<p>I have asked what costs may run before getting into procedures/tests I am not familiar with. I asked the lab or imaging office. In my case, these are tests at the lab or facility, not just sent out by the doc. No, the front desk doesn’t always have this at their fingertips, but they can usually get the info, close enough. Before a recent hosp procedure, i was also informed, by the anes, what his costs could run. (They were far less.) </p>
<p>I was also told by my insurer that when there is ER or in-patient and an out of network doc is involved (in situations where the patient has no options,) they will treat him/her as in-net. (Long story to fully explain this whole conversation.) </p>
<p>In-network, they have negotiated pricing. I’ve seen many list costs drastically reduced. OON, not so much control by the insurer, if at all. Agree the last resort for OON is get the lab to reduce what seems to be its “balance billing.” And, is there a preferred lab in OP’s daughter’s area? That’s a question for the insurer.</p>
<p>Btw, my docs can usually only vaguely discuss test prices based on feedback from other patients or some specific experience. </p>
<p>Agree that its helpful to find an in-network lab where possible to have testing, if they can perform the needed work. Not all labs can get the needed results in a format useful to the doc, as our docs have explained and shown us. </p>
<p>Good to call insurer to find out which labs, pharmacies and providers are participating and preferred in advance to minimize stress and $$$! </p>
<p>Yes, definitely file an appeal with your insurance company. We ran into something similar when my husband had hip replacement surgery in 2013. We carefully chose the surgeon and hospital because they were “in network.” We assumed that since the hospital was in our network the anesthesiologist would be, too. Wrong! He was not in our network and we got hit with a huge bill. We appealed it and our insurance co. ended up re-processing the claim as though he were “in network.” </p>
<p>^^^coffeebean, how did you “appeal it?” I just got a large bill yesterday from the anesthesiologist from my colonoscopy, which I had in October! It says insurance paid him ZERO dollars. Like you, I had made sure my doc and facility were in-network. It didn’t occur to me to prescreen the anesthesiologist.</p>
<p>Insurance companies have a group of docs they refer to as “RAP” docs – radiologists, anesthesiologists, and pathologists. No one ever chooses one of these because no one ever sees one of these. Most RAP docs have not bothered to join a network. However, if your in-network surgeon or the in-network hospital uses these out-of-network docs, the insurance company will pay these guys as if they were in-network and you will not have to pay the OON fees. You may need to appeal to get this, but this is the way it generally works.</p>
<p>To appeal, first call the customer service number and chat with the nice person. You will then probably want to follow up with a letter (sent to the address the nice person tells you) and include all back-up documentation.</p>
<p>Of course it wouldn’t occur to you!!! Why would it?! That’s what I mean by absurd. And yes, some companies will bill and others will absorb the cost but think about elderly patients who get a bill for an anesthesiologist. Many of them will just panic. They won’t know how to dispute it.</p>
<p>It is just another way for the insurance companies to screw the customer. They roll the dice to see who will buckle and many will. When the customer buckles, the insurance company wins.</p>
<p>Imagine being in an emergency situation. You bring a loved one to the ER and give them your insurance information. Is it reasonable that you would be expected to ask if every medical practitioner is in your network? Either the hospital takes the insurance or not. It should be up to them to make sure that all of the professionals are consistently participating in the plans that the hospital accepts. </p>
<p>What if you are brought to the hospital in an ambulance, unconscious and alone? Who does the asking then? It’s just ridiculous and should be considered unlawful.</p>
<p>To the OP, after appeals, negotiate with the lab for what you can comfortably afford to pay. I believe your criticism of the doctors is misplaced. Due to the nature of professional liability in this country, many tests are ordered as a cya, and I don’t blame the doctors at all. Why should a doctor have to lose everything that he has worked for in his career (or hers) because he didn’t order a test that the patient found too expensive, and that was the one case where it was needed and essential?He doesn’t know in advance (or she) that it is not essential, and neither do you. It is the patient’s health, not the doctor’s that is at issue. If a patient comes complaining of something, and a test should be done to rule out X, how can you rule out X without the test? I have been the manager of a medical office for many many years, and although we always try to use a participating lab, sometimes we don’t have all the correct information to figure that out. Yes the common insurances all make sure we know what lab to use, but the ones that are not common, not so easy. As others have said, we don’t make up the price of the test. I recently got testing done for myself, and my doctor told me that it could be very expensive, but since it was a special test and lab, they would call me if I had to pay more than a certain amount, and I could opt out then. However, if I had opted out, I would never know the result, and the result could have had big implications for my life and health. That shouldn’t be the doctor’s problem.</p>
<p>I talk to insurance companies a lot, and it is my belief that most look for reasons not to pay legitimate claims- not all of them, and not even most, but they do routinely deny a percentage for what I call “illegitimate” reasons. The plethora (or perhaps google) of plans out there from each company is mind boggling. In fact, benefits for labs etc. usually would have to be checked for each patient, even if they have the same insurance company due to the many plans, and individual choices within the plan as to deductible etc. that are available. Now, with the new ACA policies many people have multiple thousand dollar deductibles that come as a shock to them! In terms of getting medications or approval for procedures, I have been to telephone hell when I call, get forwarded to another number, then to another and after a few transfers end up at the same unresponsive number that I started at.</p>
<p>If everything worked like traditional medicare, we would all be better off. In fact if we all had that plan, we would be better off. And so long as I am raving now, why should there be any profit for insurance companies in your health care! The medicare system operates without this type of “profit”. Think of the money saved on advertising and competition. All this competition doesn’t benefit the delivery of health care!!!</p>
If D is 18+ another problem you may have is with the HIPAA compliance. We are still dealing with bills from D’s E COLI case and even the collection agency won’t speak to ME without HER permission. So she had to be present when I called in order to tell them they can talk to me, even though I’m the one paying the bill and was just trying to get an actual copy of a bill that was never paid because we never got a statement. </p>
<p>I have this problem just talking to D’s insurance company, as she has separate insurance from mine. Annually she has to sign a release form so I can talk to them about billing, coverage, etc. PIA. I pay the premiums, shouldn’t be this much of a hassle.</p>
<p>I agree this is all getting out of hand. I had to have an MRI and was billed for the procedure, the room, the onsite radiologist to preview the MRI to make sure it was “readable” so I could also get charged for the offsite radiologist who “read” the MRI. And to make the whole thing worse, I got billed at a hospital rate. The MRI center has always been adjacent to the hospital, but after a remodel they now have a door connecting the two buildings…thus…the hospital rate. </p>
<p>Insurance companies will negotiate (force) ridiculous rates for anesthesiology services. As a result, anesthesiology departments may choose to be out of network where they may collect a reasonable reimbursement. Always complain to your insurance company that you had no choice in the matter. Inform them that the hospital and surgeon you chose were in network. 9/10, the insurance company will pay. Also, don’t pick the cheapest insurance plan.</p>
<p>BB: healthcarebluebook.com
Folks, that is a good resource for info about prices for various procedures. You can put in your zip and see local and/or compare with national. Your insurer may have a lower negotiated price. Some procedures may also be a little more complex, are not cookie cutter, include an extra step, etc. Also, my insurer does have some procedure costs by physician or facility.</p>
<p>Some of you need to have a serious conversation with your insurer, to cover these sorts of questions. It’s not as simple as your insurer trying to rip you off (though, sure, some have the rep and make things challenging.) I asked mine, “and if one hospital doc is not in-net…?” Or, "if my college D needs x?</p>
<p>Agree with furgaldoc to take this an extra step further, if needed. But frankly, this isn’t always as simple as making your insurer pay inflated prices. Sometimes, the problem starts with the biller’s charges, themselves. Example just off the top of my head, but if average is, say 2k and that lab charges 2.5k (and in-net would have been 1400,) why should the whole pool in that insurance group be underwriting that lab?</p>
<p>Also, here, it is always more expensive to have imaging (and some other diagnostics) done at the hospital. My insurance includes a slightly different coverage explanation for that. Sometimes, a procedure is less expensive at an outpatient facility- but sometimes not. </p>
<p>It is so worth it to have this discussion with the insurer. I am also wondering if OP talked directly with them, re: her charges and future options. </p>
<p>The point is when you are sick you are probably not going to be comparison shopping and asking everyone who walks into your hospital room if they are in-network or shooing them away. This whole thing is terrible mess and getting quickly worse, not better. Stay healthy. </p>
<p>No, but you can ask your insurer today.<br>
another advantage to going in-net is that those docs (at least here) are not allowed to do balance billing. Out of network may.</p>
<p>You would be blown away at what I have to charge to get paid. Sometimes 10 times what I expect. The insurance company may or may not pay me at all. I don’t get it! I know an anesthesiology group that charges $150,000 for a labor epidural and one that charges roughly $2000. The insurance companies pay them relatively the same amount. The insurance companies do not pay full price. They typically pay 30-50%. In anesthesia, they typically pay 3-4 times Medicare rates no matter what the charge.</p>
<p>From a physician’s perspective and a person dealing with these billing issues on a weekly basis, a price list is of no value because I know the game. What would be of great benefit is what the insurance companies pay for each procedure. But they don’t do that and it is illegal for me to ask my competing colleagues. I only learn the prices from friends who receive services from other groups. Insurance companies don’t want physicians to have leverage with negotiations.</p>
<p>Do yourself a favor, always choose a reasonable insurance company and not the cheapest, use in network providers, always check that the procedures are covered, and always get an itemized copy of your bill. I have patients who come in for surgery with these requests.</p>
<p>This is what happens when you put an unnecessary entity between the consumer and the producer; prices must be raised, yet revenue drops. Yep, there are no free lunches or handouts.</p>
<p>FD, I have asked my insurer what they pay. I usually get a starter number but always they tell me it depends on the actual coding that comes through on the doc bill. In one case, I got the core coding in advance, from the doc office- but as the gal told me, multiple codes can apply or be added and some situations add time- which she could not predict in advance. Eg, if they found X, then Y and Z additional tests would be ordered. If something turned out to require it, they would have a 2nd (or higher order of) pathologist take a look. I got the formula for the hospital charges for the procedure room, $X per 15 minutes, and an estimate of the range of time it would take. More found would equal more time, thus a higher billing. (Also the basics for ambulatory, to make that decision.)</p>
<p>Am I uniquely “obsessive?” Maybe. But people can have these discussions, at least for generic questions. Or when they know something is up- OP’s girl needing ongoing lab tests or me having the threat of recurring kidney stones. Ask the questions about OON docs in a hosp setting. Or needs when you travel. My D2 needed tests at college, possibly a procedure and I asked. It turned out the appt wait was too long in her college town, so she scheduled the tests and subsequent procedure for an upcoming visit home.</p>