Last week I had an MRI. My claim was just processed. This is what it shows:
Provider Charge $3,831.00
Member Discounted Rate $446.35
Plan Paid to Provider $296.35
Your Amount Owed for Copayment $150.00
Your Total Cost $150.00
So if someone had no health insurance they would be expected to pay $3831? Wow!
And the diagnostic facility gave me a 20% discount on my copay because I paid up front so my out of pocket cost was only $120.
One of my kids has insurance that no doctors in his area take. He has some tests that need to be done annually. The office will let him pay the “member discounted rate” if he pays at the time IS service…so that is what he does.
Sounds like a price tag at Macy’s… with it perpetual sales and coupons.
Not necessarily. There are often different charges for different groups.
The person without insurance would be on their own to negotiate whatever discount the provider was willing to give.
“So if someone had no health insurance they would be expected to pay $3831? Wow!”
They might…and they might even if they had health insurance, but this provider was out of network or not OK’d by the primary care provider.
Of course the “retail” price is higher than the price the facility negotiates with insurers. Do you think that the insurer would negotiate UP from the retail price?
Imagine that you are running the MRI facility. You participate in ten different insurance networks. You negotiate prices for your services with each one of these ten networks. Obviously, each of those ten networks is going to expect to pay at or less than than the “retail” price that someone pays if they walk in off the street. So, you need to set your retail price. Are you going to set a low price, or a high price?
Agree with #6 that the list price is set high as a starting point in negotiations with insurance companies.
I have heard of a case where a self-pay patient was immediately given a significant discount off the (inflated-for-insurance-negotiations) list price without having to ask, probably because the provider wanted to avoid being seen as being too high priced to self-pay patients who may choose other providers instead.
I am looking at a explanation of benefits statement. The company provided medical equipment and a prescribed drug (O2). They billed $2,094.40. There was a provider adjustment. My insurer paid $216.86. I owe nothing because I already paid my max out of pocket for the year, otherwise I’d likely pay 20-30% of what insurer paid and they’d pay a bit less than they paid.
I had been billed $76.88/month, but insurer instructed me NOT to pay as the insurer would pay my portion and theirs for the rest of 2016.
I guess someone without insurance would have to negotiate to pay less than the sticker price of $2,094.40/month.
Early in Nov, I had my MD order them to remove a piece of equipment I wasn’t using and didn’t need and will see if it lowers the bill to insurer and for 2017 my portion of the bill as well.
The crazy thing is the piece of equipment they removed can be purchased outright for $500-1000, depending on the machine. It is a lot to pay every month and they never services or even checked the machine.
I have other medical bills that also show major provider adjustments, especially for lab work performed.
I’m looking at another EOB of a loved one. Total charge was $12,620 (outpatient surgery). There was an adjustment and eligible charge was $3,453.80. Medicare paid 80% and private insurance paid 20%. Yikes for folks who are uninsured!
It has been this way for a very long time. It’s completely crazy and something I can’t think of any corollary for in another industry/type of purchase especially when one usually has little choice to incur these expenses.
My last ER visit without admission had half of the amount billed approved. I paid my flat co-pay.
My last hospital stay had 1/4 of the amount billed approved. I paid nothing.
My infusion treatments for lupus/RA (abatacept) are billed at over 10k per dose but the insurance does pay about 9k of that. I pay nothing. They do not, however, pay for any of the other costs billed with my infusion appointments. I still pay nothing.
I have a high enough deductible that I always ask about cash pay discounts. It’s ranged from 0% to 30% of list price.
I pay the same $15 copay to see any MD, whether the appointment is 5 minutes or 2 hours (or any amount of time in between), whether it’s a new MD or a world famous specialist, in HI or someone in-network in the US. The amount billed (and amount paid by insurer) can vary greatly, depending on the skill of the coder, whether the facility is approved to charge for overhead, and many other factors.
I have no deductible but am always interested in charges and net payments by everyone involved in the medical system. I do look over all the statements we receive.
@“Cardinal Fang” I understand the whole “discounting” practice. What amazed me is that my insurer got an 88% discount! It is by far the largest discount I have ever seen.
@Hanna what makes you think this provider was out of network? It is very possible that this patient had this amount as a copy on in network.
Actually if this was out of network, I think the member discount rate would have been higher!
It was in network.
When I go for blood work for a physical, the lab’s non-discounted rate is usually over $600, but the insurance-negotiated-rate is only in the $85-100 range. Does anyone really pay over $600, and, if so, how do they afford it?
I helped somebody who needed a ct scan (who had insurance) but the approval process was going nowhere. I called the diagnostics center asked them how much “cash” pay was …they said 200.00 including the radiologists fees.
sounded to low like the lady made it up. I called another place and they said $210.00 for same thing and said would you like to come today? so their net charges was $200.00 as opposed to with insurance it would have been $250-300 out of pocket to the patient on her plan plus what the insurance company pays which would probably have been an additional 400-500 dollars. there is zero logic from a money perspective how this works.
she went to the place the doctor had sent her to, paid $200.00 on her credit card and that was it. insurance information was never provided to diagnostic center. moral of the story…always check on “cash” pay charges it maybe worth it.
I use to pay $950 for a mammogram. I called around for a colonoscopy, and charge was $4-6000. I waited until I was 65. I was very fortunate nothing was wrong but polyps. When I needed outpatient surgery, it took months to negotiate with insurance company, MDs, and hospital. It cost me over $6000 and several months to arrange, sending all the MRIs, etc.
I sure Medicare continues.