How to obtain contracted rates for medical procedures?

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ipo_fin_z
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How to obtain contracted rates for medical procedures?

Post by ipo_fin_z » Mon Jul 08, 2019 8:23 pm

Scenario:
  • I have an HDHP with a high deductible ($8k) I'm not going to meet
  • I have an expensive, but ordinary and low-risk specialist vsiit coming up and am trying to shop around (within my PPO's network) for the best rate. Cost is in the thousands, but definitely nowhere near meeting the deductible.
While I've easily been able to obtain the CPT codes from providers and the cash cost, only one small office has been willing to give me the negotiated rate they'll bill my insurance at (comes in about a third of the cash rates I'm hearing). Unfortunately, they are also doing some unnecessary tests I can't decline if I use their services, so they might not be the cheapest.

The offices affiliated with larger health networks (Stanford, Palo Alto Medical foundation, etc.) are not being transparent at all. When I ask for the contracted/negotiated rates, they'll transfer me to the billing department who either A) outright refuses to divulge the info or B) claims to not know and directs me to my insurance. My insurance company (Anthem) also is refusing to provide the contracted rates/allowable amount, basically claiming they don't know/won't provide them/ask the provider. (This whole thing striking me as absurd as both sides should know this information.)

I figure the point of an HDHP is for patients to face higher deductibles and thus be incentived to cut costs, but I'm finding this difficult - making me wonder if I'm doing something wrong. What's the proper way to figure out what a procedure will cost given insurance info, billing codes, and provider?

(Similarly, are the negotiated rates for provider 1 and provider 2 similar? e.g. can I use the cost estimates for that small office as an estimator for what I'll pay at a different provider?)

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SevenBridgesRoad
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Re: How to obtain contracted rates for medical procedures?

Post by SevenBridgesRoad » Mon Jul 08, 2019 9:11 pm

The only thing you are doing wrong is thinking the health care system is ready for individuals shopping like they are buying a new car.

Don’t get me wrong. I admire what you are attempting. I support it. But for the most part health care providers are not (yet) prepared to deal with individuals who are price comparing. The thinking...the paradigm...is still that you are a patient. (Think about that word for a minute. Not a customer.). I don’t like it, but paradigms are tough to overcome. You are an early adopter.

Do you mind sharing with us what the specialist visit is about? I assume there is a procedure? Context might help generate some actionable ideas.
Retired 2018 age 61 | "Not using an alarm is one of the great glories of my life." Robert Greene

rantk81
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Re: How to obtain contracted rates for medical procedures?

Post by rantk81 » Mon Jul 08, 2019 9:18 pm

ipo_fin_z wrote:
Mon Jul 08, 2019 8:23 pm
What's the proper way to figure out what a procedure will cost given insurance info, billing codes, and provider?
In my experience, my insure company (Aetna) could not quote me the negotiated rates even when I was providing them all the CPT codes and provider NPI IDs ahead of time.... I guess rolling 5 Yahtzee dice and using each as one of the digits of your bill is about as accurate a prediction as anything....

chessknt
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Re: How to obtain contracted rates for medical procedures?

Post by chessknt » Mon Jul 08, 2019 9:21 pm

Depending on what you are getting done this may not be possible.

Examples:
1-having surgery/procedure done? Anesthesia/pathology are different departments with different rates plus if a complication occurs the price changes.

2-having a consult for a medical problem? Specialist will have no idea what you will need done to diagnose/treat until they actually review your case which they do during the visit. Complexity of the case dictates billing as well which is also not known until the visit.

There is a reason these codes are billed after the fact instead of beforehand.

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SevenBridgesRoad
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Re: How to obtain contracted rates for medical procedures?

Post by SevenBridgesRoad » Mon Jul 08, 2019 9:23 pm

rantk81 wrote:
Mon Jul 08, 2019 9:18 pm
ipo_fin_z wrote:
Mon Jul 08, 2019 8:23 pm
What's the proper way to figure out what a procedure will cost given insurance info, billing codes, and provider?
In my experience, my insure company (Aetna) could not quote me the negotiated rates even when I was providing them all the CPT codes and provider NPI IDs ahead of time.... I guess rolling 5 Yahtzee dice and using each as one of the digits of your bill is about as accurate a prediction as anything....
It’s in the contracts. Nothing can be disclosed.
Retired 2018 age 61 | "Not using an alarm is one of the great glories of my life." Robert Greene

Topic Author
ipo_fin_z
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Re: How to obtain contracted rates for medical procedures?

Post by ipo_fin_z » Mon Jul 08, 2019 9:26 pm

SevenBridgesRoad wrote:
Mon Jul 08, 2019 9:11 pm
Do you mind sharing with us what the specialist visit is about? I assume there is a procedure? Context might help generate some actionable ideas.
Initial pediatric cardiology consultation. Kid has a (likely innocent) heart murmur. One of those things that 99% of the time is nothing to worry about, but still worth checking out. The cost problem is that some specialists want to go all-in initially on pricey tests before the doctor even starts the consultation - e.g. using an echo-cardiogram (which isn't even advised before initial cheaper screening) Obviously, paying the costs is critical if there is an issue -- I'm banking on there not being one.

Anyway, I came across https://www.fairhealthconsumer.org in the last hour of searching. The prices it gives look reasonable - if I take the assumption that in-network rates are roughly the same across providers for the same CPT code, it's obvious how to proceed (just pick a good doctor that doesn't over-test)

chessknt wrote:
Mon Jul 08, 2019 9:21 pm
2-having a consult for a medical problem? Specialist will have no idea what you will need done to diagnose/treat until they actually review your case which they do during the visit. Complexity of the case dictates billing as well which is also not known until the visit.
Right the problem here isn't not knowing the potential billing codes (it's probabilistic what will be charged -- I can deal with that though) -- the problem is not knowing what the cost is per code.

SevenBridgesRoad wrote:
Mon Jul 08, 2019 9:11 pm
Don’t get me wrong. I admire what you are attempting. I support it. But for the most part health care providers are not (yet) prepared to deal with individuals who are price comparing... You are an early adopter.
HDHPs have been around for quite some time (and not having insurance even longer!); I'm surprised more people aren't worrying about optimizing these costs (which are on par with buying a used car!)

toofache32
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Re: How to obtain contracted rates for medical procedures?

Post by toofache32 » Mon Jul 08, 2019 9:32 pm

The "negotiated rates" are created and kept by your insurance company, NOT the doctors office. If you have the CPT codes, just ask your insurance. Good luck on getting them to tell you though. They won't even tell the doctor's office.
The office does NOT bill the "negotiated" rate, they bill their normal rate to the insurance. Billing a lower rate will skew the UCR trends.

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JD Leonard
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Re: How to obtain contracted rates for medical procedures?

Post by JD Leonard » Mon Jul 08, 2019 9:44 pm

My health insurance provider, Cigna, has a cost estimator on its website that I've found helpful. It won't give you an exact number, but the estimates seem to be based on real data.
- JD Leonard

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tfb
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Re: How to obtain contracted rates for medical procedures?

Post by tfb » Mon Jul 08, 2019 9:50 pm

ipo_fin_z wrote:
Mon Jul 08, 2019 8:23 pm
My insurance company (Anthem) also is refusing to provide the contracted rates/allowable amount, basically claiming they don't know/won't provide them/ask the provider. (This whole thing striking me as absurd as both sides should know this information.)
Anthem supposedly provides an online tool that shows you this information.
Care & Cost Finder helps you compare costs for common health care services. Estimates are based on what your plan covers, so you get a true picture of what you’d pay.
https://www.anthem.com/blog/your-health ... st-finder/
Harry Sit, taking a break from the forums.

toofache32
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Re: How to obtain contracted rates for medical procedures?

Post by toofache32 » Mon Jul 08, 2019 9:54 pm

ipo_fin_z wrote:
Mon Jul 08, 2019 9:26 pm

Anyway, I came across https://www.fairhealthconsumer.org in the last hour of searching. The prices it gives look reasonable - if I take the assumption that in-network rates are roughly the same across providers for the same CPT code, it's obvious how to proceed (just pick a good doctor that doesn't over-test)
I think you may have some confusion on how the billing and fees work, or I might not be understanding your questions. The IN NETWORK rates are determined by the insurance company, not the doctor. The doctor's office doesn't know the insurance fees. If you go to an IN NETWORK doctor for services covered under your contract, the fee should be the same everywhere because it's the same insurance company that sets those fees. Even when under your deductible, you will be only paying the "negotiated" rates. I put "negotiated" in quotes because they will not negotiate. It's take it or leave it. This is one of the many reasons my surgical practice left the insurance networks. They pay the same for a CPT code regardless of actual complexity and regardless of experience.

Topic Author
ipo_fin_z
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Re: How to obtain contracted rates for medical procedures?

Post by ipo_fin_z » Mon Jul 08, 2019 10:00 pm

toofache32 wrote:
Mon Jul 08, 2019 9:54 pm
The IN NETWORK rates are determined by the insurance company, not the doctor. The doctor's office doesn't know the insurance fees.. They pay the same for a CPT code regardless of actual complexity and regardless of experience.
Thanks. That pretty much answers my question then - it doesn't do any good to shop around among in-network providers as if the CPT codes are identical, I'm paying the same. [Insurance's member services was suggesting different providers see different in-network rates -- but I'll trust you and some sibling posts that claim it is 100% the insurance]

(Kinda surprising though -- I always figured that doctors knew what an insurance would pay before agreeing to be in-network!)

Interestingly, I have found that doctors sometimes do know what the procedure will cost. Perhaps they are just charging lower than the in-network rate?
Unfortunately, that webapp is hosed.. doesn't load. And of course.. no support.
Last edited by ipo_fin_z on Mon Jul 08, 2019 10:03 pm, edited 3 times in total.

chessknt
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Re: How to obtain contracted rates for medical procedures?

Post by chessknt » Mon Jul 08, 2019 10:00 pm

ipo_fin_z wrote:
Mon Jul 08, 2019 9:26 pm
SevenBridgesRoad wrote:
Mon Jul 08, 2019 9:11 pm
Do you mind sharing with us what the specialist visit is about? I assume there is a procedure? Context might help generate some actionable ideas.
Initial pediatric cardiology consultation. Kid has a (likely innocent) heart murmur. One of those things that 99% of the time is nothing to worry about, but still worth checking out. The cost problem is that some specialists want to go all-in initially on pricey tests before the doctor even starts the consultation - e.g. using an echo-cardiogram (which isn't even advised before initial cheaper screening) Obviously, paying the costs is critical if there is an issue -- I'm banking on there not being one.

Anyway, I came across https://www.fairhealthconsumer.org in the last hour of searching. The prices it gives look reasonable - if I take the assumption that in-network rates are roughly the same across providers for the same CPT code, it's obvious how to proceed (just pick a good doctor that doesn't over-test)

chessknt wrote:
Mon Jul 08, 2019 9:21 pm
2-having a consult for a medical problem? Specialist will have no idea what you will need done to diagnose/treat until they actually review your case which they do during the visit. Complexity of the case dictates billing as well which is also not known until the visit.
Right the problem here isn't not knowing the potential billing codes (it's probabilistic what will be charged -- I can deal with that though) -- the problem is not knowing what the cost is per code.

SevenBridgesRoad wrote:
Mon Jul 08, 2019 9:11 pm
Don’t get me wrong. I admire what you are attempting. I support it. But for the most part health care providers are not (yet) prepared to deal with individuals who are price comparing... You are an early adopter.
HDHPs have been around for quite some time (and not having insurance even longer!); I'm surprised more people aren't worrying about optimizing these costs (which are on par with buying a used car!)
.

The other part of the equation that might be impairing the calculation is the facility fee which depends on the type of practice you are visiting. They should be able to do that and if they wont/can't then there is nothing you can do since this is 100% on the insurance company. You can ask the office what a self pay price would be like you did but it is going to be much higher than what your insurance pays. You might be able to get a prepaid cash discount from the practice but I'm unsure how this factors in to your deductible.

Ztx
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Re: How to obtain contracted rates for medical procedures?

Post by Ztx » Mon Jul 08, 2019 10:09 pm

toofache32 wrote:
Mon Jul 08, 2019 9:32 pm
The "negotiated rates" are created and kept by your insurance company, NOT the doctors office. If you have the CPT codes, just ask your insurance. Good luck on getting them to tell you though. They won't even tell the doctor's office.
The office does NOT bill the "negotiated" rate, they bill their normal rate to the insurance. Billing a lower rate will skew the UCR trends.
Toofache32 - are you talking about dental PPO insurance or medical only? My wife's dental office has fee schedule for each insurance and it's entered into practice software.

toofache32
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Re: How to obtain contracted rates for medical procedures?

Post by toofache32 » Mon Jul 08, 2019 10:12 pm

Ztx wrote:
Mon Jul 08, 2019 10:09 pm
toofache32 wrote:
Mon Jul 08, 2019 9:32 pm
The "negotiated rates" are created and kept by your insurance company, NOT the doctors office. If you have the CPT codes, just ask your insurance. Good luck on getting them to tell you though. They won't even tell the doctor's office.
The office does NOT bill the "negotiated" rate, they bill their normal rate to the insurance. Billing a lower rate will skew the UCR trends.
Toofache32 - are you talking about dental PPO insurance or medical only? My wife's dental office has fee schedule for each insurance and it's entered into practice software.
I'm talking about medical. Dental is a completely different animal and much easier to navigate. And yes the dental fee schedules are made available for viewing to decide if the dentist wants to sign up. Not true with medical.

toofache32
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Re: How to obtain contracted rates for medical procedures?

Post by toofache32 » Mon Jul 08, 2019 10:22 pm

ipo_fin_z wrote:
Mon Jul 08, 2019 10:00 pm
toofache32 wrote:
Mon Jul 08, 2019 9:54 pm
The IN NETWORK rates are determined by the insurance company, not the doctor. The doctor's office doesn't know the insurance fees.. They pay the same for a CPT code regardless of actual complexity and regardless of experience.
Thanks. That pretty much answers my question then - it doesn't do any good to shop around among in-network providers as if the CPT codes are identical, I'm paying the same. [Insurance's member services was suggesting different providers see different in-network rates -- but I'll trust you and some sibling posts that claim it is 100% the insurance]

(Kinda surprising though -- I always figured that doctors knew what an insurance would pay before agreeing to be in-network!)

Interestingly, I have found that doctors sometimes do know what the procedure will cost. Perhaps they are just charging lower than the in-network rate?
Unfortunately, that webapp is hosed.. doesn't load. And of course.. no support.
You bring up some good points and potential "gotchas". If the doctor charges less than the insurance "allowable" fee, then the fee will be obviously lower. But I cannot imagine someone charging that low since the insurance fees are already so sharply discounted. BCBS for example pays about 35% of my fees and is lower than what it costs me to provide care, pay my staff, etc.

Also, if you go to a doctor employed by a major health system such as a hospital, the fees could be different because their employer has the volume leverage to negotiate with the insurance company. But this leverage is usually to raise (not lower) the fees. Remember, many docs (like me) work IN a hospital but not FOR a hospital. A hospital-owned practice will also increase the costs because they are eligible to charge facility fees which a private office cannot. So the same service in a hospital practice can be 2 or 3 fold more expensive simply because of the facility fees.

Lastly, some doctors know the rates insurance pay for certain procedures if they are only in a few networks and the same CPT code is used frequently. This information is gained by waiting to see what the insurance pays after the service is performed. Most cannot do this because of how many plans there are these days. In my area, BCBS has over a dozen plans. Multiply that by Cigna, Aetna, Humana, United Healthscare, etc and there is no way to keep up even with a single CPT code.
Last edited by toofache32 on Mon Jul 08, 2019 10:23 pm, edited 1 time in total.

Ztx
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Re: How to obtain contracted rates for medical procedures?

Post by Ztx » Mon Jul 08, 2019 10:23 pm

toofache32 wrote:
Mon Jul 08, 2019 10:12 pm
Ztx wrote:
Mon Jul 08, 2019 10:09 pm
toofache32 wrote:
Mon Jul 08, 2019 9:32 pm
The "negotiated rates" are created and kept by your insurance company, NOT the doctors office. If you have the CPT codes, just ask your insurance. Good luck on getting them to tell you though. They won't even tell the doctor's office.
The office does NOT bill the "negotiated" rate, they bill their normal rate to the insurance. Billing a lower rate will skew the UCR trends.
Toofache32 - are you talking about dental PPO insurance or medical only? My wife's dental office has fee schedule for each insurance and it's entered into practice software.
I'm talking about medical. Dental is a completely different animal and much easier to navigate. And yes the dental fee schedules are made available for viewing to decide if the dentist wants to sign up. Not true with medical.
Thanks! I didn't know that and expected medical works the same way.

toofache32
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Re: How to obtain contracted rates for medical procedures?

Post by toofache32 » Mon Jul 08, 2019 10:37 pm

Ztx wrote:
Mon Jul 08, 2019 10:23 pm
toofache32 wrote:
Mon Jul 08, 2019 10:12 pm
Ztx wrote:
Mon Jul 08, 2019 10:09 pm
toofache32 wrote:
Mon Jul 08, 2019 9:32 pm
The "negotiated rates" are created and kept by your insurance company, NOT the doctors office. If you have the CPT codes, just ask your insurance. Good luck on getting them to tell you though. They won't even tell the doctor's office.
The office does NOT bill the "negotiated" rate, they bill their normal rate to the insurance. Billing a lower rate will skew the UCR trends.
Toofache32 - are you talking about dental PPO insurance or medical only? My wife's dental office has fee schedule for each insurance and it's entered into practice software.
I'm talking about medical. Dental is a completely different animal and much easier to navigate. And yes the dental fee schedules are made available for viewing to decide if the dentist wants to sign up. Not true with medical.
Thanks! I didn't know that and expected medical works the same way.
Most insurance companies these days simply base their fees on percentages of Medicare. If you're lucky, they will tell you "we pay 150% of Medicare rates". The Medicare fee schedule is published on their website but it's still not very simple. There are small geographic variations in Medicare fees, likely based on cost of living or who knows. Then to make it more complex, there are strange rules where insurance companies pay only percentages of their own fees when multiple procedures are combined. For a common complex surgical treatment I do, I list about 8-10 CPT codes for the different procedures. Insurance would pay 100% of THEIR fee for the first CPT code listed, then only pay 50% for the next 3 or 4 (because I was already there anyway), then nothing for the rest. Some pay 100% for the first code, then 75% for the second, then 50% and so on. And they are all different and always changing their rules which makes it impossible to know what the total amount paid will be. I don't play those games anymore since I'm not in-network. I just bundle a single fee based on what I expect to be the time and complexity.

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SevenBridgesRoad
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Re: How to obtain contracted rates for medical procedures?

Post by SevenBridgesRoad » Mon Jul 08, 2019 11:25 pm

ipo_fin_z wrote:
Mon Jul 08, 2019 9:26 pm
SevenBridgesRoad wrote: [/color]318 user_id=136479]
Do you mind sharing with us what the specialist visit is about? I assume there is a procedure? Context might help generate some actionable ideas.
Initial pediatric cardiology consultation. Kid has a (likely innocent) heart murmur. One of those things that 99% of the time is nothing to worry about, but still worth checking out. The cost problem is that some specialists want to go all-in initially on pricey tests before the doctor even starts the consultation - e.g. using an echo-cardiogram (which isn't even advised before initial cheaper screening) Obviously, paying the costs is critical if there is an issue -- I'm banking on there not being one.

Yep. You are in fairly rarified air. Peds cardiology. Low supply. High demand. No incentive to shake up the current model. Back in the day we would have told you, this is likely an innocent murmur. Let's recheck it periodically. Maybe an echo. Now the standard of care is consultation. I get it. But, small supply and high demand. Adam Smith.

chessknt wrote:
Mon Jul 08, 2019 9:21 pm
2-having a consult for a medical problem? Specialist will have no idea what you will need done to diagnose/treat until they actually review your case which they do during the visit. Complexity of the case dictates billing as well which is also not known until the visit.
Right the problem here isn't not knowing the potential billing codes (it's probabilistic what will be charged -- I can deal with that though) -- the problem is not knowing what the cost is per code.

In most practices, the system isn't geared for this.

SevenBridgesRoad wrote:
Mon Jul 08, 2019 9:11 pm
Don’t get me wrong. I admire what you are attempting. I support it. But for the most part health care providers are not (yet) prepared to deal with individuals who are price comparing... You are an early adopter.
HDHPs have been around for quite some time (and not having insurance even longer!); I'm surprised more people aren't worrying about optimizing these costs (which are on par with buying a used car!)

I'm surprised too. But most patients and families don't care (enough to demand changes)
Retired 2018 age 61 | "Not using an alarm is one of the great glories of my life." Robert Greene

rantk81
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Re: How to obtain contracted rates for medical procedures?

Post by rantk81 » Tue Jul 09, 2019 7:30 am

toofache32 wrote:
Mon Jul 08, 2019 9:54 pm
ipo_fin_z wrote:
Mon Jul 08, 2019 9:26 pm

Anyway, I came across https://www.fairhealthconsumer.org in the last hour of searching. The prices it gives look reasonable - if I take the assumption that in-network rates are roughly the same across providers for the same CPT code, it's obvious how to proceed (just pick a good doctor that doesn't over-test)
I think you may have some confusion on how the billing and fees work, or I might not be understanding your questions. The IN NETWORK rates are determined by the insurance company, not the doctor. The doctor's office doesn't know the insurance fees. If you go to an IN NETWORK doctor for services covered under your contract, the fee should be the same everywhere because it's the same insurance company that sets those fees. Even when under your deductible, you will be only paying the "negotiated" rates. I put "negotiated" in quotes because they will not negotiate. It's take it or leave it. This is one of the many reasons my surgical practice left the insurance networks. They pay the same for a CPT code regardless of actual complexity and regardless of experience.
The bolded part may be true with how your insurance company operates. However, that is NOT true with any of the insurance companies I've had. Different providers can have vastly different negotiated rates with the insurance company. Depending on what type of service, this variance in negotiated price per provider can be small or quite large. I've seen a medium-complexity doctor visit vary by 30% from one doctor to another. I've also seen lab tests that had a negotiated rate nearly 10x more from one provider than they were at a standalone lab like Quest Diagnostics.

toofache32
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Re: How to obtain contracted rates for medical procedures?

Post by toofache32 » Tue Jul 09, 2019 8:09 am

rantk81 wrote:
Tue Jul 09, 2019 7:30 am
toofache32 wrote:
Mon Jul 08, 2019 9:54 pm
ipo_fin_z wrote:
Mon Jul 08, 2019 9:26 pm

Anyway, I came across https://www.fairhealthconsumer.org in the last hour of searching. The prices it gives look reasonable - if I take the assumption that in-network rates are roughly the same across providers for the same CPT code, it's obvious how to proceed (just pick a good doctor that doesn't over-test)
I think you may have some confusion on how the billing and fees work, or I might not be understanding your questions. The IN NETWORK rates are determined by the insurance company, not the doctor. The doctor's office doesn't know the insurance fees. If you go to an IN NETWORK doctor for services covered under your contract, the fee should be the same everywhere because it's the same insurance company that sets those fees. Even when under your deductible, you will be only paying the "negotiated" rates. I put "negotiated" in quotes because they will not negotiate. It's take it or leave it. This is one of the many reasons my surgical practice left the insurance networks. They pay the same for a CPT code regardless of actual complexity and regardless of experience.
The bolded part may be true with how your insurance company operates. However, that is NOT true with any of the insurance companies I've had. Different providers can have vastly different negotiated rates with the insurance company. Depending on what type of service, this variance in negotiated price per provider can be small or quite large. I've seen a medium-complexity doctor visit vary by 30% from one doctor to another. I've also seen lab tests that had a negotiated rate nearly 10x more from one provider than they were at a standalone lab like Quest Diagnostics.
Yep I addressed that in a later post. But you HAVE to make sure you are talking about the same CPT codes. Differences are possible in institutional practices owned by large health systems or hospitals.

shorty313
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Re: How to obtain contracted rates for medical procedures?

Post by shorty313 » Tue Jul 09, 2019 8:40 am

I have had the same frustration trying to be an informed consumer. Some things are fairly easy...my local hospital was able to give me the cash and contracted rate for an EKG for my son. But on a completely different issue for him, small outpatient medical procedure, you would have thought I was asking the insurance carrier to solve a differential equation. All they could tell me, really, was that I'd hit my deductible and not to worry about the rest so it didn't matter. In the end we used an oral surgeon that told me the price up front. Up front both the oral surgeon and insurance (with the relevant CPT codes) said it was a medical claim and in network. Fine. Except it got denied as being a dental claim. :oops: So, now the claim is off to our dental ins. Assuming they cover it (codes lead me to believe they will), it will actually cost me less out of pocket so that's good. But here's to waiting to find out! :sharebeer

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dm200
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Re: How to obtain contracted rates for medical procedures?

Post by dm200 » Tue Jul 09, 2019 9:02 am

Don't you get the charges for this at the rates, etc. negotiated by your insurance company? Wouldn't you have the providers submit this to the Insurance company before you pay the bill?

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dm200
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Re: How to obtain contracted rates for medical procedures?

Post by dm200 » Tue Jul 09, 2019 9:08 am

shorty313 wrote:
Tue Jul 09, 2019 8:40 am
I have had the same frustration trying to be an informed consumer.
Me too !!!

it is even doubly frustrating and confusing because there are both the financial aspects and the health/medical aspects - and often the two are intertwined.

One example is certain medical tests, scans, etc. Your doctor wants to do a certain (not inexpensive) scan or test. You ask why - and what he/she would do or recommend differently based on the test or scan.

if the answer is "Nothing different" - then who do it - other than costing you and your insurance company more money. It seems to me that so many tests, scans, etc. are commonly being done where the results do not change anything.

shorty313
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Re: How to obtain contracted rates for medical procedures?

Post by shorty313 » Tue Jul 09, 2019 9:26 am

rantk81 wrote:
Tue Jul 09, 2019 7:30 am
toofache32 wrote:
Mon Jul 08, 2019 9:54 pm
ipo_fin_z wrote:
Mon Jul 08, 2019 9:26 pm

Anyway, I came across https://www.fairhealthconsumer.org in the last hour of searching. The prices it gives look reasonable - if I take the assumption that in-network rates are roughly the same across providers for the same CPT code, it's obvious how to proceed (just pick a good doctor that doesn't over-test)
I think you may have some confusion on how the billing and fees work, or I might not be understanding your questions. The IN NETWORK rates are determined by the insurance company, not the doctor. The doctor's office doesn't know the insurance fees. If you go to an IN NETWORK doctor for services covered under your contract, the fee should be the same everywhere because it's the same insurance company that sets those fees. Even when under your deductible, you will be only paying the "negotiated" rates. I put "negotiated" in quotes because they will not negotiate. It's take it or leave it. This is one of the many reasons my surgical practice left the insurance networks. They pay the same for a CPT code regardless of actual complexity and regardless of experience.
The bolded part may be true with how your insurance company operates. However, that is NOT true with any of the insurance companies I've had. Different providers can have vastly different negotiated rates with the insurance company. Depending on what type of service, this variance in negotiated price per provider can be small or quite large. I've seen a medium-complexity doctor visit vary by 30% from one doctor to another. I've also seen lab tests that had a negotiated rate nearly 10x more from one provider than they were at a standalone lab like Quest Diagnostics.
This is also a huge part of it. For the procedure I discussed above, first I took son to a pediatric ENT affiliated with a children's hospital. Since he has been a patient of theirs in the past (pre HDHP) I didn't think to ask how much the visit cost. Imagine my surprise when the bill for a level 3 visit was around $425 (down from $565 charge). Seriously, it was like 10 questions of history and a poke in the mouth and look in the ears. I don't get how they justify that charge. I was expecting like $250. The doc is great but I doubt I will ever return.

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Re: How to obtain contracted rates for medical procedures?

Post by nisiprius » Tue Jul 09, 2019 9:29 am

I don't have a horse in this race, I'm not on such a plan, and have no experience with them, but it does strike me that this is

1) ...exactly the problem I've always assumed there would be with HDHP plans, namely the consumer getting stuck personally paying "chargemaster" rates instead of customary negotiated rates. (From actual records of a hospital visit of a few years ago, apart from the charges actually made by the hospital itself, insurers paid and providers accepted an average of 17% of the billed amounts).

2) ...exactly what several posters in this forum have said is not supposed to happen with HDHP plans. If I remember correctly, they said that under whatever plan they had, the provider is supposed to bill the insurance company, not the policyholder; the insurance company pays and they accept the negotiated amount; and they then, in turn, get billed by the insurance company for the negotiated amount. But maybe I misunderstood.

Medical billing is quite simply insane and has been that way forever. Whenever a consumer is directly confronted with a medical bill, it becomes apparent. Thirty years ago people were complaining about hospitals charging them $30 for a dose of aspirin. When my son broke his wrist snowboarding, the ER put a splint on him and then billed us for two splints. When the insurer handles it, at least it's not my problem... or, rather, at least I pay the group average insanity, versus whatever special insanity the fickle finger of fate might to visit on me.
Last edited by nisiprius on Tue Jul 09, 2019 9:34 am, edited 1 time in total.
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Re: How to obtain contracted rates for medical procedures?

Post by shorty313 » Tue Jul 09, 2019 9:33 am

nisiprius wrote:
Tue Jul 09, 2019 9:29 am
I don't have a horse in this race, I'm not on such a plan, and have no experience with them, but it does strike me that this is

1) ...exactly the problem I've always assumed there would be with HDHP plans, namely the consumer getting stuck personally paying "chargemaster" rates instead of customary negotiated rates. (From actual records of a hospital visit of a few years ago, apart from the charges actually made by the hospital itself, insurers paid and providers accepted an average of 17% of the billed amounts).

2) ...exactly what several posters in this forum have said does not happen with HDHP plans. If I remember correctly, they said that under whatever plan they had, the provider is supposed to bill the insurance company, not the policyholder; the insurance company pays and they accept the negotiated amount; and they then, in turn, get billed by the insurance company for the negotiated amount. But maybe I misunderstood.
Sort of #2, but the bill comes from the provider after insurance has had their say. The issue is, you can't find that info out BEFORE the appointment. Well, rarely anyway.

Edit to add: other than this rather large ENT bill, all our bills have been in line with what I would expect. But no one in my family has required a hospitalization in a while, and we are all mostly healthy with no specialists.

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Re: How to obtain contracted rates for medical procedures?

Post by nisiprius » Tue Jul 09, 2019 9:38 am

shorty313 wrote:
Tue Jul 09, 2019 9:33 am
nisiprius wrote:
Tue Jul 09, 2019 9:29 am
...2) ...exactly what several posters in this forum have said does not happen with HDHP plans. If I remember correctly, they said that under whatever plan they had, the provider is supposed to bill the insurance company, not the policyholder; the insurance company pays and they accept the negotiated amount; and they then, in turn, get billed by the insurance company for the negotiated amount. But maybe I misunderstood.
Sort of #2, but the bill comes from the provider after insurance has had their say. The issue is, you can't find that info out BEFORE the appointment. Well, rarely anyway.
Just to be clear. There are three potential ways it could be.
1) #1, policyholder actually gets stuck paying the full chargemaster rate.
2) #2, policyholder gets a bill for the full rate, but after ten hours on the phone gets it reduced to something "not crazy."
3) #3, policyholder pays the negotiated rate, no problem--it's just you can't find out in advance what that rate is, and sometimes it is still a crazy rate.

You're saying the issue is #3.
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Re: How to obtain contracted rates for medical procedures?

Post by rantk81 » Tue Jul 09, 2019 9:43 am

For my Dental Insurance, my dentist seems to always know what my out of pocket cost will be, down to the penny... including any deductibles that may need to be met (or not) and how much my co-insurance will be, and the cost for services the insurance doesn't cover. I pay any out-of-pocket costs up-front, and I can't ever remember a situation where an adjustment was later necessary (after the final EOB is generated.)

My Health insurance is a COMPLETELY different story.

- In some cases, I'm initially billed nothing out of pocket, and I get bills directly from the provider at a later time for the entire amount I owe -- after the insurance company had a chance to generate the EOB.

- In some cases, the provider had me make a partial payment up-front (with the knowledge (somehow) of how much of my medical deductible had already been met), which later results in me owing the remainder of the balance after the EOB is generated later. In some other cases when this happened, I had several claims going on concurrently, and their "estimate" of my deductible owed was incorrect, and later resulted in the provider refunding me part of my initial payment.

- In another case, a provider made me make an initial $100 payment for a service, even though my remaining deductible was much much higher than that amount, AND the service would clearly be billed at quite a bit more than $100. They billed me for the remainder of it after the insurance company generated the EOB.

- In yet another case, my insurance company re-processed a claim that was nearly a year old, which resulted in the insurance company covering some service at 100% as preventative (instead of being subject to my deductible), and they sent the provider a payment directly. The provider then mailed me a check for that same amount (since I had already paid the provider in full, a year ago.)

All of these interactions lead me to believe that Medical providers (unlike Dental providers) really have no idea what the heck the final "allowed billed amount" will be from the insurance company -- and even less of an idea of what your final out of pocket cost will be.

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Re: How to obtain contracted rates for medical procedures?

Post by jayk238 » Tue Jul 09, 2019 9:53 am

ipo_fin_z wrote:
Mon Jul 08, 2019 8:23 pm
Scenario:
  • I have an HDHP with a high deductible ($8k) I'm not going to meet
  • I have an expensive, but ordinary and low-risk specialist vsiit coming up and am trying to shop around (within my PPO's network) for the best rate. Cost is in the thousands, but definitely nowhere near meeting the deductible.
While I've easily been able to obtain the CPT codes from providers and the cash cost, only one small office has been willing to give me the negotiated rate they'll bill my insurance at (comes in about a third of the cash rates I'm hearing). Unfortunately, they are also doing some unnecessary tests I can't decline if I use their services, so they might not be the cheapest.

The offices affiliated with larger health networks (Stanford, Palo Alto Medical foundation, etc.) are not being transparent at all. When I ask for the contracted/negotiated rates, they'll transfer me to the billing department who either A) outright refuses to divulge the info or B) claims to not know and directs me to my insurance. My insurance company (Anthem) also is refusing to provide the contracted rates/allowable amount, basically claiming they don't know/won't provide them/ask the provider. (This whole thing striking me as absurd as both sides should know this information.)

I figure the point of an HDHP is for patients to face higher deductibles and thus be incentived to cut costs, but I'm finding this difficult - making me wonder if I'm doing something wrong. What's the proper way to figure out what a procedure will cost given insurance info, billing codes, and provider?

(Similarly, are the negotiated rates for provider 1 and provider 2 similar? e.g. can I use the cost estimates for that small office as an estimator for what I'll pay at a different provider?)
Just to summarize and clarify the issues here

1. Focus on getting the best care. So make sure you seect the best cardiologist etc 2. Someone else said standard of care is getting consultation which is unfortunate but understandable in this age.

3. Doesnt matter who it is. If its in network and the same tier then its the same price. Cant really shop

4. Negotiated contract rates are never disclosed. Nda.

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Re: How to obtain contracted rates for medical procedures?

Post by dm200 » Tue Jul 09, 2019 9:57 am

Another example of confusing codes - I have an eye condition that needs to be "watched" - I had two tests by my then Ophthalmologist - and when I looked at the EOB - I saw one code twice and another once. I thought it was an error - so I called the insurance company. They said, without explanation, that paying this was correct.

I dug further and found out that one of the tests was "per eye" - hence that code twice and the other code was for "both eyes". :confused

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Re: How to obtain contracted rates for medical procedures?

Post by chessknt » Tue Jul 09, 2019 9:58 am

dm200 wrote:
Tue Jul 09, 2019 9:08 am
shorty313 wrote:
Tue Jul 09, 2019 8:40 am
I have had the same frustration trying to be an informed consumer.
Me too !!!

it is even doubly frustrating and confusing because there are both the financial aspects and the health/medical aspects - and often the two are intertwined.

One example is certain medical tests, scans, etc. Your doctor wants to do a certain (not inexpensive) scan or test. You ask why - and what he/she would do or recommend differently based on the test or scan.

if the answer is "Nothing different" - then who do it - other than costing you and your insurance company more money. It seems to me that so many tests, scans, etc. are commonly being done where the results do not change anything.
To a degree this is a direct reflection of defensive medicine. If your doctor doesn't get a test that could have detected a rare fatal condition that would have prevented your death then your estate can bring a lawsuit against this doctor alleging malpractice.

Or your doctor can order the test and not have to worry about that.

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Re: How to obtain contracted rates for medical procedures?

Post by dm200 » Tue Jul 09, 2019 9:58 am

4. Negotiated contract rates are never disclosed. Nda
I suspect those are guarded like the gold at Fort Knox.

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Re: How to obtain contracted rates for medical procedures?

Post by dm200 » Tue Jul 09, 2019 10:00 am

chessknt wrote:
Tue Jul 09, 2019 9:58 am
dm200 wrote:
Tue Jul 09, 2019 9:08 am
shorty313 wrote:
Tue Jul 09, 2019 8:40 am
I have had the same frustration trying to be an informed consumer.
Me too !!!
it is even doubly frustrating and confusing because there are both the financial aspects and the health/medical aspects - and often the two are intertwined.
One example is certain medical tests, scans, etc. Your doctor wants to do a certain (not inexpensive) scan or test. You ask why - and what he/she would do or recommend differently based on the test or scan.
if the answer is "Nothing different" - then who do it - other than costing you and your insurance company more money. It seems to me that so many tests, scans, etc. are commonly being done where the results do not change anything.
To a degree this is a direct reflection of defensive medicine. If your doctor doesn't get a test that could have detected a rare fatal condition that would have prevented your death then your estate can bring a lawsuit against this doctor alleging malpractice.
Or your doctor can order the test and not have to worry about that.
Yes, probably very true.

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Re: How to obtain contracted rates for medical procedures?

Post by shorty313 » Tue Jul 09, 2019 10:06 am

nisiprius wrote:
Tue Jul 09, 2019 9:38 am
shorty313 wrote:
Tue Jul 09, 2019 9:33 am
nisiprius wrote:
Tue Jul 09, 2019 9:29 am
...2) ...exactly what several posters in this forum have said does not happen with HDHP plans. If I remember correctly, they said that under whatever plan they had, the provider is supposed to bill the insurance company, not the policyholder; the insurance company pays and they accept the negotiated amount; and they then, in turn, get billed by the insurance company for the negotiated amount. But maybe I misunderstood.
Sort of #2, but the bill comes from the provider after insurance has had their say. The issue is, you can't find that info out BEFORE the appointment. Well, rarely anyway.
Just to be clear. There are three potential ways it could be.
1) #1, policyholder actually gets stuck paying the full chargemaster rate.
2) #2, policyholder gets a bill for the full rate, but after ten hours on the phone gets it reduced to something "not crazy."
3) #3, policyholder pays the negotiated rate, no problem--it's just you can't find out in advance what that rate is, and sometimes it is still a crazy rate.

You're saying the issue is #3.
For us personally, yes, the issue is #3. I have tried to further negotiate this ENT bill with no luck, as it is already the 'negotiated' rate, not the chargemaster rate.

Edit to add: I used that Fair Health link above and the CPT code from this provider, and it's giving an estimate of $350 chargmaster and $190 negotiated. Which is more like what I had been expecting!

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Re: How to obtain contracted rates for medical procedures?

Post by tfb » Tue Jul 09, 2019 10:24 am

jayk238 wrote:
Tue Jul 09, 2019 9:53 am
3. Doesnt matter who it is. If its in network and the same tier then its the same price. Cant really shop
This is not true, at least not in all places. Some providers affiliated with larger health networks, such as those mentioned in the OP, are able to receive higher rates from the same insurance plans because their larger health networks are considered too important to the insurance companies. When I paid cash as a self-pay patient to such providers I was able to pay lower than the contracted rates.
The offices affiliated with larger health networks (Stanford, Palo Alto Medical foundation, etc.)
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Re: How to obtain contracted rates for medical procedures?

Post by Cooper62 » Tue Jul 09, 2019 10:31 am

I'm very frustrated trying to get cost information from Aetna. My family is currently covered under my employer's HDHP. We have a daughter in college with the option to use the college medical plan. I'm trying to decide if it makes sense to pay for the college medical plan or keep her on the family plan. She has an expensive monthly prescription. College plan won't tell me how much the prescription will cost under their plan unless I join. I don't know if I want to join without knowing how much cost of prescriptions are.

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Re: How to obtain contracted rates for medical procedures?

Post by dm200 » Tue Jul 09, 2019 11:03 am

Cooper62 wrote:
Tue Jul 09, 2019 10:31 am
I'm very frustrated trying to get cost information from Aetna. My family is currently covered under my employer's HDHP. We have a daughter in college with the option to use the college medical plan. I'm trying to decide if it makes sense to pay for the college medical plan or keep her on the family plan. She has an expensive monthly prescription. College plan won't tell me how much the prescription will cost under their plan unless I join. I don't know if I want to join without knowing how much cost of prescriptions are.
can you get any information, such as the tiers in the formulary list?

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Re: How to obtain contracted rates for medical procedures?

Post by rantk81 » Tue Jul 09, 2019 11:16 am

Maybe check the GoodRX price? In my case, since I am a "captive customer" of CVS pharmacies (since Aetna is my insurance, and they literally don't consider any other pharmacy to be "in network for me), GoodRX prices are cheaper than my "negotiated price" for prescriptions in every instance I've checked!

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Re: How to obtain contracted rates for medical procedures?

Post by jayk238 » Tue Jul 09, 2019 11:34 am

tfb wrote:
Tue Jul 09, 2019 10:24 am
jayk238 wrote:
Tue Jul 09, 2019 9:53 am
3. Doesnt matter who it is. If its in network and the same tier then its the same price. Cant really shop
This is not true, at least not in all places. Some providers affiliated with larger health networks, such as those mentioned in the OP, are able to receive higher rates from the same insurance plans because their larger health networks are considered too important to the insurance companies. When I paid cash as a self-pay patient to such providers I was able to pay lower than the contracted rates.
The offices affiliated with larger health networks (Stanford, Palo Alto Medical foundation, etc.)
What?

Are you saying that within your single network you can see different providers of the same type ie cardiologists etc and they charge different prices each? This is hard to believe.
Usually if a large medical system is within the network then the smaller ones are not considered the same tier.

And how did you know what the contracted rate was as opposed to the cash rate?
Last edited by jayk238 on Tue Jul 09, 2019 11:35 am, edited 1 time in total.

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Re: How to obtain contracted rates for medical procedures?

Post by mlipps » Tue Jul 09, 2019 11:35 am

toofache32 wrote:
Mon Jul 08, 2019 9:54 pm
ipo_fin_z wrote:
Mon Jul 08, 2019 9:26 pm

Anyway, I came across https://www.fairhealthconsumer.org in the last hour of searching. The prices it gives look reasonable - if I take the assumption that in-network rates are roughly the same across providers for the same CPT code, it's obvious how to proceed (just pick a good doctor that doesn't over-test)
I think you may have some confusion on how the billing and fees work, or I might not be understanding your questions. The IN NETWORK rates are determined by the insurance company, not the doctor. The doctor's office doesn't know the insurance fees. If you go to an IN NETWORK doctor for services covered under your contract, the fee should be the same everywhere because it's the same insurance company that sets those fees. Even when under your deductible, you will be only paying the "negotiated" rates. I put "negotiated" in quotes because they will not negotiate. It's take it or leave it. This is one of the many reasons my surgical practice left the insurance networks. They pay the same for a CPT code regardless of actual complexity and regardless of experience.
I work as a data analyst with access to paid claims data from various companies and payers on a daily basis. That is absolutely not true. Commercial insurance plans negotiate the rates with individual providers/provider groups. Depending on the insurance/physician landscape in your state there may be more or less variance in the marketplace, but the rates are set individually by TIN or NPI.

Here in Chicago, the difference in negotiated rates for a university medical system like Rush/Northwestern/U Chicago versus an independent provider can be as much as 50%. OP, in general the independent providers are going to have less leverage and therefore lower rates BUT they may be operating in an arrangement with other small practices to have more negotiating power, so it's still really difficult to be precise in these estimations. If I were concerned about costs & unnecessary tests I would steer away from a provider tied to a major hospital. Of course, you have to make your own calculation about the quality of care & thoroughness of the provider in addition to the potential costs savings.

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Re: How to obtain contracted rates for medical procedures?

Post by mlipps » Tue Jul 09, 2019 11:36 am

jayk238 wrote:
Tue Jul 09, 2019 11:34 am
tfb wrote:
Tue Jul 09, 2019 10:24 am
jayk238 wrote:
Tue Jul 09, 2019 9:53 am
3. Doesnt matter who it is. If its in network and the same tier then its the same price. Cant really shop
This is not true, at least not in all places. Some providers affiliated with larger health networks, such as those mentioned in the OP, are able to receive higher rates from the same insurance plans because their larger health networks are considered too important to the insurance companies. When I paid cash as a self-pay patient to such providers I was able to pay lower than the contracted rates.
The offices affiliated with larger health networks (Stanford, Palo Alto Medical foundation, etc.)
What?

Are you saying that within your single network you can see different providers of the same type ie cardiologists etc and they charge different prices each? This is hard to believe.
Usually if a large medical system is within the network then the smaller ones are not considered the same tier.

And how did you know what the contracted rate was as opposed to the cash rate?
It's not that they charge different prices, it's that they have different negotiated reimbursement rates with the insurance company. Since in the HDHP you pay the costs up front until you hit the hospital, you will be the one paying the negotiated rate.

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Re: How to obtain contracted rates for medical procedures?

Post by shorty313 » Tue Jul 09, 2019 11:47 am

rantk81 wrote:
Tue Jul 09, 2019 11:16 am
Maybe check the GoodRX price? In my case, since I am a "captive customer" of CVS pharmacies (since Aetna is my insurance, and they literally don't consider any other pharmacy to be "in network for me), GoodRX prices are cheaper than my "negotiated price" for prescriptions in every instance I've checked!
Unfortunately, if you go with goodrx it doesn’t count against your in network deductible.

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Re: How to obtain contracted rates for medical procedures?

Post by dm200 » Tue Jul 09, 2019 11:50 am

It's not that they charge different prices, it's that they have different negotiated reimbursement rates with the insurance company. Since in the HDHP you pay the costs up front until you hit the hospital, you will be the one paying the negotiated rate.
So, for example, you are saying that if you have medical Procedure X done at "municipal hospital" you might be charged $500, but if done at "St Elsewhere Hospital" you might be charged, say, $600 - because of the prices negotiated with each hospital and the insurance company?

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Re: How to obtain contracted rates for medical procedures?

Post by rantk81 » Tue Jul 09, 2019 11:51 am

shorty313 wrote:
Tue Jul 09, 2019 11:47 am
rantk81 wrote:
Tue Jul 09, 2019 11:16 am
Maybe check the GoodRX price? In my case, since I am a "captive customer" of CVS pharmacies (since Aetna is my insurance, and they literally don't consider any other pharmacy to be "in network for me), GoodRX prices are cheaper than my "negotiated price" for prescriptions in every instance I've checked!
Unfortunately, if you go with goodrx it doesn’t count against your in network deductible.
I know. :(
Since I have HDHP though, I haven't hit my deductible in the past few years. Of course, when that does eventually happen, I'll be paying double. (at least.) :(

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Re: How to obtain contracted rates for medical procedures?

Post by mlipps » Tue Jul 09, 2019 11:54 am

dm200 wrote:
Tue Jul 09, 2019 11:50 am
It's not that they charge different prices, it's that they have different negotiated reimbursement rates with the insurance company. Since in the HDHP you pay the costs up front until you hit the hospital, you will be the one paying the negotiated rate.
So, for example, you are saying that if you have medical Procedure X done at "municipal hospital" you might be charged $500, but if done at "St Elsewhere Hospital" you might be charged, say, $600 - because of the prices negotiated with each hospital and the insurance company?

Yes.

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Re: How to obtain contracted rates for medical procedures?

Post by tfb » Tue Jul 09, 2019 12:06 pm

jayk238 wrote:
Tue Jul 09, 2019 11:34 am
What?

Are you saying that within your single network you can see different providers of the same type ie cardiologists etc and they charge different prices each? This is hard to believe.
Usually if a large medical system is within the network then the smaller ones are not considered the same tier.
Yes. Maybe by categorizing one group of providers as a different tier is the way to give them a higher negotiated rate, but to the consumer, the end result is the same. If you go to one group of providers you will pay a higher price for the same service. This is especially true for locally dominant players, such as Standford and PAMF in the Bay Area.
jayk238 wrote:
Tue Jul 09, 2019 11:34 am
And how did you know what the contracted rate was as opposed to the cash rate?
I had insurance that covered the providers as in-network. I paid the contracted rate. When my insurance changed and the new insurance didn't cover the doctor, I went to the same doctor as self-pay. I paid a cash rate that was lower than the contracted rate I previously paid. When insurance needed that group of providers in their network, they agreed to a higher price.
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Re: How to obtain contracted rates for medical procedures?

Post by White Coat Investor » Tue Jul 09, 2019 12:16 pm

ipo_fin_z wrote:
Mon Jul 08, 2019 8:23 pm
Scenario:
  • I have an HDHP with a high deductible ($8k) I'm not going to meet
  • I have an expensive, but ordinary and low-risk specialist vsiit coming up and am trying to shop around (within my PPO's network) for the best rate. Cost is in the thousands, but definitely nowhere near meeting the deductible.
While I've easily been able to obtain the CPT codes from providers and the cash cost, only one small office has been willing to give me the negotiated rate they'll bill my insurance at (comes in about a third of the cash rates I'm hearing). Unfortunately, they are also doing some unnecessary tests I can't decline if I use their services, so they might not be the cheapest.

The offices affiliated with larger health networks (Stanford, Palo Alto Medical foundation, etc.) are not being transparent at all. When I ask for the contracted/negotiated rates, they'll transfer me to the billing department who either A) outright refuses to divulge the info or B) claims to not know and directs me to my insurance. My insurance company (Anthem) also is refusing to provide the contracted rates/allowable amount, basically claiming they don't know/won't provide them/ask the provider. (This whole thing striking me as absurd as both sides should know this information.)

I figure the point of an HDHP is for patients to face higher deductibles and thus be incentived to cut costs, but I'm finding this difficult - making me wonder if I'm doing something wrong. What's the proper way to figure out what a procedure will cost given insurance info, billing codes, and provider?

(Similarly, are the negotiated rates for provider 1 and provider 2 similar? e.g. can I use the cost estimates for that small office as an estimator for what I'll pay at a different provider?)
I hate this part about health care and see no fix coming from the private market. Fixing this problem will be a major part of fixing our health care mess.
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Re: How to obtain contracted rates for medical procedures?

Post by Tanelorn » Tue Jul 09, 2019 12:22 pm

A recent executive order from last month should help with pricing transparency in healthcare. Supposedly in another 1-2 months, HHS will have rules for the insurance companies and healthcare providers (not that they will be happy about that).

https://www.whitehouse.gov/presidential ... nts-first/
Within 90 days of the date of this order, the Secretaries of Health and Human Services, the Treasury, and Labor shall issue an advance notice of proposed rulemaking, consistent with applicable law, soliciting comment on a proposal to require healthcare providers, health insurance issuers, and self-insured group health plans to provide or facilitate access to information about expected out-of-pocket costs for items or services to patients before they receive care.

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Re: How to obtain contracted rates for medical procedures?

Post by dm200 » Tue Jul 09, 2019 12:38 pm

I hate this part about health care and see no fix coming from the private market. Fixing this problem will be a major part of fixing our health care mess
Yes! One, of the many, aspect of our confusing healthcare system.

I think I recall, many decades ago, that HMOs were supposed to make things much better - both financially and medically. As soon as I could (from a megacorp employer), I chose an HMO. One "theory" back then was that HMOs woud not charge the patients any copays for most visits. Then folks would be and stay so healthy that they would not need as much care. it did not work.

I was, generally, happy - BUT there was one condition where there was a gaping hole - and I encountered that condition. Today, fortunately, HMOs must cover that condition as they do for others.

For whatever reason(s), HMOs - while having advantages - did not "solve" the problem - as they were predicted by some to do.

I still like HMOs - we are with Kaiser. That HMO I enrolled in decades ago with megacorp - went out of business, as did another, similar HMO in this area. Both of those were the "dedicated" type (like Kaiser) with their own facilities. For some reason, Kaiser seems to be doing well - growing every year and adding more facilities her almost every year. Kaiser got its foothold here by "purchasing" an existing HMO (Georgetown Health plan) and it was Kaiser Georgetown health plan for a while - until they dropped the Georgetown part of the name.

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dm200
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Re: How to obtain contracted rates for medical procedures?

Post by dm200 » Tue Jul 09, 2019 12:46 pm

From discussions here, and with friends and acquaintances - there seems to be a general belief that more money spent on many kinds of care means that the care is better. I seem to be in the minority - in that I believe there is not this direct correlation and that lower cost approaches to medical care can be just as good quality (sometimes better) as higher cost.

I have even seen some, credible in my opinion, impartial reports and studies that some expensive treatments and procedures do not work at all.

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