Questions on how we spend our money and our time - consumer goods and services, home and vehicle, leisure and recreational activities
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Under ACA individual (not employer) a scan is covered, but only every 2 years. The doctor wants a scan after one year. I’m fine with paying out of pocket, but I would like to know if I can still get the in-network price? How does that work? Based on the previous EOB for the scan, the discounted price for having insurance was about 25% of the price submitted to the insurance company.
It varies from plan to plan, and facility to facility. In our case, the plan processed the claim with the insurance discount, and then said not covered, and the remainder amount as patient responsibility. So it counted against our deductible and out of pocket max. YMMV.
Ask the scan provider what their cash price is - might even be less than your insurer's listed price! Regardless, definitely negotiate the price in writing before the procedure.
Is there any possibility that your health care provider, the one wanted another scan sooner, could request some sort of exception (or appeal of a denial) or such to have it covered as "medically necessary"?
This signature is a placebo. You are in the control group.
I would also agree to ask your provider.
If you haven't, or your provider hasn't, submitted a prior authorization for this, you should do that. If this is one of the preventive services that are supposed to be covered, it may be the case where the diagnostic is covered as a preventative service (so 100% covered) every n years, but if you need testing more frequently it may be covered under your normal diagnostic and imaging cost sharing limits.
Google MD Save to get discount prices on medical tests. Prior to Medicare I had a high deductible health insurance plan. I used MD Save for an ultrascan and paid 50% of what I would have paid at a local hospital.