible family plan with a $3500 deductible. My maximum out-of-pocket also happens to be $3500. Therefore, once I pay the deductible during the year, almost everything (prescriptions, wellness checkups, hospitalizations, etc) is covered 100%. No co-pays!

We hit our deductible in July. I love going to the pharmacy now and seeing "Price: $225.00 You pay: $0.00".

Our plan also allows us to use this plan with an FSA account. So, due to the tax benefits of the FSA, I actually get $4000 in a spending account that only deducts $3200 from my paychecks - and is available on Jan 1st in its entirety.

Not surprisingly, nearly 70% of the employees where I work chose the High-deductible plan with an FSA.

My employer + Humana FTW

(Of course, Humana will probably dump this plan for 2010).
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Old 08-24-09, 03:56 PM   #27
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Re: What is the best way to negotiate a Medical, ER Bill?

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Originally Posted by Sdallnct View Post
That would not be correct. All my stuff that I do in town is "in network". My Dr. the hospital that any my family has been to, is all "in network".

Now I travel a lot for work. And if I have to go to a 24 hour clinic when I'm out of town I just tell them I don't have insurance. And 90% of the time they LOWER their rate, not raise it. Then, in fact I submit it to my insurance company who reimburses. For example, I went to a 24 hour clinic out of town for a sinus infection. She asked if I had insurance and I just said "I'll be paying cash".
If you're talking about a HSA, then you're talking about something that not a lot of people even use. For just about any type of private insurance, if you're going to an in-network provider, you pay a copay only (you certainly wouldn't pay the whole thing up front and get reimbursed, which would defeat the purpose of having a copay in the first place). You have a HSA, so it's apparently quite a bit different that what most people have, so keep that in mind.

Quote:
After the deductible my HSA pays 80% if in network and like 65% if out of network work.
That's initially what I said, i.e. pay the deduct, then pay a percentage after it's met. With typical (non HSA) private insurance, all you pay is the copay when staying within the network. What you're describing is similar to "out-of-network" for private insurance. Like I said, I have a PPO plan with no deductible and a just a copay if I stay in-network, which is typical of most other PPO plans (but again, this isn't what you're using).

Quote:
You are saying the Dr/Hospital's charge whatever they want and than accept whatever they get and than don't go after the patient. I would say this is not only not my experience but makes little sense. No Dr./Hospital is going to "contract" with an insurance company to lose money.
It's not about accepting "whatever they can get." Again, I'm NOT talking about a HSA here. Let's say someone has a Blue Cross Blue Shield PPO plan, and they stay in-network, and pay a $15 copay for a $200 office visit-- that doctor's office is not getting $185.00 back from their insurance company. Not even close. As a contracted provider, yes, they do agree to accept less their billed amount. Sometimes reimbursement sucks, and doctors try to leave certain plans because their liability to do a particular procedure isn't worth the discounted rate that the insurance company wants to pay the doctor for being in their network.

Anyone who has an explanation of benefits from their (non HSA) insurance plan can see what I'm talking about, so I'm not making this up; they see the charge submitted by the doctor, what was allowed by the insurance company (i.e. the total payment allowed for the claim), what the insurance company paid, and your (or "member's") responsibility, which is usually just the copay if you're staying in-network.

Take the amount submitted by your doctor, than compare it to the sum of "your responsibility" and the amount paid by the insurance company and it will almost always be less than the billed amount. Again, this isn't the type of plan that you have so you won't see this, but pretty much anyone with a PPO or HMO who stays in-network will see what I'm talking about.

Last edited by Dave7393; 08-24-09 at 03:59 PM.
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Old 08-24-09, 04:28 PM   #28
Sdallnct
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Re: What is the best way to negotiate a Medical, ER Bill?

Quote:
Originally Posted by Dave7393 View Post
If you're talking about a HSA, then you're talking about something that not a lot of people even use. For just about any type of private insurance, if you're going to an in-network provider, you pay a copay only (you certainly wouldn't pay the whole thing up front and get reimbursed, which would defeat the purpose of having a copay in the first place). You have a HSA, so it's apparently quite a bit different that what most people have, so keep that in mind.



That's initially what I said, i.e. pay the deduct, then pay a percentage after it's met. With typical (non HSA) private insurance, all you pay is the copay when staying within the network. What you're describing is similar to "out-of-network" for private insurance. Like I said, I have a PPO plan with no deductible and a just a copay if I stay in-network, which is typical of most other PPO plans (but again, this isn't what you're using).



It's not about accepting "whatever they can get." Again, I'm NOT talking about a HSA here. Let's say someone has a Blue Cross Blue Shield PPO plan, and they stay in-network, and pay a $15 copay for a $200 office visit-- that doctor's office is not getting $185.00 back from their insurance company. Not even close. As a contracted provider, yes, they do agree to accept less their billed amount. Sometimes reimbursement sucks, and doctors try to leave certain plans because their liability to do a particular procedure isn't worth the discounted rate that the insurance company wants to pay the doctor for being in their network.

Anyone who has an explanation of benefits from their (non HSA) insurance plan can see what I'm talking about, so I'm not making this up; they see the charge submitted by the doctor, what was allowed by the insurance company (i.e. the total payment allowed for the claim), what the insurance company paid, and your (or "member's") responsibility, which is usually just the copay if you're staying in-network.

Take the amount submitted by your doctor, than compare it to the sum of "your responsibility" and the amount paid by the insurance company and it will almost always be less than the billed amount. Again, this isn't the type of plan that you have so you won't see this, but pretty much anyone with a PPO or HMO who stays in-network will see what I'm talking about.
I've only been on a HSA for three years. Prior to that I had "regular group". Than I had a HMO. Then back to regular group. Now an HSA that happens to be a plan thru Blue Cross Blue shield. The HSA "part" is just something my company does. It is basically regular group insurance. But I have a very large deducible, $5,000. And my company puts aside $2,500 each year in an account to help off set that deductible. Otherwise my coverage is EXACTLY like anyone else that has Blue Cross/Blue Shield. Same coverages, co-pay, in network out, etc. It is just instead of a $250, $500 or $1,000 deductible I save money on premiums by using the HSA plan.

What I'm say is this, forget the deductible, but if I get an xray that cost $1,000 and have a 20% copay that means, I pay $200 and the insurance pays $800. Per every Dr I have ever been to if my insurance company refuses to pay $800 REGARDLESS of reason (not covered, they think it is to much, whatever) then I'm responsible for anything the insurance does not pay.

If understand you correctly then you are saying health insurance A has agree with the Dr to only charge $700 for the same Xray. That I get. But then that is what the Dr charges, they don't charge a higher amount other wise it would effect your co-pay. So since I have super star health insurance my Dr "only" charges $700 for the xray. That means he charges $700 and my co-pay of 20% is now $140. It makes no sense that they charge $1,000 to get $200 from me than only accept $500 ($500 from insurance + $200 copay =$700). I would never accept that.

BTW by far the best insurance I ever had was the HMO! They were fantastic! I wish I still had them now!
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Old 08-24-09, 04:31 PM   #29
Sdallnct
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Re: What is the best way to negotiate a Medical, ER Bill?

Quote:
Originally Posted by Kmical View Post
Unlike many people, I'm actually happy with my medical coverage from my employer:

I have a high-deductible family plan with a $3500 deductible. My maximum out-of-pocket also happens to be $3500. Therefore, once I pay the deductible during the year, almost everything (prescriptions, wellness checkups, hospitalizations, etc) is covered 100%. No co-pays!

We hit our deductible in July. I love going to the pharmacy now and seeing "Price: $225.00 You pay: $0.00".

Our plan also allows us to use this plan with an FSA account. So, due to the tax benefits of the FSA, I actually get $4000 in a spending account that only deducts $3200 from my paychecks - and is available on Jan 1st in its entirety.

Not surprisingly, nearly 70% of the employees where I work chose the High-deductible plan with an FSA.

My employer + Humana FTW

(Of course, Humana will probably dump this plan for 2010).
<-------Another one who loves his insurance. I work for a large company. I chose to work for this company as I knew they had excellent benefits. I could work somewhere else for 15%-20% more, but than I wouldn't have the great benefits and choices. I switch my health insurance every few years to try something new. HMO was best I ever had. And I used it a lot.
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Old 08-24-09, 04:37 PM   #30
Sdallnct
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Re: What is the best way to negotiate a Medical, ER Bill?

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Originally Posted by WallyOPD View Post
I don't know why you assume that the contract would cause them to lose money.
I don't assume it. That is my point. The cost is the cost. The Dr/Hospital is going to charge what they charge for expenses, labor, material and profit. Just like any other product. And if an insurance company doesn't want to pay that, than the Dr/Hospital is going to say "great, who cares, not us. We charge what we charge".

Could they give a "discount" to some insurance companies based on the amount of business they do or how easy they make billing or to get "in network". Sure. But I doubt that is 50% or anything. I'm sure it is 10%, 15%, 20% maybe...That is always my point with a national plan. Unless you are going to dictate cost, your still going to have to pay what you pay. Either in premium or taxes. It is the same money, just moving from one pile to another.
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Old 08-24-09, 04:46 PM   #31
Dave7393
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Re: What is the best way to negotiate a Medical, ER Bill?

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Originally Posted by Sdallnct View Post
I've only been on a HSA for three years. Prior to that I had "regular group". Than I had a HMO. Then back to regular group. Now an HSA that happens to be a plan thru Blue Cross Blue shield. The HSA "part" is just something my company does. It is basically regular group insurance. But I have a very large deducible, $5,000. And my company puts aside $2,500 each year in an account to help off set that deductible. Otherwise my coverage is EXACTLY like anyone else that has Blue Cross/Blue Shield. Same coverages, co-pay, in network out, etc. It is just instead of a $250, $500 or $1,000 deductible I save money on premiums by using the HSA plan.
Do you find that you save money by having a higher deductible? (just curious)

Quote:
What I'm say is this, forget the deductible, but if I get an xray that cost $1,000 and have a 20% copay that means, I pay $200 and the insurance pays $800. Per every Dr I have ever been to if my insurance company refuses to pay $800 REGARDLESS of reason (not covered, they think it is to much, whatever) then I'm responsible for anything the insurance does not pay.
Yeah, that's pretty true no matter where you go. You can have the best insurance plan "on paper," but if they don't pay, then the doctor will certainly come after you.

Quote:
If understand you correctly then you are saying health insurance A has agree with the Dr to only charge $700 for the same Xray. That I get.
Well, the doctor can charge whatever he wants, but yeah, the insurance company will usually reimburse him for a lower amount, if he's in their network. If the contracted amount is $50, let's say, anything above the allowed amount for that claim will be ignored (if he's participating).

Quote:
But then that is what the Dr charges, they don't charge a higher amount other wise it would effect your co-pay. So since I have super star health insurance my Dr "only" charges $700 for the xray. That means he charges $700 and my co-pay of 20% is now $140. It makes no sense that they charge $1,000 to get $200 from me than only accept $500 ($500 from insurance + $200 copay =$700). I would never accept that.
As I understand it, it's illegal for medical providers to have a 2 tier system of billing, i.e. one set of fees for insurance, and one non-insurance patients for the same procedure.

Quote:
BTW by far the best insurance I ever had was the HMO! They were fantastic! I wish I still had them now!
That may well be the case-- some that I"ve had (or heard about) have been pretty good. The plan I'm in now is the best I've ever had, but the time in my life I was the sickest (and had the biggest doctor bill of my life), I had the shittiest insurance.
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Old 08-24-09, 05:28 PM   #32
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Re: What is the best way to negotiate a Medical, ER Bill?

Based off my recent experience in the ER, you should be able to negotiate to ~33% of the original bill. I fractured my leg in three places. The ER visit, consultation, surgery, one night in the hospital was billed for a total of $35,500. Based on the bills I saw, my insurance paid something like $12,500 for full payment in agreement with the hospital (well, I paid a $50 co-pay).
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Old 08-24-09, 05:33 PM   #33
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Re: What is the best way to negotiate a Medical, ER Bill?

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Based on the bills I saw, my insurance paid something like $12,500 for full payment in agreement with the hospital (well, I paid a $50 co-pay).
This is exactly what I'm talking about. This is usually how it works, if you have a good insurance plan (you don't pay a deductible, or percentage of the bill, etc. You pay your copay, and the insurance pays the contracted amounts for the procedure codes submitted, case closed).
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Old 08-24-09, 05:46 PM   #34
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Re: What is the best way to negotiate a Medical, ER Bill?

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Originally Posted by Dave7393 View Post
Do you find that you save money by having a higher deductible? (just curious)
Some years yes, some years no. IMO all these variences of programs only do things to move the money around. Meaning sure some years I save a lot with the HSA plan and other years I spend more than a normal plan with higher premiums and a set $500 deductible. Over say a 10 or 15 year span, I bet it is pretty much a wash.

If you could predict when you needed to turn in claims (and I guess for some you might be able to) than I could see saving money on one plan over another. For example, many a HMO is the most expensive option. But no or low deductible and little or now co-pay and covers preventative care. So if you knew for sure you were going to start a family (have a baby) that might be the way to go.

On the other hand if you are in your mid 20's super good shape and rarely get sick a very high deductible plan may be the way to go and save the money on premiums.

My kids are teen's now so that is why I've tried the HSA. Saved money the first two years, lost a some last year.
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Last edited by Sdallnct; 08-24-09 at 05:50 PM.
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Old 08-25-09, 12:02 AM   #35
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Re: What is the best way to negotiate a Medical, ER Bill?

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Originally Posted by Dave7393 View Post
This is exactly what I'm talking about. This is usually how it works, if you have a good insurance plan (you don't pay a deductible, or percentage of the bill, etc. You pay your copay, and the insurance pays the contracted amounts for the procedure codes submitted, case closed).
my dad was in the same boat. well, he did have to pay double ($100) but that was his ER deductible. the hospital billed around $9k, and the insurance paid around $4k.

btw, the insurance plan that i'm on costs nearly $500 a month (i'm single), and i pay i think around 10-15% of it. honestly, i'd rather them offer a high deductible plan, and let me pocket the difference, but, atlas, no go.
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Old 08-25-09, 10:00 AM   #36
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Re: What is the best way to negotiate a Medical, ER Bill?

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Originally Posted by Sdallnct View Post
-Negotiating after services rendered seems odd to me. I mean to relate it to buying a car, you generally agree to prices before taking the mechandise. I'm curious, if they ER said "we really need this X-ray to see what is wrong with you, but it will cost $1,000. What would you say?" Or is it fair to ask a question on a "potential" life saving issue?
In my experience with HMO, PPO, and now my first year in a HDHP w/ HSA I've learned that medical billing is quite variable. Comparing uninsured health costs and scenarios to buying a car couldn't possibly be a more apples to oranges comparison (in today's climate for both).
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Old 08-25-09, 02:52 PM   #37
Nefarious
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Re: What is the best way to negotiate a Medical, ER Bill?

CMS (Centers for Medicare & Medicaid Services) publish the fee schedule for providers and facilities on the website. From what you describe, a self-pay discount was already applied and it seems pretty generous (they knocked off, what -- almost 50%)?

Anyway, if you desire, go online and see what Medicare would pay for the same services. You'll need detailed billing information to get the CPT/DRG/other codes to reference though.

If it is a non-profit hospital you can inquire about any low-income, charity options they might have if you might qualify. Many non-profits, especially Catholic based ones, write-off tons of bad debt every year.

Negotiated rates in healthcare vary widely and there are a lot of factors that influence it. Payor mix; # of hospitals/providers in the area; competition; quality; etc. In some places physician services are discounted routinely by about 50-60% off billed-charges for contracted payors. In others, though, the discount could be as little as 10% off billed. Same goes for hospitals.

As someone previously mentioned, the most precarious position in healthcare is that of the uninsured/self-pay person who exceeds income levels to qualify for Medicaid, debt-forgiveness, etc.

Also, it isn't uncommon to receive multiple bills for the different aspects of service. For example, let's say a person goes in for surgery that requires anesthesia and imaging (x-rays; ct; mri; etc.). They could get a bill for the facility charges; one for physician/surgeon charges; anesthesiologist charges; and radiologist charges all separately. This is often a very confusing aspect of healthcare for people. The reason is that the providers may be private practices that handle their billing separately.

If you were billed separately for physician services and no discount has been applied then I would suggest you try to negotiate a discount with the provider.

Last edited by Nefarious; 08-25-09 at 03:07 PM. Reason: Update provider billing info.
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Old 08-25-09, 04:40 PM   #38
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Re: What is the best way to negotiate a Medical, ER Bill?

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Originally Posted by Nefarious View Post
CMS (Centers for Medicare & Medicaid Services) publish the fee schedule for providers and facilities on the website. From what you describe, a self-pay discount was already applied and it seems pretty generous (they knocked off, what -- almost 50%)?

Anyway, if you desire, go online and see what Medicare would pay for the same services. You'll need detailed billing information to get the CPT/DRG/other codes to reference though.
That's a pretty good idea, and it'll at least give anyone who's interested a starting point. Some medicare reimbursement amounts are pretty low though, but it'll give someone a general idea of how much money changes hands for some of those codes sometimes (even if it's Medicare).

Quote:
Also, it isn't uncommon to receive multiple bills for the different aspects of service. For example, let's say a person goes in for surgery that requires anesthesia and imaging (x-rays; ct; mri; etc.). They could get a bill for the facility charges; one for physician/surgeon charges; anesthesiologist charges; and radiologist charges all separately. This is often a very confusing aspect of healthcare for people. The reason is that the providers may be private practices that handle their billing separately.
This issue rears its ugly head in the maternity wing pretty often. Ofcourse you'll know if your ob/gyn is in your network ahead of time (you've probably been getting EOBs in the mail for months already), but if the only anesthesiologist available at the time you need one is not in your network, you may be hit with that bill, since it might be a doctor in private practice who has nothing to do with your plan at all.
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Old 08-25-09, 05:06 PM   #39
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Re: What is the best way to negotiate a Medical, ER Bill?

One of the issues facing a lot of carriers, even some of the bigger ones, is that specialist like emergency medicine (er), radiology, anesthesiology, and sometimes neurology are refusing to contract with insurance/managed care companies. The only 800 lb gorillas, so to speak, are CMS & BC/BS. Some payors have good power in specific markets but none wield the power of CMS & the Blues. CMS is largely because it's the government -- it's gonna do whatever it chooses to do. The Blues usually do it because they can due to market share.

There's no one reason but some of it has to do with the amount of bad-debt/uninsured business the providers have to eat, high malpractice costs of these specialties, and the decreasing reimbursement and payment methodologies. The last item, for example, a radiologist might get paid 100% of the contracted rate -- which might be equivalent to 25-50% of billed charges for the first procedure done but a sliding scale 50-25-25-0 for procedures done after that. And those additional %'s are also of the contracted/negotiated rate -- not billed charges. Anyway, many of them have decided it isn't worth contracting and that they have a captured audience to an extent. If you need anesthesia or x-rays, what the hell are you gonna do? Bite a stick? Buy your own MRI/CT machine? You might have some choice for elective/outpatient procedures but so often people have zero control over some of these aspects. This issue is so prevalent in places like Texas that the Texas DOI requires all insurance companies to disclose to members when they do web-based searches that these specialties may not be contracted, etc.

I don't support all aspects of health care reform but there are serious flaws in the system which produce waste and disadvantages for both providers and patients.

Another option, which may be harder to come by, is to get a copy of Mag Mutual (might be available at a Barnes&Noble -- not sure). It lists prices for procedures where it shows high, low, and median. I think regional factors can be applied, as well.

Last edited by Nefarious; 08-25-09 at 05:16 PM.
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Old 08-25-09, 08:12 PM   #40
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Re: What is the best way to negotiate a Medical, ER Bill?

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Originally Posted by Dave7393 View Post
As I understand it, it's illegal for medical providers to have a 2 tier system of billing, i.e. one set of fees for insurance, and one non-insurance patients for the same procedure.
In effect that is exactly what the negotiated rate is: a special rate for people with that particular insurance.
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Old 08-25-09, 08:23 PM   #41
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Re: What is the best way to negotiate a Medical, ER Bill?

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Originally Posted by Pistol Pete View Post
In effect that is exactly what the negotiated rate is: a special rate for people with that particular insurance.
Not exactly but I can understand why you might think so. In essence the provider is taking a reduced, negotiated rate is because that provider is having business steered to him. This is especially true in a gated, HMO environment and generally true in a PPO (caveat being rare exceptions where all providers are participating).

There is additional incentive because the payor is acting as a guarantor of sorts for payment. They also provide ease of administration in that for a large # of patients you bill the same place and have payments arrive via EFT.

Providers will often refuse to contract with plans that do not offer enough incentives to make it worthwhile (too small membership; no EFT; can't take electronic claims, etc.).

So it isn't exactly the same as creating separate, tiered billed pricing.

UPDATE:

Also, it is important to note that negotiated rates only apply to "covered services" which are defined by the benefit plan. The types of services covered can vary from plan to plan (e.g. Catholic based organizations won't pay for tubal ligation; vasectomy -- other insurance plans might). Non-covered services are not applicable to the negotiated discount rates. This is another area that causes lots of confusion and angst. A member doesn't understand the procedure is a non-covered service (e.g. breast augmentation) because it isn't "medically necessary" and the provider doesn't inform them up front. Next thing they know they have a huge bill and wonder why their insurance won't cover it. This is an exception and most providers are very clear with people up-front and typically require a signed form stating awareness that it may considered non-covered and that the individual is liable. A less reputable provider may not be so clear but they are an exception.

Last edited by Nefarious; 08-25-09 at 08:33 PM.
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Old 08-25-09, 08:40 PM   #42
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Re: What is the best way to negotiate a Medical, ER Bill?

Yes, The hospital did give me a generous discount already. I called them yesterday about a copy of the detailed billing and they are sending me a copy. She said that it would take 10-30 days for me to receive. She put a hold on my account until I can review the billing details and then we could talk about payment.
I paid 1 bill for the "viewing" of my x-ray, which was $36. One doctor bill they said to send a letter, which I am Wednesday since they don't discuss special payment or discounts over the phone. and the last doctor bill, I have been having a problem with getting to talk to someone live....I will see what happens hopefully next week....
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Old 08-25-09, 09:13 PM   #43
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Re: What is the best way to negotiate a Medical, ER Bill?

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Originally Posted by Sdallnct View Post
What I'm say is this, forget the deductible, but if I get an xray that cost $1,000 and have a 20% copay that means, I pay $200 and the insurance pays $800. Per every Dr I have ever been to if my insurance company refuses to pay $800 REGARDLESS of reason (not covered, they think it is to much, whatever) then I'm responsible for anything the insurance does not pay.
There are two things at play here: 1) Billed Charges 2) Allowed Amount (i.e. negotiated rate). If you have a 20% co-insurance, then that is 20% of whatever the Allowed Amount would be for the service. So if the billed charge is $1000 and the Allowed Amount is $800 then you would pay 20% of the $800 and the insurance/payor would pay 80%. The provider cannot balance bill for the $200 discount. That's all assuming it is a covered service.

If an insurance company denies the charges then it is important to find out why and this determines whether or not the provider can bill you for it. If the insurance denied it because it is a non-covered service and you were informed then the provider has a right to bill you for it. If the denial was because the service wasn't medically necessary then they shouldn't bill the patient and if I were the patient I'd refuse to pay. For example, an MRI is likely a covered service under most any plan. That doesn't mean any provider can just order a $5k MRI and get it paid. If they order it in a situation where an MRI is not medically warranted (say, on a standard broken arm where a standard x-ray will do) then the charges will be denied/unpaid because it wasn't medically necessary by established standards. In that instance, if I'm a member, I refuse to pay.


Quote:
Originally Posted by Sdallnct View Post
If understand you correctly then you are saying health insurance A has agree with the Dr to only charge $700 for the same Xray. That I get. But then that is what the Dr charges, they don't charge a higher amount other wise it would effect your co-pay. So since I have super star health insurance my Dr "only" charges $700 for the xray. That means he charges $700 and my co-pay of 20% is now $140. It makes no sense that they charge $1,000 to get $200 from me than only accept $500 ($500 from insurance + $200 copay =$700). I would never accept that.
A co-pay is usually a nominal amount ($25, $50, $100 for ER visit -- something like that). The %'s are usually co-insurance. So for example, PPO A has in-network co-insurance of 20% and they pay 80%. For out-of-network they might only pay 60% leaving a 40% co-insurance.

The co-insurance should apply to the Allowed Amount, not the billed amount. If a provider applies it to the full billed amount then the overpayment on the co-insurance will get refunded to the member. Not doing so would up them in violation of their agreement and they risk losing the contract (access to the members) or non-payment for the service.

Last edited by Nefarious; 08-25-09 at 10:32 PM.
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