There needs to be regulation regarding a hospital being in network, and then the doctors and radiologists not. We’ve had the most trouble by far with radiologists on that issue and on billing issues in general. I’ve had several clients who live in on little town, served by only one ambulance company. Their local employer provided insurance does not have this ambulance co. in network and they have been stuck with outrageous balance billing.
My family is struggling with insurance. My 54 year old brother was diagnosed with stage 3 colon cancer in February. No prior colon cancer in the family. He had surgery and has now started chemo. Unfortunately, the chemo has killed almost all his white blood cells so every week when he goes in for chemo they can’t do it because his white blood cell count is too low.
There is a shot that his oncologist prescribed for him that brings up white blood cells, but the insurance has repeatedly denied it. Of course, the shot is costly. My brother is paying up front for it right now because…no shot…no chemo…what is the choice here. My brother needs chemo to survive and he needs the shot for chemo and the insurance is saying no…
They probably realize we would sell everything to get my brother chemo. It is so devastating in an already hard situation.
Thank you for letting me vent!
@eyeamom Thanks for explaining things through the eyes of an insider. However, I think in some of the cases mentioned here, patients and their families would just be happy to know ahead of time what the costs would be, not necessarily what their out of pocket will be. If they can determine the hospital’s and doctors’ billings ahead of time they can then talk to their insurance provider and determine under their exact insurance plan at least an estimate of their out of pocket charges.
The patient might know that he has a $300 copay for the ER, but he doesn’t know what’s considered part of the ER services. The physician? Usually. The x-rays? Maybe. The radiologist who reads the x-rays? Perhaps. The cast? Maybe. The pain medication? Perhaps.
In my experience (~35 years in employee benefits) there is something called a “RAP benefit.” “RAP” docs are radiologists, anesthesiologists, and pathologists, whom one rarely meets and doesn’t choose. IME, those docs’ charges are paid at the in-network level, since you didn’t have a choice. I’m surprised to hear that’s not a standard practice.
I agree, if patients could get a ballpark of what the costs would be charged, that would be excellent. We understand that insurers have so many different plans with little tweaks for each, but at least the price range would be nice.
Patients being told it’s too complicated to even get a quote is totally unhelpful in making an informed decision.
Have had a great pharmacist who is willing to work with us to figure out how to get our Rx covered best under our drug plan. For one Rx–omperezole (Prilosec generic), he ran first as a pill and found it wasn’t covered at all. He then ran it as a capsule and it WAS covered but copay varied by whether you got a 30 day supply ($15 copay) or 90 day supply (no copay). Similar situation with Flonase. Also, if you buy these Rx over the counter, no coverage, even tho they are available that way.
@HImom: Some plans exclude from coverage prescription drugs that are available in smaller dosages over the counter.
Just pointing out that the company is paying for whatever you don’t pay for. Health insurance isn’t cheap for employers, either.
Yes, but I’m getting the same doses that are sold OTC. I really don’t understand the pricing–guess they want patients to comply with their maintenance meds and take them regularly for the full 90 days.
Keeping patients well, functioning, and out of hospital and trouble saves everyone money and allows for better quality of life too.
Regarding ER docs, anesthesiologists, pathologists, and other providers who often aren’t in network, even at an in-network hospital. This is unconscionable. Luckily, in CA out of network providers are not permitted to balance-bill for ER visits, but that is not the case in a lot of states. You can have good insurance, carefully go to in-network facilities, do everything in your power to follow the rules – and still get stuck with ruinous medical bills. Like many things in this crazy quilt we call a health insurance system, what you get depends on where you live. It’s a disgrace.
I just switched to Anthem this year. This arrived in my email today. Not sure exactly how it works and how accurate it is but thought it pertinent to this discussion: https://www.insidemyplan.com/page.aspx?qs=5c591a8916642e7362a786eabbb8eaa69ea3e9c958f95615f851465e93c953a2225d98f77491ea0a9b3cde5cb3ae606810c9b0a888a3bb1308a555f630308528dd58c3c291729e0a5db91dd687eb4169f1161cce0436865a32243e70f576e03e040495fff2693f085e7e638dded91918c099de452b892dbe
Hospitals can negotiate rates with insurers. Its often harder for the providers, unless they are part of a large group.
I used to work at a medical software company. What I learned was that often medical providers and insurance companies have pre-negotiated reimbursement rates that patients aren’t aware of. So a medical provider may send an invoice to the patient saying the cost of a particular medical procedure is $10,000, and the patient’s portion of that is 20%, or $2000. But the medical provider won’t receive $8000 from the insurance company. It’s more likely the insurance company will only pay something like $3500, which was the pre-negotiated rate. So the medical provider ultimately only gets $5500, which was what they knew they’d get all along.
Medical providers used our software because it allowed them to charge as much as possible. Their desire wasn’t to reduce medical costs to patients.
Hospital administrators are among the highest paid executives around. I always remember that when the local hospitals do their fund-raising drives, as if they were charities in need of donations.
That is not correct. If a provider is in network with a patient’s insurance company, they can only charge the patient the percent of the allowable charge. So if a doctor charges $10K for a procedure but the insurance allows only $3500, the doctor can charge only 20% of the $3500 (assuming deductibles have been met).
Some billing software sends out bills to patients on a monthly basis which shows the amount due even before insurance has processed the claim. That can be confusing to the patient because it looks like they owe $10K when they really only owe 20% of $3500.
If the software led the patient to believe they owed the provider 20% of the charge rather than 20% of the allowable amount (ant the Dr is in network with the insurance company) this is smarmy. For the doctor to overcharge or balance bill, it is unethical an probably also illegal, and it is in violation of their contract with the insurance company. Patients can complain to the insurance company and the doctors can be in hot water. If, however, a service is NOT covered by the insurance company, the doctor is free to charge the patient the full amount.
Then what’s the point of sending an invoice of $10,000 to the patient?
A bill that doesn’t clearly show that the claim has been submitted to the insurance company is very misleading. The reason that the billing software sends monthly statements to patients should be so they know the status of their account. If the insurer is dragging their feet and not processing the claim, the patient can contact the insurance company to inquire as to why the claim has not been processed. In most states, insurance companies are required to respond to a claim within 45 days of when it is submitted, and a statement from the provider can provide documentation of when the claim was submitted to the insurance company. In rare cases, an insurance company will pay interest on a delayed payment. They are supposed to pay interest on delayed payments, but they often have some claim that they responded to the claim in some fashion within the time period.
@jym626, I’m not really talking about delayed payments or how long it takes to process claims.
In a lot of states (I know California is an exception) the negotiated reimbursement rates between medical provider and insurance company are secret. So saying the patient’s portion of the bill has to be based off the insurer’s reimbursement rate is going to be very hard to enforce. How can the patient know if his 20% payment is based off the insurer’s reimbursement rate if he doesn’t have access to those rates?
BTW - Not talking about a company like Kaiser, which is in effect both the medical provider and insurance company in one.
I am sorry but that simply isn’t true. The providers (or perhaps their billing department or company) usually are aware of what the negotiated rate is for most standard procedures they use, and/or the providers can get the fee schedule from the insurance company. It’s not “secret”, except that doctors cannot discuss billing/reimbursement amounts with each other, lest they be accused of price fixing and violating federal antitrust laws. So the negotiated rates are only “secret” between doctors, not between doctors and patients.
When you go to the doctor for an outpatient visit, you typically have either a flat copay for the visit or a co-insurance (percent of allowable) . Sometimes there are both (a visit may have a copay, but a test or other service provided during the visit may have a coinsurance- yes it’s confusing if the insurance company processes one charge as an office visit and another as a testing procedure, with different copays.) Most Drs offices will verify your benefits before you are seen, so when you check out they know what, if anything, to collect from you. They know that the allowable for procedure A is $XXXX even if the charged amount is $YYYY, and they collect the percentage of X, not Y. That said, sometimes the claims are not processed by the insurance company the way the benefits were quoted by the benefits folks when the insurance was verified, so there may be an outstanding amount due by the patient. It isn’t the Drs fault, but the insurance companies often try to make it look that way and try to throw the Drs under the bus. Whenever a Drs office verifies benefits, the recording or human says “verification of benefits in not a guarantee of payment. Payment decisions are made at the time a claim is processed”. And often the benefits department is nowhere near the claims department (often one or both are offshore) and my favorite (NOT) is when the 2 computer systems don’t even talk to each other. That’s absurd, IMO.
Ethically, at least in my profession, we are supposed to tell a patient what their expected payment/ financial responsibility will be at the time of service. This is based on verification of their benefits with the diagnosis ( or anticipated diagnosis) and procedure code for insurance companies for which we are in network. This is standard operating procedure.
Forgot to mention, when the claim is processed, the patient typically gets, or can look up on line, their EOB (Explanation of benefits). It clearly shows what the charges are, what the allowable is for each charge, what the patient’s financial responsibility is and what the Dr must write off. There is nothing secret about this. Nothing.
I don’t send bills until after insurance has paid, I have found it’s too confusing to send an invoice to the patient, and it costs money.
Some docs choose not to become in network so they don’t have to accept the low rates, but my suspicion in hospitals is that the docs not in network are new to the hospital just haven’t been credentialed yet.
There is no way however hospital staff is going to even begin to know how much you’ll be charged for every procedure and you really don’t want the clinical staff getting bogged down in being sales people too.
The out of network ER doc who saw my kid had been working in that ER for TEN years. But insurance agreed…when in the ER, you don’t have a choice and you certainly don’t flash your insurance card to the doctor…who probably has no idea where he is in or out of network!
I’ve had to educate my MD about the importance of proper coding and how insurance can accept or deny a claim based on the code. They get used to what they’ve always done, or what their billing dept tells them and are unaware of the vagaries of the insurance industry. It’s annoying that I have to know more about this stuff than they do.