Medical Charges vs Contract Price - Non Covered Work

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Topic Author
bogleviewer
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Medical Charges vs Contract Price - Non Covered Work

Post by bogleviewer »

I just received a bill from a physician [pediatrician] group that circles the hospital where my child was born. Our primary pediatrician doesn't do rounds in the hospital which I assume isn't out of his own choice because his office is less than a mile away from the hospital (I assume hospitals only contract out with groups rather than individual practices).

In any event as many of you know a pediatrician comes in for a few minutes, checks vitals and then goes on his/her way. Two days in the hospital and discharge the third day we got a bill for three different dates with different codes (99460 99462 99238). The sum total that they billed my insurance was $550.

My insurance sent me an explanation of benefits that the contract reprice amount is $150. Difference of $400 or basically 1/4 of the billed price. This $150 is what the contracted out price is that is the maximum that this group would have received for the maximum 15 minutes in the room in the three days.

Unfortunately (but fortunately due to my premium compared to new ACA plans) my plan doesn't cover "routine well-baby care of a newborn infant".

So even though I received an EOB showing that the price the insurance reprice would have been is $150 (which I would have paid out of pocket for with high deductible plan) the physician group will not honor that price. They said that I owe them $550 since my insurance doesn't cover the work.

Just to be absolutely clear on this. The physician group is willing to accept $150 from me if my insurance would have covered the work but since my insurance didn't cover they want $550. The maximum they would have ever received had it been covered between my insurance and myself is $150 but they won't accept this because my plan didn't cover the work. They want $550.

Same work one price of $550 billed to me rather than $150 that they would have accepted from me had my child been covered with the insurance (INSURANCE WOULD HAVE PAID NOTHING).

I think that this is totally wrong and morally reprehensible. I am going to pay $550 for work that they have agreed that is worth $150 (and they still run a profit at $150)??

Anyone here have any recommendations on fighting this, like my other thread, simply out of principle? I did call insurance and they knew immediately upfront when I called "let me guess, the provider is billing you the full amount rather than the contracted out price?" and I said "yep" and insurance said "that is their right, I don't think that they should but that is their business and unfortunately they aren't obligated to honor a price that they would have given you had your child been covered".

The physician group said that they can send me a financial assistance form via the mail (of which I am certain I wouldn't qualify). I don't want financial assistance, I want them to honor what they would have accepted from me if insurance would have covered it for them to net $150 rather than $550 for the same amount of work. This is such a joke. The services rendered have not changed but instead of paying $150 I am going to pay $550?

Is this how the medical industry has always been run? What would you do? This group is huge, several hundred physicians so I don't think I am going to get anything escalated to anyone that cares or has any power. As some of you may have seen in my other thread about a different doctor experience, I am a man of principle irrespective of the dollar amount involved.
123
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by 123 »

There will usually be a number of "routine well-baby care of a newborn infant" visits in the early months. Doctor visits are a normal part of a child's life. If the out-of-pocket costs are too much of a burden you may want to adjust the insurance coverage. Depending on how old the child is now you may be able to adjust your coverage.

Often the greatest benefit of health insurance coverage is the negotiated prices.
The closest helping hand is at the end of your own arm.
Trapper
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by Trapper »

You sound stirred up and I don't blame you.
Given the scenario you outlined you could pay the $550 and file a small claims court action for $400. You would most likely lose, but it is a way for David to poke the Goliath.
Nowizard
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by Nowizard »

Yes, it is their prerogative, and a primary reason for medical bankruptcy since these bills hit hardest those who can least afford it. I know my billing accepted insurance allotments in such cases as full payment and accepted what had been the co-payment as total payment if someone lost insurance while still being treated. It might also be noted that many hospitals report the submitted charges, not the insurance allowance when quoting the amount of charity service they provide.

Tim
mnaspbh
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by mnaspbh »

You chose a plan (grandfathered non-ACA?) that doesn't cover some forms of care. You (your family) received the care it doesn't cover. Your insurance isn't covering that care. Because the care wasn't covered at all, you don't benefit from the insurance company's negotiated rates. Did you save enough in lower premiums to make up the cost?

With a new child in the family, you may be able to change insurance plans to buy one that will cover more services in the future. Pay very close attention to whatever legal restrictions the insurance company puts on each policy, especially around what doctors and facilities are in vs out-of-network. Hope that the insurance company doesn't decide to remove your preferred or available providers from the network mid-year.

This is how health insurance works in America. You can try to repeat negotiations with the hospital, or raise a stink on social media, but I would not expect much traction. If you feel American health insurance should work differently, contact your elected officials.
midnightrun
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by midnightrun »

In addition, I hope you understand that the insurance company is using you as a pawn in their contract negotiations with the group. I suspect that $150 does not cover overhead. That's roughly Medicaid rate depending on the state. Medicaid level reimbursement loses money for most groups.

The insurance company is hoping you believe that if the group were in network they'd be happy to work for $150. Then you'll get upset and pressure the group/hospital to go in network. If enough patients complain, then the group will accept a lowball contract. In reality, your plan is making a crappy/below market offer to the group so they never agreed to a contract. My guess is that they (and all non-employed physicians) would never accept $150 for this service as it's a money loser but might take $250-$300 if the plan offered that. If there's anyone you should be angry at...it's the plan
bberris
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by bberris »

This isn't a way for the insurance co to pressure docs to join. It's a way for hospitals and doctors to collude and avoid negotiated rates for care. These are the same drive-by docs who you never see but are always used in operating rooms, and are never in network.
Dottie57
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by Dottie57 »

Call the insurance co and verify what the physicians group has stated. The physician group is not the authority for the plan YOU have. Seriously call.
strafe
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by strafe »

Trapper wrote:You sound stirred up and I don't blame you.
Given the scenario you outlined you could pay the $550 and file a small claims court action for $400. You would most likely lose, but it is a way for David to poke the Goliath.
My guess is that the insurance benefit summary spells out that this service is not covered. Suing the insurance company over a non-covered service will likely be a fruitless and costly effort.
strafe
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by strafe »

bberris wrote:This isn't a way for the insurance co to pressure docs to join. It's a way for hospitals and doctors to collude and avoid negotiated rates for care. These are the same drive-by docs who you never see but are always used in operating rooms, and are never in network.
More on this here:
http://www.npr.org/sections/health-shot ... y-theories
Trapper
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by Trapper »

Strafe, the smalls claims action would be against the provider, not the insurance company. It would only require a filing fee to initiate. Provider would probable use attorney . It would be a nuisance for them to defend. I agree with you that it would probably be unsuccessful.
jacoavlu
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by jacoavlu »

Perhaps you have a copy of your insurance policy, or could obtain one from the company, preferably in electronic format, and CTRL-F search for "contractual adjustment" and "non-covered charges" or similar terms.

You may be likely to find language in the policy to the effect of you will only receive a contractual adjustment on services covered by your insurance company.
GUMD
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by GUMD »

This is a very challenging situation indeed. In reality, the pediatrician probably did more than check some vitals. The codes correspond to "Initial hospital or birthing center care, per day, for E/M of normal newborn infant," and subsequent hospital care for the normal newborn is reported once per day with code 99462 while discharge services provided on a date subsequent to admission is reported with code 99238.

To bill these codes, the pediatrician would have to at least perform a physical exam and see the baby in follow-up while you were there. If your pediatrician did not touch your baby, then indeed you have a fair objection. But if the pediatrician performed a physical exam, then there are dozens of things (some life threatening) that your pediatrician tested your baby for in a matter of minutes.

I agree that medical billing is frustrating and the difference between the insurance contracted rate and the amount billed is referred to as usual and customary charges. There are certain scenarios where you can get billed U&C charges even when your insurance company has paid the contracted rate (rare). At any rate, $150 is well below the fully allocated costs it required to provide those services. I know I wouldn't get up early on a Saturday to drive to the hospital and miss my son's basketball game just to check your baby for $150. I'm not surprised the group told your insurance company to get lost.

That being said, here is some simple advice. You can negotiate almost anything in this world - even with medicine. Try calling them and making them an offer. Offer them $250, and when they say "no", tell them that you are simply not paying $550, you never agreed to this price and had you known the price, you would have never have let them even come in the room.
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Nate79
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by Nate79 »

Sounds like you need to sign up for insurance that gives you the contracted rates instead of complaining that you have to pay list price.
jacoavlu
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by jacoavlu »

GUMD wrote:Offer them $250, and when they say "no", tell them that you are simply not paying $550, you never agreed to this price and had you known the price, you would have never have let them even come in the room.
this seems reasonable but the trouble is the provider almost certainly knows nothing about what level of coverage the parents do or don't have before (or likely even after) the encounter.
In my experience over literally tens of thousands of patient encounters never once have I known beforehand whether a patient even had insurance or not, let alone details about their particular level of coverage
Topic Author
bogleviewer
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by bogleviewer »

mnaspbh wrote:You chose a plan (grandfathered non-ACA?) that doesn't cover some forms of care. You (your family) received the care it doesn't cover. Your insurance isn't covering that care. Because the care wasn't covered at all, you don't benefit from the insurance company's negotiated rates. Did you save enough in lower premiums to make up the cost?

With a new child in the family, you may be able to change insurance plans to buy one that will cover more services in the future. Pay very close attention to whatever legal restrictions the insurance company puts on each policy, especially around what doctors and facilities are in vs out-of-network. Hope that the insurance company doesn't decide to remove your preferred or available providers from the network mid-year.

This is how health insurance works in America. You can try to repeat negotiations with the hospital, or raise a stink on social media, but I would not expect much traction. If you feel American health insurance should work differently, contact your elected officials.
Indeed I am in a grandfathered non-ACA plan. It made some changes (and subsequently quadrupled my premium since ACA enacted) but, believe it or not, if I was in a non-grandfathered plan (an actual ACA plan) my premium would be 10 times more expensive than before ACA passed. No joke. Several thousand dollars PER MONTH is what an ACA plan would be for my family with my high deductible, non smokers, fairly young. Absolute insanity.

In any event, the physician group that does rounds at the hospital was IN NETWORK. My plan has the newborn wellness checks as an exclusion. The pediatrician all three days didn't spend more than 5 minutes in the room on any of the given days (15 minutes max in room) and in fact on the day of discharge didn't show up for 8 hours past when she should have been there (the hospital didn't bill us for that day because they said that it wasn't our fault and that they are the ones that contracted out the group). Either way we were inconvenienced sitting in a hospital for 8 hours longer than necessarily with a newborn. I don't care about that since it is what it is and people make mistakes, miss appointments, have stuff come up, etc. I get it (although I wasn't compensated for my time and inconvenience only not billed for a 4th day from the hospital)

What I don't get is that the negotiated contract price had my insurance covered it is 1/4 the price that they want to charge me.

Once again, to be clear, had my insurance covered the wellness checkups, I, bogleviewer, would have paid $150 to the physician group and the insurance company would have paid $0. Instead, because it wasn't covered by my insurance, the physician group doesn't want $150, they want $550. Either way, whether the $150 (covered insurance) or $550 (not covered with insurance) the insurance company would pay $0 since my deductible wasn't hit yet. My insurance pays ZERO until my deductible is hit. I just want to make it clear because it seems like some people posted thinking that I would be billed $150 and the insurance picked up the remainder and that simply isn't the case. The max the physician group would get is $150 TOTAL had insurance covered while I would be the one paying it, not insurance.

Why would someone WITH insurance but not covered be charged 4 times more?

I don't understand (or maybe I just feel it is so completely immoral) that someone would pay 4 times more for something because of their insurance situation (or lack there of). If I didn't have insurance at all, would I be billed $550? $1000? More? Less?

WHY THE HECK DOES IT MATTER WHAT INSURANCE OR LACK OF INSURANCE SOMEONE HAS? Why don't doctors bill everyone the same?

i've heard the argument that insurance provides business to doctors but I don't believe that for a second. Patients may *verify* that a particular doctor is in-network before scheduling but the insurance company didn't provide the doctor the patient.

This may be off topic but we should have a system where there is known, transparent and upfront pricing for everyone, regardless of type of insurance or no insurance and let insurance be what it should be which is to pay a premium to avoid catastrophic financial ruin. Why (this isn't off topic now) does doctor bill X, get renegotiated to Y (from insurance) but if no insurance or not covered insurance bill X? Why are there pricing games like this? Honestly, this is the secondary point of this thread to understand how or why the system is setup this way.

On a related side note, had an emergency room visit with this same child when only a few months old and the hospital bill alone, not the doctor or blood work or anything was over $15,000 with the insurance negotiated contract price of $2000. High deductible plan, so insurance didn't pay a penny and I paid out of pocket $2000 for only the hospital charges....... but using the same logic the original post, had the emergency room visit not been covered in my insurance contract then the hospital would bill me for $15,000 even though they would accept $2000 from me if it is covered with my plan? Ludicrous. That is financial ruin for most American's.
jacoavlu
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by jacoavlu »

bogleviewer wrote: Why would someone WITH insurance but not covered be charged 4 times more?
see my post above - you generally would not get a contractual adjustment (the negotiated rate between your provider and your insurance company) for non-covered (as per your policy with your insurance company) services
bogleviewer wrote: I don't understand (or maybe I just feel it is so completely immoral) that someone would pay 4 times more for something because of their insurance situation (or lack there of). If I didn't have insurance at all, would I be billed $550? $1000? More? Less?
this provider would have billed you $550
bogleviewer wrote: WHY THE HECK DOES IT MATTER WHAT INSURANCE OR LACK OF INSURANCE SOMEONE HAS?
one might actually say it doesn't matter even in your situation; after all, your child was cared for, and had something been discovered on newborn screening I'm sure the pediatrician would have continued to care for your child as long as needed
bogleviewer wrote: On a related side note, had an emergency room visit with this same child when only a few months old and the hospital bill alone, not the doctor or blood work or anything was over $15,000 with the insurance negotiated contract price of $2000. High deductible plan, so insurance didn't pay a penny and I paid out of pocket $2000 for only the hospital charges....... but using the same logic the original post, had the emergency room visit not been covered in my insurance contract then the hospital would bill me for $15,000 even though they would accept $2000 from me if it is covered with my plan? Ludicrous. That is financial ruin for most American's.
emergency services are almost certainly covered services on your policy, hence you receive the contractual adjustment
Had you had no insurance at all, your bill would likely have been $15k
toofache32
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by toofache32 »

bogleviewer wrote:
In any event, the physician group that does rounds at the hospital was IN NETWORK. My plan has the newborn wellness checks as an exclusion. The pediatrician all three days didn't spend more than 5 minutes in the room on any of the given days (15 minutes max in room) and in fact on the day of discharge didn't show up for 8 hours past when she should have been there (the hospital didn't bill us for that day because they said that it wasn't our fault and that they are the ones that contracted out the group). Either way we were inconvenienced sitting in a hospital for 8 hours longer than necessarily with a newborn. I don't care about that since it is what it is and people make mistakes, miss appointments, have stuff come up, etc. I get it (although I wasn't compensated for my time and inconvenience only not billed for a 4th day from the hospital)
The doctor spent 5 minutes each visit in your room. You have part of the equation but you need to give us the rest. How much time did he spend on your case outside the room? On the computer checking labs, vitals, reading through all the other chart notes from other doctors/nurses, writing his own chart notes, etc?
jacoavlu
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by jacoavlu »

bogleviewer wrote:Why don't doctors bill everyone the same? [/b]
Generally they do bill everyone the same amount for the same service. But the adjustment is then applied per the contract with the payer.
toofache32
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by toofache32 »

bogleviewer wrote:
What I don't get is that the negotiated contract price had my insurance covered it is 1/4 the price that they want to charge me.

Once again, to be clear, had my insurance covered the wellness checkups, I, bogleviewer, would have paid $150 to the physician group and the insurance company would have paid $0. Instead, because it wasn't covered by my insurance, the physician group doesn't want $150, they want $550. Either way, whether the $150 (covered insurance) or $550 (not covered with insurance) the insurance company would pay $0 since my deductible wasn't hit yet. My insurance pays ZERO until my deductible is hit. I just want to make it clear because it seems like some people posted thinking that I would be billed $150 and the insurance picked up the remainder and that simply isn't the case. The max the physician group would get is $150 TOTAL had insurance covered while I would be the one paying it, not insurance.

Why would someone WITH insurance but not covered be charged 4 times more?

I don't understand (or maybe I just feel it is so completely immoral) that someone would pay 4 times more for something because of their insurance situation (or lack there of). If I didn't have insurance at all, would I be billed $550? $1000? More? Less?

WHY THE HECK DOES IT MATTER WHAT INSURANCE OR LACK OF INSURANCE SOMEONE HAS? Why don't doctors bill everyone the same?

i've heard the argument that insurance provides business to doctors but I don't believe that for a second. Patients may *verify* that a particular doctor is in-network before scheduling but the insurance company didn't provide the doctor the patient.

This may be off topic but we should have a system where there is known, transparent and upfront pricing for everyone, regardless of type of insurance or no insurance and let insurance be what it should be which is to pay a premium to avoid catastrophic financial ruin. Why (this isn't off topic now) does doctor bill X, get renegotiated to Y (from insurance) but if no insurance or not covered insurance bill X? Why are there pricing games like this? Honestly, this is the secondary point of this thread to understand how or why the system is setup this way.

On a related side note, had an emergency room visit with this same child when only a few months old and the hospital bill alone, not the doctor or blood work or anything was over $15,000 with the insurance negotiated contract price of $2000. High deductible plan, so insurance didn't pay a penny and I paid out of pocket $2000 for only the hospital charges....... but using the same logic the original post, had the emergency room visit not been covered in my insurance contract then the hospital would bill me for $15,000 even though they would accept $2000 from me if it is covered with my plan? Ludicrous. That is financial ruin for most American's.
Fees are not "negotiated" and you've been drinking the insurance koolaid if you believe this. The insurance company pays as little as they can and tell doctors to take it or leave it.

Regarding your ER experience and why providers/hospitals bill crazy high amounts.... The fact is, doctors will accept much lower rates but if they are in-network, they are forced to bill these higher rates. Wonder why?
Here's why physicians bill for much higher fees than they would otherwise accept: every doctor has maybe 50-100 codes they bill for commonly. They have no idea what each insurance will pay and they find out when they get their check. Every once in a blue moon, there will be an insurance company that pays their full fee for 1 particular code. This means the insurance company's allowed amount is actually higher than what was billed for some reason. So to capture the maximum THAT insurance will pay next time, they raise the fee for that code. But remember, now they have to bill that amount to ALL insurances and uninsured patients. Over time, this happens to most of the codes so now we have an entire fee schedule that is inflated. The in-network provider is contractually required to bill this inflated fee to everyone including uninsured patients. This is by design to force uninsured patients to think "oh man I need to get some insurance" and is how insurance companies contractually use doctors to boost their business.
toofache32
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by toofache32 »

jacoavlu wrote:
bogleviewer wrote:Why don't doctors bill everyone the same? [/b]
Generally they do bill everyone the same amount for the same service. But the adjustment is then applied per the contract with the payer.
They DO bill everyone the same. But the insurance company pays less than the full bill. The insurance companies REQUIRE by contract that providers bill everyone the same. See my above post explaining why.
Erwin007
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by Erwin007 »

bogleviewer wrote:
mnaspbh wrote:You chose a plan (grandfathered non-ACA?) that doesn't cover some forms of care. You (your family) received the care it doesn't cover. Your insurance isn't covering that care. Because the care wasn't covered at all, you don't benefit from the insurance company's negotiated rates. Did you save enough in lower premiums to make up the cost?

With a new child in the family, you may be able to change insurance plans to buy one that will cover more services in the future. Pay very close attention to whatever legal restrictions the insurance company puts on each policy, especially around what doctors and facilities are in vs out-of-network. Hope that the insurance company doesn't decide to remove your preferred or available providers from the network mid-year.

This is how health insurance works in America. You can try to repeat negotiations with the hospital, or raise a stink on social media, but I would not expect much traction. If you feel American health insurance should work differently, contact your elected officials.
WHY THE HECK DOES IT MATTER WHAT INSURANCE OR LACK OF INSURANCE SOMEONE HAS? Why don't doctors bill everyone the same?
Despite posting in two different threads and receiving many good explanations (which you seem to have disregarded or ignored), you still seem to have zero understanding about how medical billing works and what each involved party (particularly the doctors) are able to do or not do. Specifically, doctors do bill everyone the same--platinum insurance, Tricare, Medicare, Medicaid, or self-pay--all get "billed" the same by the doctor. The difference is what your insurance company, the one you have contracted with to provide health insurance for you and your family, pays or does not pay, and how your insurance company has contracted with the specific doctor or group that provides your family's care.

Also, you need to get past the "he only spent 2 minutes in the room so the service he provided couldn't have been worth what we were charged" business. As numerous people before me have said (that you continually ignore), the professional fees charged by physicians include paying for the expertise they have gained by years and years and years of education, training, and experience. Put another way, seems ridiculous that PGA golfers make a million bucks for winning a golf tournament...after all, that was "only for like four days of work..." :oops:
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StevieG72
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by StevieG72 »

I understand your frustration.

Regardless of ability to pay, the billing department will allow you to make payments interest free. I use this method just because it is an interest free loan.

Be glad its only $550, I got surprised by a $2500 bill from an ER visit with my daughter!

It is not worth your time or frustration to persue.

Congratulations on the healthy newborn!
Fools think their own way is right, but the wise listen to others.
Quark
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by Quark »

strafe wrote:
bberris wrote:This isn't a way for the insurance co to pressure docs to join. It's a way for hospitals and doctors to collude and avoid negotiated rates for care. These are the same drive-by docs who you never see but are always used in operating rooms, and are never in network.
More on this here:
http://www.npr.org/sections/health-shot ... y-theories
There's a difference between theories that mainly consist of not believing in science and theories that people are trying to maximize their income. Just because both sets of theories cover medical care does not make them equally plausible.
Quark
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by Quark »

bogleviewer wrote:...WHY THE HECK DOES IT MATTER WHAT INSURANCE OR LACK OF INSURANCE SOMEONE HAS? Why don't doctors bill everyone the same?

i've heard the argument that insurance provides business to doctors but I don't believe that for a second. Patients may *verify* that a particular doctor is in-network before scheduling but the insurance company didn't provide the doctor the patient....
Doctors are trying to maximize their income. They make more money this way.

Consider why someone buying wholesale pays a lower price than someone buying retail.

Patients verifying that a doctor is in-network means that the patient won't use an out-of-network doctor. The doctors lose the business if they don't agree to be in network. This pressures them to join the network, at the costs of lower rates.

Consider Medicare. If doctors don't accept it, they risk losing a large number of patients. They agree to lower rates to make sure they don't lose these patients.
strafe
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by strafe »

Trapper wrote:Strafe, the smalls claims action would be against the provider, not the insurance company. It would only require a filing fee to initiate. Provider would probable use attorney . It would be a nuisance for them to defend. I agree with you that it would probably be unsuccessful.
Sorry, I guess I misunderstood your David vs Goliath comment. It's usually insurance companies, and not lowly pediatricians, that are compared to Philistines.

In any case, reading later posts it's clear this is not really about the money.
strafe
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by strafe »

Quark wrote:
strafe wrote:
bberris wrote:This isn't a way for the insurance co to pressure docs to join. It's a way for hospitals and doctors to collude and avoid negotiated rates for care. These are the same drive-by docs who you never see but are always used in operating rooms, and are never in network.
More on this here:
http://www.npr.org/sections/health-shot ... y-theories
There's a difference between theories that mainly consist of not believing in science and theories that people are trying to maximize their income. Just because both sets of theories cover medical care does not make them equally plausible.
Belief in a nefarious and secret collusion that is unsupported by evidence falls into conspiracy theory territory. The poster above intimated two ideas:
1. hospitals maintain a 'taxi stand'-like pool of intentionally out-of-network general pediatricians on the post-partum unit (like the consultants "always" used in operating rooms); and
2. this particular pediatrician conducting a routine newborn exam was somehow doing something improper (like billing a face-to-face encounter without actually seeing the patient)
Any healthcare worker who has spent time in operating rooms or hospital wards knows both of these fall pretty far into tinfoil hat territory.
Last edited by strafe on Sat Jan 21, 2017 7:57 am, edited 1 time in total.
blueman457
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by blueman457 »

Medical billing in the United States is horrendous on multiple levels as you can see on you EOB.

Did you negotiate with the billing office at all?
Quark
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by Quark »

strafe wrote:
Quark wrote:
strafe wrote:
bberris wrote:This isn't a way for the insurance co to pressure docs to join. It's a way for hospitals and doctors to collude and avoid negotiated rates for care. These are the same drive-by docs who you never see but are always used in operating rooms, and are never in network.
More on this here:
http://www.npr.org/sections/health-shot ... y-theories
There's a difference between theories that mainly consist of not believing in science and theories that people are trying to maximize their income. Just because both sets of theories cover medical care does not make them equally plausible.
Belief in a nefarious and secret collusion that is unsupported by evidence falls into conspiracy theory territory. The poster above intimated two ideas:
1. hospitals maintain a 'taxi stand'-like pool of intentionally out-of-network general pediatricians on the post-partum unit (like the consultants "always" used in operating rooms); and
2. this particular pediatrician conducting a routine newborn exam was somehow doing something improper (like billing a face-to-face encounter without actually seeing the patient)
Any healthcare worker who has spent time in operating rooms or hospital wards knows both of these fall pretty far into tinfoil hat territory.
The two ideas you describe are not very plausible; their main problem is that they don't make much sense. They certainly are not rational income maximizing strategies. Believing vaccines cause autism is an entirely different class of nonsense. It's not the case that all incorrect beliefs, or all tinfoil hat beliefs, are incorrect for the same reason. That was the point I attempted to make.
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by jacoavlu »

to be clear it seems the pediatrician that saw the child in this case was not out of network; the $550 bill received by the OP is not a result of out-of-network charges, but rather non-contractually adjusted (full retail) charges as a result of the fact that the service provided was amongst the non-covered charges in the OP's high deductible insurance policy
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by strafe »

bogleviewer wrote: My insurance sent me an explanation of benefits that the contract reprice amount is $150. Difference of $400 or basically 1/4 of the billed price. This $150 is what the contracted out price is that is the maximum that this group would have received for the maximum 15 minutes in the room in the three days.

Unfortunately (but fortunately due to my premium compared to new ACA plans) my plan doesn't cover "routine well-baby care of a newborn infant".

...

Just to be absolutely clear on this. The physician group is willing to accept $150 from me if my insurance would have covered the work but since my insurance didn't cover they want $550. The maximum they would have ever received had it been covered between my insurance and myself is $150 but they won't accept this because my plan didn't cover the work. They want $550..
Congrats on the newborn! I understand your frustrations. Medical insurance and billing can be confusing.

Your assumption that the pediatric group accepted a $150 contract rate is almost certainly incorrect.

You have an insurance plan that doesn't cover many common physician services. The allowable charge your insurer shows on the EOB has no meaning. It's made up by the insurer. (And I would bet in- vs out-of-network may be mostly a marketing tool for your plan since they won't pay for many services in either group...)

Payment rates and in- vs out-of-network participation are plan-dependent, even within the same insurance carrier. Under a different plan by the same insurer that actually covers the physician service, the negotiated fee with the pediatric group likely would have been much more.

As others have pointed out, everything is negotiable. The codes you provided add up to about 6 RVUs. Assuming an average $45/RVU for commercial insurance (highly variable by geography and other factors), the "average" insurance plan would have paid the practice $270 for that work. Medicaid (rock bottom at $30/RVU) would have paid about $180. I suggest you offer to pay somewhere in the low end of that range and negotiate up.
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by jacoavlu »

strafe wrote: Your assumption that the pediatric group accepted a $150 contract rate is almost certainly incorrect.

You have an insurance plan that doesn't cover many common physician services. The allowable charge your insurer shows on the EOB has no meaning. It's made up by the insurer. (And I would bet in- vs out-of-network may be mostly a marketing tool for your plan since they won't pay for many services in either group...)

Payment rates and in- vs out-of-network participation are plan-dependent, even within the same insurance carrier. Under a different plan by the same insurer that actually covers the physician service, the negotiated fee with the pediatric group likely would have been much more.
this is incorrect, at least in my experience as a physician. I'm not a pediatrician.

As an in-network provider, the pediatrician you saw has a contract with your insurance company. They have agreed upon a fee schedule. If they had not, they would not be in network.

The allowable charge on the EOB ($150) does have meaning; that's the agreed upon rate per the fee schedule.

In my experience, fee schedules (what each particular code pays) negotiated with private payers (insurance companies) are expressed as a percentage of the medicare physician fee schedule. There is not a uniquely negotiated price for each individual code. The medicare fee schedule is set by CMS (the government). The negotiated rate with private payers will be greater than 100% - medicare and medicaid don't pay very much, which is why some physicians won't accept any medicare or medicaid patients.

My practice will have an established charge for each code, and that would be the "full retail" price, which someone would be billed if they have no insurance. That would be shown on the EOB (in the OP's case, $550) and then adjusted per the negotiated fee schedule.
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by Trapper »

I am learning a lot from this thread, and appreciate everyone's input and perspectives
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by dm200 »

jacoavlu wrote:to be clear it seems the pediatrician that saw the child in this case was not out of network; the $550 bill received by the OP is not a result of out-of-network charges, but rather non-contractually adjusted (full retail) charges as a result of the fact that the service provided was amongst the non-covered charges in the OP's high deductible insurance policy
My understanding (I thought) was that when the patient was responsible for an in network service amount (but that particular charge was not covered), the patient got the in network amount. Maybe I missed it in the discussions, but I would contact the insurance company to determine what the rules are for the i network providers. It seems to me that this situation would be in some of the fine print.
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Re: Medical Charges vs Contract Price - Non Covered Work

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This thread is now in the Personal Finance (Not Investing) forum (insurance).

Please state your concerns in a civil, factual manner.
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by HueyLD »

I re-read my insurance contract and it says clearly that if one incurs a non-covered expense, one is responsible for 100% of the charge. Look at it this way, if an in-network dermatologist also performs (non covered) cosmetic moles removal, the patient will be responsible for 100% of the charge.

The only exception is for "emergency" visits where the insurance company will pay the in-network amount and the patient pays the remainder (balance billing).

In the past, I was able to discuss with the provider's office to waive the balance billing because I had no control over where my doctor sent the diagnostic sample to. YMMV.
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by strafe »

jacoavlu wrote:
strafe wrote: Your assumption that the pediatric group accepted a $150 contract rate is almost certainly incorrect.

You have an insurance plan that doesn't cover many common physician services. The allowable charge your insurer shows on the EOB has no meaning. It's made up by the insurer. (And I would bet in- vs out-of-network may be mostly a marketing tool for your plan since they won't pay for many services in either group...)

Payment rates and in- vs out-of-network participation are plan-dependent, even within the same insurance carrier. Under a different plan by the same insurer that actually covers the physician service, the negotiated fee with the pediatric group likely would have been much more.
this is incorrect, at least in my experience as a physician. I'm not a pediatrician.

As an in-network provider, the pediatrician you saw has a contract with your insurance company. They have agreed upon a fee schedule. If they had not, they would not be in network.

The allowable charge on the EOB ($150) does have meaning; that's the agreed upon rate per the fee schedule.

In my experience, fee schedules (what each particular code pays) negotiated with private payers (insurance companies) are expressed as a percentage of the medicare physician fee schedule. There is not a uniquely negotiated price for each individual code. The medicare fee schedule is set by CMS (the government). The negotiated rate with private payers will be greater than 100% - medicare and medicaid don't pay very much, which is why some physicians won't accept any medicare or medicaid patients.

My practice will have an established charge for each code, and that would be the "full retail" price, which someone would be billed if they have no insurance. That would be shown on the EOB (in the OP's case, $550) and then adjusted per the negotiated fee schedule.
I don't disagree with anything you have said and I certainly wasn't trying to imply that the insurer sets rates code by code. My guess is that the pediatric group signed a contract with the insurer for participation in a variety of plans, of which the "mainstream" plans paid a more typical rate relative to Medicare. As part of that package, they may have nominally agreed to participate in the original poster's plan -- a plan that does not actually cover the bread and butter pediatric E/M services. The "contracted" multiplier for this plan is only about 70% of the Medicare schedule, but from the practice perspective the amount of the multiplier is moot since the contract doesn't actually apply to the types of services they provide. (Ironic that I'm saying this given my prior post above about unsubstantiated conspiracies. :happy )
Last edited by strafe on Sat Jan 21, 2017 10:44 am, edited 1 time in total.
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by dm200 »

jacoavlu wrote:
strafe wrote: Your assumption that the pediatric group accepted a $150 contract rate is almost certainly incorrect.
You have an insurance plan that doesn't cover many common physician services. The allowable charge your insurer shows on the EOB has no meaning. It's made up by the insurer. (And I would bet in- vs out-of-network may be mostly a marketing tool for your plan since they won't pay for many services in either group...)
Payment rates and in- vs out-of-network participation are plan-dependent, even within the same insurance carrier. Under a different plan by the same insurer that actually covers the physician service, the negotiated fee with the pediatric group likely would have been much more.
this is incorrect, at least in my experience as a physician. I'm not a pediatrician.
As an in-network provider, the pediatrician you saw has a contract with your insurance company. They have agreed upon a fee schedule. If they had not, they would not be in network.
The allowable charge on the EOB ($150) does have meaning; that's the agreed upon rate per the fee schedule.
In my experience, fee schedules (what each particular code pays) negotiated with private payers (insurance companies) are expressed as a percentage of the medicare physician fee schedule. There is not a uniquely negotiated price for each individual code. The medicare fee schedule is set by CMS (the government). The negotiated rate with private payers will be greater than 100% - medicare and medicaid don't pay very much, which is why some physicians won't accept any medicare or medicaid patients.
My practice will have an established charge for each code, and that would be the "full retail" price, which someone would be billed if they have no insurance. That would be shown on the EOB (in the OP's case, $550) and then adjusted per the negotiated fee schedule.
Under past insurance coverages, this is my experience as well. One example, I recall. Under Podiatry coverage, there was coverage for one (something - cannot recall deatils). The wuestion was that if I got two (I think shoe inserts), what would be MY charge - the uninsured Podiatrist charge of the insurance charge on my plan (lower). The answer was the lower insurance charge.
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by dm200 »

HueyLD wrote:I re-read my insurance contract and it says clearly that if one incurs a non-covered expense, one is responsible for 100% of the charge. Look at it this way, if an in-network dermatologist also performs (non covered) cosmetic moles removal, the patient will be responsible for 100% of the charge.

The only exception is for "emergency" visits where the insurance company will pay the in-network amount and the patient pays the remainder (balance billing).

In the past, I was able to discuss with the provider's office to waive the balance billing because I had no control over where my doctor sent the diagnostic sample to. YMMV.
What does that mean? is it 100% of the higher "cash" price, or 100% of the insurance company contracted price?
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by bogleviewer »

toofache32 wrote: The doctor spent 5 minutes each visit in your room. You have part of the equation but you need to give us the rest. How much time did he spend on your case outside the room? On the computer checking labs, vitals, reading through all the other chart notes from other doctors/nurses, writing his own chart notes, etc?
Good question..... 5 minutes in the room and 10 - 15 minutes outside of the room? Maybe a physician that does rounds in hospitals for HEALTHY newborn babies can comment. Having several relatives in the medical industry (MD's, PA's, etc) they said generally for healthy case charting takes no more than 15 minutes if done immediately after seeing the patient. Again, maybe someone that works in a baby delivering hospital can attest.
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by dodecahedron »

The question that comes to my mind is why your insurance company bothered to report on the EOB what they would have allowed had it been a covered expense.

It seems to me that the insurance company would have been completely within its rights to issue you an EOB that simply stated that the entire $550 was for a noncovered service and not to even take the trouble to report the hypothetical amount they would have allowed had it been for a covered category of expense.

In that case you would never even have known what they would have allowed in the hypothetical situation where you had chosen a policy that covered that type of expense.

If I have a policy that, for example, doesn't cover acupuncture (or routine eye exams or dentistry or whatever), and an acupuncturist (or eye doctor, dentist, etc.) submits a bill to my insurance company anyway, I don't expect to get an EOB telling me what they might have allowed for that service on a different type of policy than the one I happen to have, I simply expect to get an EOB telling me it is a noncovered service.
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by bogleviewer »

Erwin007 wrote: Despite posting in two different threads and receiving many good explanations (which you seem to have disregarded or ignored), you still seem to have zero understanding about how medical billing works and what each involved party (particularly the doctors) are able to do or not do. Specifically, doctors do bill everyone the same--platinum insurance, Tricare, Medicare, Medicaid, or self-pay--all get "billed" the same by the doctor. The difference is what your insurance company, the one you have contracted with to provide health insurance for you and your family, pays or does not pay, and how your insurance company has contracted with the specific doctor or group that provides your family's care.

Also, you need to get past the "he only spent 2 minutes in the room so the service he provided couldn't have been worth what we were charged" business. As numerous people before me have said (that you continually ignore), the professional fees charged by physicians include paying for the expertise they have gained by years and years and years of education, training, and experience. Put another way, seems ridiculous that PGA golfers make a million bucks for winning a golf tournament...after all, that was "only for like four days of work..." :oops:
Erwin007 i am not trying to be ignorant to the subject. My profession and expertise has proven time and time again that I am a very rational and logical thinker. I believe the hang up is that I am trying to get to the bottom of the nonsense and not simply that I am ignoring or disregarding information presented. I am taking it in and challenging it.

Thank you for pointing out that "doctors do bill everyone the same". This is a great point. This group did indeed bill my insurance $550. When insurance didn't cover, they turned around and billed me $550. They billed us the same.

I disagree with your analogy about PGA golfers as it is not applicable in this situation. A PGA golfer got paid millions of dollars for 4 days of work because they beat out all of the competition; the large majority came away with a fraction of the top 3 in any particular tournament. The point is, that the million dollars received is based upon outcome of services rendered. It was solely based upon their own ability to perform for those 4 days in relationship to the competition. Your argument is that a doctor doesn't bill for time but they also don't bill for outcome (as the PGA golfer analogy). They bill for procedures, irrespective of outcome. The PGA golfer field may have 50 golfers with only the top 3 making over a million and the rest coming out with tens of thousands to hundreds of thousands. They all played the same course and spent the same amount of work on the course (irrespective of how much time they spent outside of the course/tournament on the range, putting green, etc). This doesn't equate out the same to the medical industry. In the medical industry with how the system is built, if you have 50 doctors that play the same field (newborn baby care in a hospital in a given day) they would all bill the same. Let's just assume that it was the same patients, same conversations, etc. They would all bill the same dollar amounts and codes but all of the doctors would receive different dollar amounts based upon the insurances and lack of insurances in the patient pool (again, this is hypothetical where all the same patients for all 50 doctors but let's just assume for the scenario that insurance acceptance wasn't the same for all of these 50 doctors.... so same patients, 50 doctors but different insurances accepted between the doctors). In other words, any one particular doctors expertise, experience, years and years of education have zero effect on pay. One is paying for their expertise, experience and education and not their time, I agree, but even fresh out of medical school doctor would bill the same as a widely renown doctor. The billing code would be the same and it is possible the freshly minted doctor would get paid more than the renown doctor because the freshly minted doctor's patient didn't have insurance and the renown doctor's had the best insurance. Same procedure, different amount paid to the doctor. Unless I am understanding this wrong. Or do doctors bill different dollar amounts for the same billing code (assuming doctors are in the same geographic location)? In other words, for the $550 I was billed, would any peditrician charge $550 for those three billing codes or does every doctor bill differently? Are the billing codes standardized in that billing code 12345 is billable in geological location zip code 54321 at $100 irrespective of your medical education or does the doctor that runs along side you bill more or less? Is it standardized?

The point of the thread is the discussion for options as a consumer but also knowledge about how and why it works this way. If they bill the insurance $550 and the insurance says "nah, we will accept only $150" then provider will accept $150 regardless of who pays (insurance bank account or patient bank account) but the point is that the doctor is willing to accept $150. However, if the insurance says "we will pay $150, but ohh wait, this code actually isn't covered" and then for the doctor to bill $550 directly to the consumer seems ludicrous to me when they would have accepted $150. Same work conducted, if insurance covered they would have got $150 but because it didn't they get $550. Seems bizarre. Why not bill $150 to all? It seems like it hoses those that are less fortunate and the ones that probably have the least amount of means to pay higher prices.

I am trying to equate this into a normal business of retail versus wholesale. As a retail customer, if you go into a wholesale store you may be charged $50 for an item because you bought one of them and you are a retail customer afterall. If you are a reseller customer that buys from the wholesale store the store will sell it to you for $40 because you buy 10 at a time or even if as a reseller you bought one would still receive $40 because you have resell status. The reseller customer received a different lower price than the retail customer. The retail customer would have an uphill battle getting this the wholesale store to honor $40 reseller price to the retail customer; after all, the retail customer is worth less and is more work to the wholesale store. That is how the normal business operations work. How does this work and come into play in the medical industry where there are also three parties: provider, insurance and patient? Does an insurance company provide more volume to providers or is it simply a game controlled either by providers, insurance companies or collusion between the two?
Last edited by bogleviewer on Sat Jan 21, 2017 11:17 am, edited 1 time in total.
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HueyLD
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by HueyLD »

dm200 wrote:
HueyLD wrote:I re-read my insurance contract and it says clearly that if one incurs a non-covered expense, one is responsible for 100% of the charge. Look at it this way, if an in-network dermatologist also performs (non covered) cosmetic moles removal, the patient will be responsible for 100% of the charge.

The only exception is for "emergency" visits where the insurance company will pay the in-network amount and the patient pays the remainder (balance billing).

In the past, I was able to discuss with the provider's office to waive the balance billing because I had no control over where my doctor sent the diagnostic sample to. YMMV.
What does that mean? is it 100% of the higher "cash" price, or 100% of the insurance company contracted price?
100% of the gross charge by the provider.
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bogleviewer
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by bogleviewer »

dodecahedron wrote:The question that comes to my mind is why your insurance company bothered to report on the EOB what they would have allowed had it been a covered expense.

It seems to me that the insurance company would have been completely within its rights to issue you an EOB that simply stated that the entire $550 was for a noncovered service and not to even take the trouble to report the hypothetical amount they would have allowed had it been for a covered category of expense.

In that case you would never even have known what they would have allowed in the hypothetical situation where you had chosen a policy that covered that type of expense.

If I have a policy that, for example, doesn't cover acupuncture (or routine eye exams or dentistry or whatever), and an acupuncturist (or eye doctor, dentist, etc.) submits a bill to my insurance company anyway, I don't expect to get an EOB telling me what they might have allowed for that service on a different type of policy than the one I happen to have, I simply expect to get an EOB telling me it is a noncovered service.
I did actually ask this to the insurance company when I called about this and they said that they provide it so that you and the provider can see the contracted price as some providers will honor the contracted price. In this case, they won't.

I agree, this would have been much easier for me if I got an EOB saying "not covered" and subsequently a bill for $550. Pay the $550 and be on my way. That would benefit the medical industry though because it doesn't provide transparency to the consumer for me to question the status quo and try to understand the mechanisms at work as to why it works this way.

Another poster said that I could potentially negotiate with the provider; I would love to but part of negotiations I have to have something of power. I have nothing as a consumer in the medical industry. Nothing at all. What can I do and what leverage do I have? They already said NO when I asked if they would honor the $150 and even though I told them that I think it is nonsense to bill me $550 when they would have received $150 from me for the same services rendered had it been covered with my insurance policy and the repsentative was actually nice "I understand and agree, but that isn't our policy". Okay, so what do I have to come back at her with? Nothing. If I don't pay the bill, the account gets sent to collections and I get my fico score into the dumps and the doctors in the practice wouldn't know (or probably even care) and so the point never gets across to the doctors or groups. Correct me if I am wrong, but again, I don't see as a consumer having any leverage or anything of worth to the provider in a negotiation to get the price inbetween the contracted price and full retail price.
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by ResearchMed »

bogleviewer wrote:
toofache32 wrote: The doctor spent 5 minutes each visit in your room. You have part of the equation but you need to give us the rest. How much time did he spend on your case outside the room? On the computer checking labs, vitals, reading through all the other chart notes from other doctors/nurses, writing his own chart notes, etc?
Good question..... 5 minutes in the room and 10 - 15 minutes outside of the room? Maybe a physician that does rounds in hospitals for HEALTHY newborn babies can comment. Having several relatives in the medical industry (MD's, PA's, etc) they said generally for healthy case charting takes no more than 15 minutes if done immediately after seeing the patient. Again, maybe someone that works in a baby delivering hospital can attest.
Don't forget... the physician also pays for significant other expenses: rent of offices, salaries for office staff (including those who do office work, ahem billing, and also medical care), insurance, etc.
The amount billed doesn't just reflect "salary prorated for time per stopwatch" or such.
(I have absolutely no idea what percentage range these additional costs involve. And as previously mentioned, professionals who spent many years in training usually get compensated well, although probably not like in the past, and certainly not evenly in all specialties.)

Additional question for OP: Did you have no choice whatsoever in the choice of pediatrician, such that you could have been searching prior to the birth for a pediatrician recommended by others (for example) and also to verify insurance coverage issues?
Sorry if I missed this above.

RM
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by dodecahedron »

bogleviewer wrote:
dodecahedron wrote:The question that comes to my mind is why your insurance company bothered to report on the EOB what they would have allowed had it been a covered expense.

It seems to me that the insurance company would have been completely within its rights to issue you an EOB that simply stated that the entire $550 was for a noncovered service and not to even take the trouble to report the hypothetical amount they would have allowed had it been for a covered category of expense.

In that case you would never even have known what they would have allowed in the hypothetical situation where you had chosen a policy that covered that type of expense.

If I have a policy that, for example, doesn't cover acupuncture (or routine eye exams or dentistry or whatever), and an acupuncturist (or eye doctor, dentist, etc.) submits a bill to my insurance company anyway, I don't expect to get an EOB telling me what they might have allowed for that service on a different type of policy than the one I happen to have, I simply expect to get an EOB telling me it is a noncovered service.
I did actually ask this to the insurance company when I called about this and they said that they provide it so that you and the provider can see the contracted price as some providers will honor the contracted price. In this case, they won't.
Ah, okay, I can see why in some cases the provider might agree. If the provider happened to be your regular pediatrician, for example, s/he might agree to accept your insurance company's negotiated price on an uncovered service just to maintain your goodwill and ongoing good relationship.

It is likely different for this kind of short-term medical encounter. When I think about the malpractice exposure for in-hospital pediatricians doing this kind of work and the hassles of opening and maintaining records on short-term patients, I can understand why the doctors want to charge $550 for three short (but potentially important) visits.

I still recall (with warm fuzzy hazy memories) how our family practice doctor and my nurse-midwife visited both of us (mother and child) twice on the two mornings when I was in the hospital after the birth of my younger child over two decades ago. We had comprehensive employer-provided HMO coverage that covered everything (family practice doc was of course in network, as was the OB group including the nurse-midwife who had delivered my daughter) and I doubt I scrutinized those EOBs at all, but I imagine their charges were very reasonable. Both of them were, of course, already thoroughly familiar with family medical history due to our longstanding prior relationship.
Last edited by dodecahedron on Sat Jan 21, 2017 11:27 am, edited 1 time in total.
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bogleviewer
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by bogleviewer »

ResearchMed wrote:
bogleviewer wrote:
toofache32 wrote: The doctor spent 5 minutes each visit in your room. You have part of the equation but you need to give us the rest. How much time did he spend on your case outside the room? On the computer checking labs, vitals, reading through all the other chart notes from other doctors/nurses, writing his own chart notes, etc?
Good question..... 5 minutes in the room and 10 - 15 minutes outside of the room? Maybe a physician that does rounds in hospitals for HEALTHY newborn babies can comment. Having several relatives in the medical industry (MD's, PA's, etc) they said generally for healthy case charting takes no more than 15 minutes if done immediately after seeing the patient. Again, maybe someone that works in a baby delivering hospital can attest.
Don't forget... the physician also pays for significant other expenses: rent of offices, salaries for office staff (including those who do office work, ahem billing, and also medical care), insurance, etc.
The amount billed doesn't just reflect "salary prorated for time per stopwatch" or such.
(I have absolutely no idea what percentage range these additional costs involve. And as previously mentioned, professionals who spent many years in training usually get compensated well, although probably not like in the past, and certainly not evenly in all specialties.)

Additional question for OP: Did you have no choice whatsoever in the choice of pediatrician, such that you could have been searching prior to the birth for a pediatrician recommended by others (for example) and also to verify insurance coverage issues?
Sorry if I missed this above.

RM
It is certainly a business to a doctor and I am not disputing that fact. When someone sells a widget for $50 it is fair to assume that that price includes the business owner's best ability to assess how much profit margin he needed to pay for his education, rent, utilities, employees, etc and then some left over for him. I am not arguging this fact, it is how all businesses operate that provide goods and services.

My argument/question/concern/etc is that the doctor is willing to accept $150 for the same procedure from X but $550 from Y. I am trying to figure out why someone without insurance should pay nearly 4 times as much as someone with insurance. As another poster pointed out is that some of the best benefit of insurance is the contract out price and not necessarily that insurance would actually pay anything. But why?

As far as I am aware as a consumer we did not have a choice of pediatrician. We did ask our primary pediatrician that has his office a mile away from this big baby hospital and he said he didn't have rights or whatever to practice within the hospital. So as far as I am aware and concerned, I have no rights to pick and choose a particular pediatrician at this baby hospital. Irrespective, my insurance wouldn't cover an at hospital newborn wellness checkup so why I have no choice is for another discussion. :)
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bogleviewer
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by bogleviewer »

dodecahedron wrote:
bogleviewer wrote:
dodecahedron wrote:The question that comes to my mind is why your insurance company bothered to report on the EOB what they would have allowed had it been a covered expense.

It seems to me that the insurance company would have been completely within its rights to issue you an EOB that simply stated that the entire $550 was for a noncovered service and not to even take the trouble to report the hypothetical amount they would have allowed had it been for a covered category of expense.

In that case you would never even have known what they would have allowed in the hypothetical situation where you had chosen a policy that covered that type of expense.

If I have a policy that, for example, doesn't cover acupuncture (or routine eye exams or dentistry or whatever), and an acupuncturist (or eye doctor, dentist, etc.) submits a bill to my insurance company anyway, I don't expect to get an EOB telling me what they might have allowed for that service on a different type of policy than the one I happen to have, I simply expect to get an EOB telling me it is a noncovered service.
I did actually ask this to the insurance company when I called about this and they said that they provide it so that you and the provider can see the contracted price as some providers will honor the contracted price. In this case, they won't.
Ah, okay, I can see why in some cases the provider might agree. If the provider happened to be your regular pediatrician, for example, s/he might agree to accept your insurance company's negotiated price on an uncovered service just to maintain your goodwill and ongoing good relationship. That is my thinking as well. If this was our primary care pediatrician he would accept the $150 to chalk it up for goodwill considering he will be making thousands upon thousands over the course of years from our child(ren) and future child(ren). Since this wasnt primary care but rather a no-named doctor who we will never encounter again the customer service doesn't need to be there. I'm going to call the hospital to see if they would allow an "outside" pediatrician but something is telling me the answer is no and to use the group that they contract to do rounds.

It is likely different for this kind of short-term medical encounter. When I think about the malpractice exposure for in-hospital pediatricians doing this kind of work and the hassles of opening and maintaining records on short-term patients, I can understand why the doctors want to charge $550 for three short (but potentially important) visits. Yes, but $150 from me if using insurance contract price, but $400 more from me if not using contract price. The risk exposure is 100% identical.

I still recall (with warm fuzzy hazy memories) how our family practice doctor and my nurse-midwife visited both of us (mother and child) twice on the two mornings when I was in the hospital after the birth of my younger child over two decades ago. We had comprehensive employer-provided HMO coverage that covered everything (family practice doc was of course in network, as was the OB group including the nurse-midwife who had delivered my daughter) and I doubt I scrutinized those EOBs at all, but I imagine their charges were very reasonable. Both of them were, of course, already thoroughly familiar with family medical history due to our longstanding prior relationship. Maybe this is part of the problem? You as a consumer didn't care or even look into the EOBs because you weren't paying for it as the money came directly from the insurance bank account. With high deductible plans consumers are paying out of pocket for anything until they hit their deductible (mine is $7500).
my response in red.
Last edited by bogleviewer on Sat Jan 21, 2017 11:51 am, edited 1 time in total.
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dodecahedron
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by dodecahedron »

bogleviewer wrote: As far as I am aware as a consumer we did not have a choice of pediatrician. We did ask our primary pediatrician that has his office a mile away from this big baby hospital and he said he didn't have rights or whatever to practice within the hospital. So as far as I am aware and concerned, I have no rights to pick and choose a particular pediatrician at this baby hospital. Irrespective, my insurance wouldn't cover an at hospital newborn wellness checkup so why I have no choice is for another discussion. :)
My guess is that reimbursement rates are so low that it simply does not make sense for most office-based physicians to "make rounds" in hospitals as they once did. Any given office-based pediatrician may only have one or two newborns in the hospital on any given day (and even if there are two newborns on the same day, they might be in different hospitals!) The hassle of making a trip to the hospital, walking from the parking lot, dealing with the hospital's idiosyncratic computerized medical record system can just make it not economically viable for an office-based doc to make these kinds of visits.

We had a family physician (rather than a pediatrician) many years ago when our younger child was born. No computerized record system in those days. She probably had other patients in the hospital (not necessarily newborns) to visit the day she visited us and her office was very close to the hospital. And, as already mentioned, she was already thoroughly familiar with me and our family medical history.
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Kenkat
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Re: Medical Charges vs Contract Price - Non Covered Work

Post by Kenkat »

It is a screwed up system. I understand why you are aggravated, I would be too. $150 is probably too low of a charge - after all, the doctor came three times if I understand correctly. That's only $50 per visit which is really low to me. It wouldn't cover what I would expect to make to perform work, and I am not even a doctor. That said, $550 is probably too high and people without coverage seem too get the short end of the stick. Most people without coverage can least afford to pay "full price"; no wonder people just don't ever pay their medical bills in full - collections or not.

I think you are stuck paying unfortunately. If you want to make a Don Quixote type point, you could tell them you can't afford $550 and want a payment plan of $50/month. It's actually probably more work from your point, but I would probably get some sense of strange satisfaction from this. They will probably go for it. You can also ask if they offer any discounts if you pay the full amount now, sometimes they do.
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