Hospital wants me to prepay for procedure. Normal?

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BHawks87
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Hospital wants me to prepay for procedure. Normal?

Post by BHawks87 » Sun Mar 09, 2014 5:54 pm

I'm having surgery in a couple weeks and the hospital called me and went over my insurance plan (deductible, out of pocket max, etc) and gave me an estimated cost for my surgery based on all of the above and they want me to pay that amount on the day of the surgery. I just recently got off of my parents insurance and got my own so this is a first for me and I'm not sure if this is normal.

Do I have the right to say no and have them bill my insurance first? I plan on paying my bills of course but I dont want to get screwed somehow. The surgeon also wants a $5,000 deposit whereas my out of pocket max is $4,000. Is this normal as well?

Laura
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Re: Hospital wants me to prepay for procedure. Normal?

Post by Laura » Sun Mar 09, 2014 6:15 pm

I have had them want me to pay what is obviously my part of the bill which I will end up paying in the end. I have never seen where the surgeon also wants a $5k deposit when the most you can pay out of pocket is $4k. I would ask the surgeon's office about that.

Laura
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General Disarray
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Re: Hospital wants me to prepay for procedure. Normal?

Post by General Disarray » Sun Mar 09, 2014 6:26 pm

I'm guessing this is an elective medical procedure (for instance, cosmetic surgery <--- Not saying that it is cosmetic surgery here, but using that as an example of elective surgery).

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BHawks87
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Re: Hospital wants me to prepay for procedure. Normal?

Post by BHawks87 » Sun Mar 09, 2014 6:30 pm

General Disarray wrote:I'm guessing this is an elective medical procedure (for instance, cosmetic surgery <--- Not saying that it is cosmetic surgery here, but using that as an example of elective surgery).
Yes it is an elective surgery. Is this normal for elective surgery? Will they deny me if I say no to prepaying?

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Re: Hospital wants me to prepay for procedure. Normal?

Post by General Disarray » Sun Mar 09, 2014 6:41 pm

Requiring payment upfront is not uncommon. Of course, I myself would be a bit suspicious of the practice. There is something so greedy about this practice, to the point of being unethical, in my opinion, especially if services are withheld.

On the other hand, the doctor and hospital are viewing this more from the business side, rather than the medical side. Since the insurance company isn't going to foot the bill, that means you will have to do so. Requiring at least some payment upfront ensures at least partial payment. If the procedure were completed and you were to walk out without paying, the doctor/hospital gets nothing. But with some prepayment, at least they get something.

I really do not like the direction of medical care in the United States. To me, it is increasingly all about $ and less about health care.

General Disarray
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Re: Hospital wants me to prepay for procedure. Normal?

Post by General Disarray » Sun Mar 09, 2014 6:46 pm

BHawks87 wrote:[Will they deny me if I say no to prepaying?
You need to have a frank conversation with the hospital about this.

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Re: Hospital wants me to prepay for procedure. Normal?

Post by stan1 » Sun Mar 09, 2014 6:47 pm

I would tell the hosptial that you prefer to wait and get a final bill after you see how much the insurer will cover and that you will pay it immediately upon receipt. See what they say.

Here's what happened to me: I was having an expensive procedure done. The day before the hospital called and told me I would owe 20% of the cost (let's say it was $10,000) as a co-pay. That didn't sound right to me and told them I would wait for a statement from the insurer. The person on the phone said that was OK. What I came to find out later was the $10K was the "rack rate" -- not the negotiated rate my insurer has with the hospital. In this case the negotiated rate was around $3000 so I ended up owing around $600 -- not $2000. If I had paid what the hospital requested I would have had to claw back $1400.

It is a dirty trick, and in my case the hospital had outsourced bill collection to another company who was making the call obviously hoping they would find a naive person who might not fight to get their money back very hard so they could carry the the cash on their books for months.

Of course, if they say you can't have the surgery without paying up front you are stuck. But you won't know until you try.

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ResearchMed
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Re: Hospital wants me to prepay for procedure. Normal?

Post by ResearchMed » Sun Mar 09, 2014 6:58 pm

Please check your insurance policy carefully, or - better yet - phone the insurance company.

Truly "elective" surgery might *not* be covered, or might be covered with lower benefits.

This might be why you are being asked to pre-pay more than your expected "out of pocket", which assumes that the insurance *will* cover the rest.
It might not.

[For example, if strictly elective plastic surgery - no medical need, cosmetic only - was covered *fully* once deductibles are paid, for example, we'd all be seeing a lot more really, really bad facelifts walking around. There are already too many of those! :shock: ]

RM

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Re: Hospital wants me to prepay for procedure. Normal?

Post by Laura » Sun Mar 09, 2014 7:06 pm

Elective surgery is often not covered at all and you may need to pay 100% of the costs.

Laura
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BHawks87
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Re: Hospital wants me to prepay for procedure. Normal?

Post by BHawks87 » Sun Mar 09, 2014 7:24 pm

Thanks everyone for the responses.

I will call my insurance tomorrow and see what they say about this. The hospital did say I can pay 20% if I pay in cash which they said would be around $300. It seems my bill would be higher than that after insurance but I would still feel better having the bill go through insurance first.


ResearchMed wrote:Please check your insurance policy carefully, or - better yet - phone the insurance company.

Truly "elective" surgery might *not* be covered, or might be covered with lower benefits.

This might be why you are being asked to pre-pay more than your expected "out of pocket", which assumes that the insurance *will* cover the rest.
It might not.

[For example, if strictly elective plastic surgery - no medical need, cosmetic only - was covered *fully* once deductibles are paid, for example, we'd all be seeing a lot more really, really bad facelifts walking around. There are already too many of those! :shock: ]

RM
This surgery requires review and approval by my insurance and they reviewed it and approved it. This is why the surgeon wants $5,000 up front as a deposit in case insurance doesn't pay for it but in my case its already pre approved so I will see if they will waive that (or lower it to my out of pocket max).

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ResearchMed
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Re: Hospital wants me to prepay for procedure. Normal?

Post by ResearchMed » Sun Mar 09, 2014 7:32 pm

BHawks87 wrote:Thanks everyone for the responses.

I will call my insurance tomorrow and see what they say about this. The hospital did say I can pay 20% if I pay in cash which they said would be around $300. It seems my bill would be higher than that after insurance but I would still feel better having the bill go through insurance first.


ResearchMed wrote:Please check your insurance policy carefully, or - better yet - phone the insurance company.

Truly "elective" surgery might *not* be covered, or might be covered with lower benefits.

This might be why you are being asked to pre-pay more than your expected "out of pocket", which assumes that the insurance *will* cover the rest.
It might not.

[For example, if strictly elective plastic surgery - no medical need, cosmetic only - was covered *fully* once deductibles are paid, for example, we'd all be seeing a lot more really, really bad facelifts walking around. There are already too many of those! :shock: ]

RM
This surgery requires review and approval by my insurance and they reviewed it and approved it. This is why the surgeon wants $5,000 up front as a deposit in case insurance doesn't pay for it but in my case its already pre approved so I will see if they will waive that (or lower it to my out of pocket max).
That sounds better! :happy

Have you shown the surgeon, the hospital, and others the pre-approval letter?
Has the insurer agreed with surgeon and hospital on costs?
(That would be "without complications", the regular charges for this type of surgery. If they approve the surgery, they'd likely also cover the cost of any complications.)

Don't forget that "others" often bill separately. These might include people like radiologists, anaesthesiologists, pathologists, and such.
Some tests might be billed separately, too.

Good luck with the insurance, and especially good luck with the surgery!

RM

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Re: Hospital wants me to prepay for procedure. Normal?

Post by bottlecap » Sun Mar 09, 2014 7:38 pm

General Disarray wrote:Requiring payment upfront is not uncommon. Of course, I myself would be a bit suspicious of the practice. There is something so greedy about this practice, to the point of being unethical, in my opinion, especially if services are withheld.
Huh? If the insurance didn't pay, the hospital and the doctor would be out thousands of dollars. How is it greedy that they would want the money up front? Do you know how many people would mistakenly, and even intentionally, receive surgery that their insurance might not pay for or approve and wind up not paying in the end? Doctors and hospitals aren't giving out interest-free loans.

Try getting a lawyer without a retainer or to get a contractor to start a job without some money up front. Collecting a bill from someone who "decides" not to pay for services already received is one of the hardest things to do in business.

It's fairly normal. We paid up front for most of the services for the birth of our child, for instance. I didn't have a second thought about it.

JT

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celia
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Re: Hospital wants me to prepay for procedure. Normal?

Post by celia » Sun Mar 09, 2014 7:43 pm

You should first call the insurance company and ask how everything is supposed to work. They will want the procedure codes for the each procedure you will be billed for (type of surgery, assistant surgeon, length of time under anesthesia, use of operating room, recovery room, etc.) before giving you dollar amounts. The first 3 examples are the individual doctors' bills. They can get pre-authorization ahead of time from your insurance company. The others are part of the hospital bill. They can get pre-authorization from the insurance company too.

The problem with pre-paying anyone ahead of time is that it will not match what the insurance company calculates. Say you give the surgeon $4,000 which is your out-of-pocket maximum and he will expect to get paid the rest from the insurance company. The hospital bill will probably arrive at the insurance company first and they will pay the hospital everything the contract says except for your $4,000 out-of-pocket maximum. You will have to pay that to the hospital directly. Then you will have to wait until the surgeon gets around to billing insurance. When (s)he is fully paid, they should refund your $4,000.

This gets unnecessarily complicated if you don't let your insurance company do its thing first. Every one is free to verify your insurance to ensure they will be paid. I'd tell that to the hospital who wants payment up front. Of course, everyone will be owed money and is entitled to know how the bill will be paid. But you are entitled to also know how it will work on your end.
Last edited by celia on Sun Mar 09, 2014 7:48 pm, edited 1 time in total.
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Re: Hospital wants me to prepay for procedure. Normal?

Post by General Disarray » Sun Mar 09, 2014 7:46 pm

bottlecap wrote:
General Disarray wrote:Requiring payment upfront is not uncommon. Of course, I myself would be a bit suspicious of the practice. There is something so greedy about this practice, to the point of being unethical, in my opinion, especially if services are withheld.
Huh? If the insurance didn't pay, the hospital and the doctor would be out thousands of dollars. How is it greedy that they would want the money up front? Do you know how many people would mistakenly, and even intentionally, receive surgery that their insurance might not pay for or approve and wind up not paying in the end? Doctors and hospitals aren't giving out interest-free loans.

Try getting a lawyer without a retainer or to get a contractor to start a job without some money up front. Collecting a bill from someone who "decides" not to pay for services already received is one of the hardest things to do in business.

It's fairly normal. We paid up front for most of the services for the birth of our child, for instance. I didn't have a second thought about it.

JT
Good points, and it made me see the contradiction in my response.

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Re: Hospital wants me to prepay for procedure. Normal?

Post by LordB » Sun Mar 09, 2014 7:47 pm

I had an ambulance company call me repeatedly and try to get me to pay claiming that I would get reimbursed by my insurer. Sure enough the insurer paid them direct. I have no desire to be an unsecured creditor to some random ambulance company.

If at all possible I would let the insurance company sort things out before you pay anything and not pay any $$$ to the doctor until you see what insurance does and doesn't cover.

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Re: Hospital wants me to prepay for procedure. Normal?

Post by rkhusky » Mon Mar 10, 2014 7:17 am

We've never had to pay up front for the entire bill, except where the procedure was obviously not covered by our insurance. If a doctor takes your insurance, they should know what is covered or not. If it is a borderline situation, one should get an approval document from the insurance company and provide it to the doctor's office. We've only had to prepay deductibles and co-insurance, and often not even that for our regular doctors.

I've been in doctor's offices where they ask to see ID and an insurance card before the doctor will see them (maybe for the first time or for specialists that aren't seen often). I would hope that the staff can quickly determine whether the patient is really covered by the insurance company, kind of like a credit card authorization.

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Re: Hospital wants me to prepay for procedure. Normal?

Post by Njwolf » Mon Mar 10, 2014 7:33 am

If the surfera is NOT civered by insurance, thenmutual the Dr and facility will charge you the list price which is intended to be extremely profitable for them. Negotiate with them.

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Re: Hospital wants me to prepay for procedure. Normal?

Post by desiderium » Mon Mar 10, 2014 7:58 am

Unfortunately, this is the new normal. Here is the reason.

Insurance plans have increased annual out of pocket deductibles over the last several years. $4000 is a common figure, and some range up to $12000. In most cases, surgery is going to max out the annual deductible, so the hospital has to collect that number from you, regardless how good your insurance company is for the balance. Most people do not fit the financial profile of this forum, and do not have this kind of cash available, so the hospital becomes a creditor. It also puts the hospital in competition with the doctor, as to who is going to have to collect the $4000 from you.

Hospitals are racking up debt this way, and it is a huge problem. They can't delay urgent surgeries or care for acute illness over this issue, so they are trying to draw the line at elective procedures and get the money up front.

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Re: Hospital wants me to prepay for procedure. Normal?

Post by tivattom » Mon Mar 10, 2014 8:02 am

I just had some surgery done, and the hospital called me before asking me to pay. I simply told them I understand the costs and that I have the money in a combination of HSA and FSA accounts, but need to have a bill in order to withdraw the money from the accounts. They said "no problem" and I went on with the surgery.

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Re: Hospital wants me to prepay for procedure. Normal?

Post by Professor Emeritus » Mon Mar 10, 2014 8:11 am

bottlecap wrote:
Try getting a lawyer without a retainer
JT
A retainer is not a prepayment . It is a guarantee of payment once services are rendered. Lawyers are required to maintain retainers in special escrow accounts until earned.

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Re: Hospital wants me to prepay for procedure. Normal?

Post by gerrym51 » Mon Mar 10, 2014 8:16 am

when my wife had an elective procedure-eyelid surgery-she had to pay upfront.

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Re: Hospital wants me to prepay for procedure. Normal?

Post by johnubc » Mon Mar 10, 2014 8:18 am

Very common.

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Re: Hospital wants me to prepay for procedure. Normal?

Post by Nowizard » Mon Mar 10, 2014 12:02 pm

The key is "elective." Another example is that there are some procedures included in numerous insurance policies that are no cost to the subscriber if done as a matter of routine screening. A colonoscopy every ten years falls in this category. However, if one is done for diagnostic purposes, the same policy may not pay.

Tim

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Re: Hospital wants me to prepay for procedure. Normal?

Post by leonard » Mon Mar 10, 2014 12:21 pm

BHawks87 wrote:I'm having surgery in a couple weeks and the hospital called me and went over my insurance plan (deductible, out of pocket max, etc) and gave me an estimated cost for my surgery based on all of the above and they want me to pay that amount on the day of the surgery. I just recently got off of my parents insurance and got my own so this is a first for me and I'm not sure if this is normal.

Do I have the right to say no and have them bill my insurance first? I plan on paying my bills of course but I dont want to get screwed somehow. The surgeon also wants a $5,000 deposit whereas my out of pocket max is $4,000. Is this normal as well?
If they are going to require pre-payment - this is an outstanding opportunity to pre-negotiate.
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Re: Hospital wants me to prepay for procedure. Normal?

Post by whomever » Mon Mar 10, 2014 12:39 pm

"Try getting a lawyer without a retainer..."

This piqued my interest. I frequently hear 'lawyer on retainer', but in my thankfully minor encounters with the legal profession (wills, trusts, real estate) they have always done the work and billed afterwards. I'm curious what kinds of experiences people have where a retainer was required up front?

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Re: Hospital wants me to prepay for procedure. Normal?

Post by LowER » Mon Mar 10, 2014 12:54 pm

And, I have seen more insurance companies recently going back on their "pre-approval," even when every i was dotted and t crossed.

Is this actually a hospital or an ambulatory surgery center?

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Re: Hospital wants me to prepay for procedure. Normal?

Post by leonard » Tue Mar 11, 2014 12:25 pm

Professor Emeritus wrote:
bottlecap wrote:
Try getting a lawyer without a retainer
JT
A retainer is not a prepayment . It is a guarantee of payment once services are rendered. Lawyers are required to maintain retainers in special escrow accounts until earned.
If a customer doesn't pay - will the lawyer take the fee out of the retainer? If they will, then - If it looks, feels and acts like a prepayment...
Leonard | | Market Timing: Do you seriously think you can predict the future? What else do the voices tell you? | | If employees weren't taking jobs with bad 401k's, bad 401k's wouldn't exist.

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Re: Hospital wants me to prepay for procedure. Normal?

Post by Professor Emeritus » Tue Mar 11, 2014 12:33 pm

leonard wrote:
Professor Emeritus wrote:
bottlecap wrote:
Try getting a lawyer without a retainer
JT
A retainer is not a prepayment . It is a guarantee of payment once services are rendered. Lawyers are required to maintain retainers in special escrow accounts until earned.
If a customer doesn't pay - will the lawyer take the fee out of the retainer? If they will, then - If it looks, feels and acts like a prepayment...
Lawyers maintain fiduciary trust accounts when they handle other people's money. In virtually all states (except NY) Retainers are kept in these accounts. When a lawyer has properly earned a fee the lawyer can withdraw the payment from the trust account. These funds are highly regulated. More lawyers are disbarred for improperly dealing with trust accounts than all other causes put together. In my state all lawyers pay a special assessment to maintain a fund to repay clients whose lawyers steal from the fund.

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Re: Hospital wants me to prepay for procedure. Normal?

Post by Professor Emeritus » Tue Mar 11, 2014 12:37 pm

LowER wrote:And, I have seen more insurance companies recently going back on their "pre-approval," even when every i was dotted and t crossed.
?
Can you provide any specifics? The only case I know if the hospital was paid but the IC went after the client/patient for fraud. Hospitals have a legal "right to rely" on pre -approvals

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Re: Hospital wants me to prepay for procedure. Normal?

Post by leonard » Tue Mar 11, 2014 12:38 pm

Professor Emeritus wrote:
leonard wrote:
Professor Emeritus wrote:
bottlecap wrote:
Try getting a lawyer without a retainer
JT
A retainer is not a prepayment . It is a guarantee of payment once services are rendered. Lawyers are required to maintain retainers in special escrow accounts until earned.
If a customer doesn't pay - will the lawyer take the fee out of the retainer? If they will, then - If it looks, feels and acts like a prepayment...
Lawyers maintain fiduciary trust accounts when they handle other people's money. In virtually all states (except NY) Retainers are kept in these accounts. When a lawyer has properly earned a fee the lawyer can withdraw the payment from the trust account. These funds are highly regulated. More lawyers are disbarred for improperly dealing with trust accounts than all other causes put together. In my state all lawyers pay a special assessment to maintain a fund to repay clients whose lawyers steal from the fund.
OK. but, the money is at least in part a prepayment - although the trust can be used for other purposes as well.
Leonard | | Market Timing: Do you seriously think you can predict the future? What else do the voices tell you? | | If employees weren't taking jobs with bad 401k's, bad 401k's wouldn't exist.

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Re: Hospital wants me to prepay for procedure. Normal?

Post by frugaltype » Tue Mar 11, 2014 7:32 pm

Nowizard wrote:The key is "elective." Another example is that there are some procedures included in numerous insurance policies that are no cost to the subscriber if done as a matter of routine screening. A colonoscopy every ten years falls in this category. However, if one is done for diagnostic purposes, the same policy may not pay.

Tim
Really? Perhaps I am not understanding the word diagnostic?

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Re: Hospital wants me to prepay for procedure. Normal?

Post by Professor Emeritus » Tue Mar 11, 2014 7:55 pm

leonard wrote:
Professor Emeritus wrote:
leonard wrote:
Professor Emeritus wrote:
bottlecap wrote:
Try getting a lawyer without a retainer
JT
A retainer is not a prepayment . It is a guarantee of payment once services are rendered. Lawyers are required to maintain retainers in special escrow accounts until earned.
If a customer doesn't pay - will the lawyer take the fee out of the retainer? If they will, then - If it looks, feels and acts like a prepayment...
Lawyers maintain fiduciary trust accounts when they handle other people's money. In virtually all states (except NY) Retainers are kept in these accounts. When a lawyer has properly earned a fee the lawyer can withdraw the payment from the trust account. These funds are highly regulated. More lawyers are disbarred for improperly dealing with trust accounts than all other causes put together. In my state all lawyers pay a special assessment to maintain a fund to repay clients whose lawyers steal from the fund.
OK. but, the money is at least in part a prepayment - although the trust can be used for other purposes as well.
NO it is not a "prepayment" it is a deposit into trust to guarantee payment . A prepayment becomes the property of the party receiving it. A deposit in trust does not.

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Re: Hospital wants me to prepay for procedure. Normal?

Post by Professor Emeritus » Tue Mar 11, 2014 7:59 pm

frugaltype wrote:
Nowizard wrote:The key is "elective." Another example is that there are some procedures included in numerous insurance policies that are no cost to the subscriber if done as a matter of routine screening. A colonoscopy every ten years falls in this category. However, if one is done for diagnostic purposes, the same policy may not pay.

Tim
Really? Perhaps I am not understanding the word diagnostic?
I have a colonoscopy every 5 years after age 50 it's screening. if I have one after a bellyache its diagnostic.

Same is true for a mammogram without or with a lump Without=screening with=diagnostic

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Re: Hospital wants me to prepay for procedure. Normal?

Post by leonard » Tue Mar 11, 2014 8:05 pm

Professor Emeritus wrote:NO it is not a "prepayment" it is a deposit into trust to guarantee payment . A prepayment becomes the property of the party receiving it. A deposit in trust does not.
Perhaps there is a legal distinction. In the real world, that's semantics.

If a company doesn't eventually earn a prepayment and therefore recognize the revenue - they are supposed to give it back of you. From the layman's point of view - these 2 processes look pretty darn close. I give a company (or lawyer) money. They either do something to earn that money. Or, they don't and they give it back to me. Call it a "deposit in trust" or a "prepayment" - still works the same way.
Leonard | | Market Timing: Do you seriously think you can predict the future? What else do the voices tell you? | | If employees weren't taking jobs with bad 401k's, bad 401k's wouldn't exist.

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Re: Hospital wants me to prepay for procedure. Normal?

Post by dm200 » Tue Mar 11, 2014 8:49 pm

There are a lot of posts, so I could have missed some similar posts.

1. I am not sure either what "elective" surgery means in general or in your case. I think the important classification, as far as insurance is concerned, is "medically justified" or "medically necessary". I would get your insurance company to pre-approve the surgery and related costs.

2. It is also very important, depending on the type of surgery, that the doctors fully document and justify that this surgery is (or should be) covered by your insurance.

Two, perhaps similar, experiences I had with "elective" eyelid surgery and insurance.

After just living with an eyelid condition for many decades, I finally decided to get it fixed and consulted an ophthalmologist who specialized in this type of surgery. A great percentage of this type of surgery in purely or mostly "cosmetic" - and not covered by insurance. Mine was not cosmetic, and was medically justified. The insurance company and the surgeon went back and forth for almost a year before the claim was paid. It seemed to me that the surgeon had not done (and documented) all the details that justified this as medically necessary. A few years later, the eyelid condition needed some more (and very similar) attention. This time, before the surgery, I checked with the surgeon's office folks that all was fully in order to justify the insurance claim. This time, the claim was paid right away.

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Re: Hospital wants me to prepay for procedure. Normal?

Post by frugaltype » Wed Mar 12, 2014 9:18 am

Professor Emeritus wrote:
frugaltype wrote:
Nowizard wrote:The key is "elective." Another example is that there are some procedures included in numerous insurance policies that are no cost to the subscriber if done as a matter of routine screening. A colonoscopy every ten years falls in this category. However, if one is done for diagnostic purposes, the same policy may not pay.

Tim
Really? Perhaps I am not understanding the word diagnostic?
I have a colonoscopy every 5 years after age 50 it's screening. if I have one after a bellyache its diagnostic.

Same is true for a mammogram without or with a lump Without=screening with=diagnostic
I should have put in a rolling eyes smiley. What kind of insurance pays for a screening procedure but not for the same procedure needed because someone is actually sick was my real question.

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Re: Hospital wants me to prepay for procedure. Normal?

Post by LowER » Wed Mar 12, 2014 7:19 pm

Professor Emeritus wrote:
LowER wrote:And, I have seen more insurance companies recently going back on their "pre-approval," even when every i was dotted and t crossed.
?
Can you provide any specifics? The only case I know if the hospital was paid but the IC went after the client/patient for fraud. Hospitals have a legal "right to rely" on pre -approvals
Yes, but I would end up in HIPAA prison. Unfortunately, insurance companies are the new gunslingers in medicine and hospitals are notoriously bad at billing. You would think that the insurance-company-mandated pre-approvals would hold weight within their own organization, and usually they do, but not always unless their feet are held to the fire in the form of multiple wasted hours on phone calls and writing letters and threatening to go to the insurance commissioner or 60 Minutes or both. There is a term for this tactic: IIRC, it's "denial fatigue." After years of ridiculous insurance company shenanigans, doctors tire, fight less, and lose more. I read an article on FierceHealthCare recently that reported that insurance company denials increased by 42% between 2011 and 2012. I cannot vouch for veracity, but it certainly "feels" like that's the case. The amount of resources wasted on prior auths and pre-approvals is mind boggling. I now have to get a prior auth to give B12 by injection, maybe a nickel worth of medicine and my staff has to sit on hold with the insurance co for approval. Your hard-earned healthcare dollars at work....

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frugaltype
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Re: Hospital wants me to prepay for procedure. Normal?

Post by frugaltype » Thu Mar 13, 2014 6:45 am

LowER wrote: There is a term for this tactic: IIRC, it's "denial fatigue." After years of ridiculous insurance company shenanigans, doctors tire, fight less, and lose more. I read an article on FierceHealthCare recently that reported that insurance company denials increased by 42% between 2011 and 2012. I cannot vouch for veracity, but it certainly "feels" like that's the case. The amount of resources wasted on prior auths and pre-approvals is mind boggling. I now have to get a prior auth to give B12 by injection, maybe a nickel worth of medicine and my staff has to sit on hold with the insurance co for approval. Your hard-earned healthcare dollars at work....
UnitedHealthcare must be a master at denial fatigue, based on my interactions with them before I went on Medicare. This just cries out for an expose.

I get a B-12 injection every month (I get deficient without it), and as far as I know it requires no preauthorization from Medicare, or if it does, it's invisible to me. I just show up, no appointment necessary, and get zapped. Is this Medicare to the rescue, compared to "regular insurance"? (I don't know what UHC would have done, although I can imagine, since this wasn't happening then.)

toofache32
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Re: Hospital wants me to prepay for procedure. Normal?

Post by toofache32 » Mon Apr 07, 2014 10:22 pm

Any updates? Did you have your surgery?

StrangePenguin
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Re: Hospital wants me to prepay for procedure. Normal?

Post by StrangePenguin » Fri Oct 04, 2019 1:22 pm

I'm reviving this old thread to see if anybody has any personal experience with this. I guess it is becoming more and more common ( https://www.vox.com/policy-and-politics ... ay-surgery ).

My SO recently had surgery (not elective). The day before the surgery (which was scheduled months in advance), the hospital called her and told her she needed to prepay. The amount they requested was exactly the amount left up to our Out-of-Pocket Max for the year (at that time). She put it on our credit card and the surgery happened. Now more medical bills are slowly arriving in the mail. Some of those are for tests done in the weeks before the surgery (the dates of service for those were before the surgery but they had not been billed to insurance yet at the time of the surgery). The first surgery-related bill to arrive was the anesthesiologist. Because of the fractured way that medical billing works, this bill is payable to a different entity than the hospital itself. Also, in the meantime since the surgery, we've racked up a few more medical charges (prescriptions, for example). What all of this means is that eventually, once all of the surgery-related bills percolate through insurance, I expect that the hospital will owe us a substantial refund -- they collected the whole remaining Out-of-Pocket amount on a certain date, but after that date we are being billed hundreds of dollars more by other entities.

I'm curious if anybody has practical experience with this type of thing. Can I trust the hospital will actually refund us the appropriate money in the end? I have about 4 weeks of grace period before I have to pay the credit card bill with the prepayment to the hospital. But given how slow medical billing is, I'm afraid that all of the surgery-related claims will not have percolated through the insurance yet even at that time.

To make matters even worse, in the next few weeks I need to see a specialist and schedule a (more minor) surgery of my own, so there will be more claims pouring into our insurance.

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ResearchMed
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Re: Hospital wants me to prepay for procedure. Normal?

Post by ResearchMed » Fri Oct 04, 2019 1:30 pm

StrangePenguin wrote:
Fri Oct 04, 2019 1:22 pm
I'm reviving this old thread to see if anybody has any personal experience with this. I guess it is becoming more and more common ( https://www.vox.com/policy-and-politics ... ay-surgery ).

My SO recently had surgery (not elective). The day before the surgery (which was scheduled months in advance), the hospital called her and told her she needed to prepay. The amount they requested was exactly the amount left up to our Out-of-Pocket Max for the year (at that time). She put it on our credit card and the surgery happened. Now more medical bills are slowly arriving in the mail. Some of those are for tests done in the weeks before the surgery (the dates of service for those were before the surgery but they had not been billed to insurance yet at the time of the surgery). The first surgery-related bill to arrive was the anesthesiologist. Because of the fractured way that medical billing works, this bill is payable to a different entity than the hospital itself. Also, in the meantime since the surgery, we've racked up a few more medical charges (prescriptions, for example). What all of this means is that eventually, once all of the surgery-related bills percolate through insurance, I expect that the hospital will owe us a substantial refund -- they collected the whole remaining Out-of-Pocket amount on a certain date, but after that date we are being billed hundreds of dollars more by other entities.

I'm curious if anybody has practical experience with this type of thing. Can I trust the hospital will actually refund us the appropriate money in the end? I have about 4 weeks of grace period before I have to pay the credit card bill with the prepayment to the hospital. But given how slow medical billing is, I'm afraid that all of the surgery-related claims will not have percolated through the insurance yet even at that time.

To make matters even worse, in the next few weeks I need to see a specialist and schedule a (more minor) surgery of my own, so there will be more claims pouring into our insurance.
Why won't your insurance pay for the other charges, if you've met your OOP max, and these are valid charges?

RM
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StrangePenguin
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Re: Hospital wants me to prepay for procedure. Normal?

Post by StrangePenguin » Fri Oct 04, 2019 2:25 pm

ResearchMed wrote:
Fri Oct 04, 2019 1:30 pm
[
Why won't your insurance pay for the other charges, if you've met your OOP max, and these are valid charges?

RM
The issue is the sequencing.
Usually a medical expense is billed as follows (at least under a high-deductible health plan framework):

Date of procedure X: no payment
Some time later the medical provider bills insurance for procedure X
The insurance company processes that claim, checks your deductible remaining and OOP Max status, and pays the medical provider
The medical provider receives the payment and sends a bill to the patient for any remaining amount.

As long as this ordering is not violated, then everything works fine.
In this "surgery prepayment" case, the hospital has asked for and collected payment from the patient before actually submitting a claim to the insurance. So the insurance company does not apply that payment to the OOP Max. In the meantime the insurance has received claims from other providers, who provided medical services on dates before the surgery but didn't bill insurance until shortly after the surgery (roughly). (i.e. they used the normal framework where billing is a slow process).

I expect that the hospital will eventually bill insurance for the surgery under the normal procedure. At that point they will apply our prepayment to whatever our share of the bill is. And I expect that they will eventually see that our prepayment is greater than our eventual responsibility, because we will have exceeded our OOP Max. I am curious if anyone else has been in this situation and how the hospital handled it in their case.

I hope this makes it clearer. Perhaps if it is still unclear I can try to lay out the whole timeline with real dates. I have a whole spreadsheet to track these bills.

(in our real situation, the surgery required by my SO required a whole sequence of office visits and expensive pre-treatments. These were all billed *very slowly* under the normal billing procedure. Some of the bills for those pre-treatments were still being processed by insurance when the surgery happened. To make matters worse, clearly hospital billing is fairly incompetent -- they don't always even submit claims to insurance in the same chronological order as the procedures)

cochlearboy
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Re: Hospital wants me to prepay for procedure. Normal?

Post by cochlearboy » Fri Oct 04, 2019 2:35 pm

Your story is just another data point in how broken the US healthcare system is.

I doubt you will get a quick and painless refund. You will likely have to submit multiple rounds of paperwork between your insurance and the hospital... I see small claims court in your future... My advice to you is to keep track of all receipts and reimbursements. In addition, if you can - pay that credit card bill. You may still end up responsible for interest/late payment charges.

In the future, with respect to these kind of requests from hospitals, I advise you to tell the hospital that you have already met your OOP status for the year (lie to them if you have to).... This excuse should force them to submit the claims to your insurance...

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Re: Hospital wants me to prepay for procedure. Normal?

Post by anon_investor » Fri Oct 04, 2019 2:42 pm

My spouse just had surgery last month. The week before the surgery the hospital did call asking if we wanted to repay the amount up to our deductible. This was not a requirement or a demand, just a request. We said no thank you and that was that. We have a high deductible health plan, and we have never have to pay anything up front, instead we just wait for it to process through insurance and then have the medical provider issue us a bill. Almost 100% of the time, the bill issued by the medical provider to our insurance is reduced due to contractual limits, so what we end up paying out of pocket is less than what the medical provider was originally trying to bill. Therefore, I would never prepay.

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ResearchMed
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Re: Hospital wants me to prepay for procedure. Normal?

Post by ResearchMed » Fri Oct 04, 2019 2:54 pm

That's a bit odd, but we don't have a "high deductible" plan, although the deductible isn't all that small...

The insurance just pays when the bill comes in.
They have no way to know if there will ever be other bills coming in for other treatments/services provided prior to the "currently billed" procedure. So the insurer just keep paying, subject to co-pays/etc., (and any "normal/customary" limits, if such are applicable) as the bills come in.
Then, when we've paid the OOP maximum, suddenly our amount becomes "$0.00", whether it be for a surgeon or for an inexpensive (or expensive!) Rx.

All that matters is that the service is provided in the same calendar year (our plans are on calendar years; no idea if all plans work that way).
Once a service is provided on Jan 1st of the next year, the counter starts over.
However --> any bills still coming in from the previous year are still paid per the terms/limits of that previous year, so those might be zero from us, whereas something from the "new year" would be 100% from us, until the deductible is met.
It's the date of service that matters, not the date the bill is received, at least for any plan we've ever had.
(As long as there wasn't some oddball and exceedingly long delay or such, I suppose...)

And our situation is like anon_investor just described as well.
The hospital (or other provider) doesn't usually know in advance precisely what the "negotiated rate" is going to be for *our* policy, so they -and we - wait for the EOB (Explanation of Benefits) comes in and the billed amounts, for provider and us, are known.
And even if there is still some OOP amount still appearing to be due from us, there could be other bills coming in soon, before the current provider gets into the queue. It's then possible that less will be due from us than might appear.

The only place we have a request for prepayment is for major dental procedures, such as a crown, when they might request that we pre-pay what it appears we'll be responsible for. (But our dental plan works *quite* differently from the medical/surgical in terms of insurance coverage.)

RM
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Big Dog
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Re: Hospital wants me to prepay for procedure. Normal?

Post by Big Dog » Fri Oct 04, 2019 3:01 pm

cochlearboy wrote:
Fri Oct 04, 2019 2:35 pm
Your story is just another data point in how broken the US healthcare system is.

I doubt you will get a quick and painless refund. You will likely have to submit multiple rounds of paperwork between your insurance and the hospital... I see small claims court in your future... My advice to you is to keep track of all receipts and reimbursements. In addition, if you can - pay that credit card bill. You may still end up responsible for interest/late payment charges.

In the future, with respect to these kind of requests from hospitals, I advise you to tell the hospital that you have already met your OOP status for the year (lie to them if you have to).... This excuse should force them to submit the claims to your insurance...
I couldn't disagree more with the totality of this post (with the exception of saving your receipts). If the hospital has been overpaid, it will certainly not require small claims court to obtain a refund.

btw: the hospital already knew that the OP had not met his/her deductible and out of pocket expenses, as they called the carrier to confirm insurance coverage and reimbursement level.

HereToLearn
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Re: Hospital wants me to prepay for procedure. Normal?

Post by HereToLearn » Fri Oct 04, 2019 3:05 pm

cochlearboy wrote:
Fri Oct 04, 2019 2:35 pm
Your story is just another data point in how broken the US healthcare system is.

I doubt you will get a quick and painless refund. You will likely have to submit multiple rounds of paperwork between your insurance and the hospital... I see small claims court in your future... My advice to you is to keep track of all receipts and reimbursements. In addition, if you can - pay that credit card bill. You may still end up responsible for interest/late payment charges.

In the future, with respect to these kind of requests from hospitals, I advise you to tell the hospital that you have already met your OOP status for the year (lie to them if you have to).... This excuse should force them to submit the claims to your insurance...
You can't lie to them because the hospital has already called and verified the remaining OOP max.

@ResearchMed--I had the same request the afternoon before a colonoscopy. The payment was to the facility, not the doctor. The carrier ended up paying for the full cost of the colonoscopy, which I do not think they should have done, but they did, so I had to make a few phone calls to have the facility reimburse me since they had been paid twice.

Once your carrier processes the hospital bill, I would call the hospital's billing department. Actually, wait at least a week after the time you see the online payment as the member can often view the information before the provider. Good luck pursuing your refund.

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eye.surgeon
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Re: Hospital wants me to prepay for procedure. Normal?

Post by eye.surgeon » Fri Oct 04, 2019 3:11 pm

Ever tried to repossess a surgery? You pay up front for the portion you are anticipated to be responsible for.
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HomeStretch
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Re: Hospital wants me to prepay for procedure. Normal?

Post by HomeStretch » Fri Oct 04, 2019 3:19 pm

I have had good luck getting refunds from doctors and dentists who have collected at time of procedure but owed me a refund due to the claims processing sequencing described above. As soon as I see the insurance company’s online Explanation of Benefit statement, I call the provider to request a refund which is usually received within two weeks. I hold off on disputing the charge with my credit card company unless I have an issue with the provider not refunding timely (happened once).

More providers in my area are asking for payment at time of exam/procedure for patients with high deductible healthcare plans (HDHP).

My guess is the HDHPs have turned into a significant collections effort for the providers. Instead of billing and collecting from one credit-worthy party (insurer), the providers have to rebill and collect from multiple patients who may or may not pay, ask for a further discount, ask for a no-interest payment plan.

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CULater
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Re: Hospital wants me to prepay for procedure. Normal?

Post by CULater » Fri Oct 04, 2019 3:34 pm

Happened to me once - $28,000 up front hospital charges for cancer surgery. They thought I wasn't covered by insurance so I would have been heartlessly put out on the street in NYC after flying there for the surgery had I not had the $28K in my account and my checkbook. The surgeons didn't ask for upfront-- it was the hospital. They held onto the entire amount for months until they got every cent from the insurance and then deducted all the incidentals not paid by the insurance from my $28K. I learned what life is like for people who don't have insurance -- brutal.
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