How to obtain contracted rates for medical procedures?

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

Post by FIREchief » Tue Jul 09, 2019 12:47 pm

rantk81 wrote:
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.) :(
Technically, CVS does have a process where you can get "credit" for out of network RX purchases against your deductible. The reality in my case was that it was impossible to use this process. They have a form that needs to be completed by the "competing" pharmacy, and it asks for information that was not generated/available for the routine prescriptions I was filling; thus the form could not be fully completed.
I am not a lawyer, accountant or financial advisor. Any advice or suggestions that I may provide shall be considered for entertainment purposes only.

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

Post by toofache32 » Tue Jul 09, 2019 1:07 pm

dm200 wrote:
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?
This is called pre-authorization. This only tells if there is coverage. It does not give fees.

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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 1:11 pm

toofache32 wrote:
Tue Jul 09, 2019 1:07 pm
dm200 wrote:
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?
This is called pre-authorization. This only tells if there is coverage. It does not give fees.
I don't think so - if I am understanding.

You need X, Y and Z medical services. You have the HDHP plan and you go to a facility and providers who are all "in network" for your insurance. You do not tell any of the providers that you have not met the deductible for the year. They submit the claims to your insurance for X, Y and Z. The claims go back to the providers and the providers then bill you for X, Y and Z at the insurance negotiated rates. Isn't this the normal process?

I think the EOB would then look something like this for X, Y and Z:

Gross amount for service X: $10,000
Less insurance discount: (6,500)
Net due: $3,500

Insurance pays: $0 - not met deductible.

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

Post by autolycus » Tue Jul 09, 2019 1:20 pm

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. That's exactly what happens. The major issuers have some standardized contract offers and many providers will accept those as the rate they'll take to be part of the network. Other providers will not. Google your network provider's name (e.g. Anthem) and something like "network contract lapse" and you'll probably see multiple stories about different network contracts ending without a new agreement in place. That's because that particular medical provider/hospital network had enough leverage to refuse the standardized offers and demand higher contract rates for themselves.

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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 1:23 pm

autolycus wrote:
Tue Jul 09, 2019 1:20 pm
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. That's exactly what happens. The major issuers have some standardized contract offers and many providers will accept those as the rate they'll take to be part of the network. Other providers will not. Google your network provider's name (e.g. Anthem) and something like "network contract lapse" and you'll probably see multiple stories about different network contracts ending without a new agreement in place. That's because that particular medical provider/hospital network had enough leverage to refuse the standardized offers and demand higher contract rates for themselves.
I would certainly "play dumb" with any of the providers about the high deductible issue. Let the providers go through the "normal" process of filing an insurance claim.

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

Post by autolycus » Tue Jul 09, 2019 1:29 pm

dm200 wrote:
Tue Jul 09, 2019 1:23 pm
autolycus wrote:
Tue Jul 09, 2019 1:20 pm
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. That's exactly what happens. The major issuers have some standardized contract offers and many providers will accept those as the rate they'll take to be part of the network. Other providers will not. Google your network provider's name (e.g. Anthem) and something like "network contract lapse" and you'll probably see multiple stories about different network contracts ending without a new agreement in place. That's because that particular medical provider/hospital network had enough leverage to refuse the standardized offers and demand higher contract rates for themselves.
I would certainly "play dumb" with any of the providers about the high deductible issue. Let the providers go through the "normal" process of filing an insurance claim.
Always wait for your EOB before you pay in full.

That said... That doesn't really solve the problem of trying to find the most cost-effective medical provider. You will be obligated to pay the contract rate (aka the "allowed amount") for whatever network provider you use, even if Provider A's contract rate is higher than Provider B's.
Last edited by autolycus on Tue Jul 09, 2019 1:29 pm, edited 1 time in total.

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

Post by toofache32 » Tue Jul 09, 2019 1:29 pm

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.
These are often CYA tests. I do those sometimes. Thank your friendly attorneys for this.

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

Post by toofache32 » Tue Jul 09, 2019 1:34 pm

rantk81 wrote:
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.
Yes, this is what I have been saying here for years. But everyone thinks the doctors have all the insurance info.

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

Post by Archimedes » Tue Jul 09, 2019 1:42 pm

If it was me, I would simply ask the pediatrician to order an echocardiogram on my child. If the echo is normal, there is no need for cardiology consultation. But I have medical training, so it is easy for me to say that.

Broken Man 1999
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Re: How to obtain contracted rates for medical procedures?

Post by Broken Man 1999 » Tue Jul 09, 2019 1:47 pm

dm200 wrote:
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.
I was an early adopter of HMOs. Never had any problems with coverage, had access to the doctors we had already established ties to, mainly the children's pediatricians.

Each year at sign-up time, we would see which plan the pediatricians were a part of, as the daughters consumed the most health care as they moved through the usual childhood ailments.

For a few years MegaCorp actually had private clinic set up for employees. You go in for a nasty cut/scratch, get a shot for tetanus, leave with enough bandages, ointments to set up a clinic yourself. :shock:

No charge ever generated.

Broken Man 1999
“If I cannot drink Bourbon and smoke cigars in Heaven than I shall not go. " -Mark Twain

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

Post by toofache32 » Tue Jul 09, 2019 3:07 pm

dm200 wrote:
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
Some insurance companies want the claims for bilateral procedures to simply be submitted twice with -LT and -RT modifers. Others want it listed once with the -50 modifier for bilateral procedures. The most amazing part is that they will not tell you how they want it. You have to submit it and go through denials and learn the hard way.

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

Post by toofache32 » Tue Jul 09, 2019 4:45 pm

mlipps wrote:
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.
IF they are allowed to negotiate. Insurance companies don't negotiate unless you are a major health system such as a university system or hospital.

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

Post by Artsdoctor » Tue Jul 09, 2019 5:45 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?)
Several things. (1) You say you want to stay within your PPO network but at the same time, you want to cost comparison shop; if you're a provider in a plan, you have agreed to take the agreed amount and can't really negotiate with patients in the plan separately. Of course, you don't KNOW what that rate might be for all of the reasons stated above. (2) You can try going out of your network. You might find that prices are competitive if you tell the provider that you're interested in a "cash package." We do this all of the time, and if you're in an area where there's a lot of international patient activity, practices are used to cash package rates. (3) I really can't imagine having a pediatric cardiologist do a consultation without an echocardiogram. If you've already had an echo done, they may be willing to use that echo for their evaluation. (4) No one is going to tell you negotiated rates. The rates are just too variable. One insurance carrier will pay varying amounts for the same procedure to different providers; this is just a fact. Institutional rates will usually be higher that private doctors' rate because there's a hospital cost factor (both in-patient and out-patient).

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

Post by baritone » Tue Jul 09, 2019 6:02 pm

I have seen this medical clinic featured at least twice in the news. I think it's fascinating.

https://surgerycenterok.com

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

Post by SlowMovingInvestor » Tue Jul 09, 2019 6:53 pm

Artsdoctor wrote:
Tue Jul 09, 2019 5:45 pm
(4) No one is going to tell you negotiated rates. The rates are just too variable. One insurance carrier will pay varying amounts for the same procedure to different providers; this is just a fact. Institutional rates will usually be higher that private doctors' rate because there's a hospital cost factor (both in-patient and out-patient).
I've had (not too complex) procedures done at a large practice, where I was given total cost prior to doing the procedure. Besides the operating doctor, there was also an anaesthesiologist and a pathologist). The cost exactly matched the EOB from the insurance.

Note that I asked for the cost after I had scheduled the procedure. I don't know if they would have given it to me before I scheduled the procedure.

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

Post by SlowMovingInvestor » Tue Jul 09, 2019 6:57 pm

tfb wrote:
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/
At least one insurance company (I think it was Aetna that I used in the past) would give you your exact cost for a procedure/test from local providers (specific cost per provider). My recollection is that it used to be pretty accurate, but I did not have an HDHP in those days, so fees for visits were very simple ($25/$30/$40). But for things like MRI scan (with radiologists report) it was accurate.

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

Post by Artsdoctor » Tue Jul 09, 2019 7:01 pm

^ If an office does a limited number of procedures and the biller is really up to date on reimbursements, you might be able to get the EOB payment rate in advance. However, this would be very, very unusual. The office is going to be paid different amounts from different insurance plans, and then there's no reason why the amount can't be increased or decreased at a later date. Now, if the office is going to bill a specific amount for each procedure and that amount is usually below the contracted rate, then they number is going to be predictable.

ronno2018
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Re: How to obtain contracted rates for medical procedures?

Post by ronno2018 » Tue Jul 09, 2019 7:19 pm

Interesting discussion about this problem I noticed the other day -- https://www.balloon-juice.com/2019/07/0 ... formation/

I would stay away from the HDHP plans if you have a larger family. Yes the investment option is nice, but unless you are quite wealthy it is a pain or impossible to optimize and plan your spending. Too stressful!

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

Post by ram » Tue Jul 09, 2019 7:30 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.
I work for a medical facility which has many different geographic locations. Medicare pays 10% more for the exact same thing done at those locations that they deem as "physician shortage areas".

It does not have to be 2 different providers of the same type. It can be the exact same provider providing the same service at location A for a payment of $100 from medicare on Monday and payment of $110 at location B on Tuesday.

https://www.cms.gov/Outreach-and-Educat ... fctsht.pdf
Ram

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

Post by CppCoder » Tue Jul 09, 2019 7:38 pm

I wonder if the internet can "break" this paradigm. Could one setup a website to crowd source medical payment information? Get an EOB, submit your CPT codes, provider, insurance, and negotiated rates. Do some data analytics, and presto, after months, all of this becomes public. Waze for health care costs. You participate because it ultimately helps you too. Company monetizes by...advertising? I think the first rule of internet startups is get eyeballs first, ask monetization questions later...we'll figure out the business model in year 3.

Did I "sign" something during open enrollment that said I wouldn't disclose an EOB? If the website were anonymous, would my insurance know anyway?

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

Post by toofache32 » Tue Jul 09, 2019 7:40 pm

ram wrote:
Tue Jul 09, 2019 7:30 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.
I work for a medical facility which has many different geographic locations. Medicare pays 10% more for the exact same thing done at those locations that they deem as "physician shortage areas".

It does not have to be 2 different providers of the same type. It can be the exact same provider providing the same service at location A for a payment of $100 from medicare on Monday and payment of $110 at location B on Tuesday.

https://www.cms.gov/Outreach-and-Educat ... fctsht.pdf
Yeah but this is 10% of MEDICARE fees. In real dollars, this is a 1% difference.
Last edited by toofache32 on Tue Jul 09, 2019 7:42 pm, edited 1 time in total.

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

Post by toofache32 » Tue Jul 09, 2019 7:40 pm

ram wrote:
Tue Jul 09, 2019 7:30 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.
I work for a medical facility which has many different geographic locations. Medicare pays 10% more for the exact same thing done at those locations that they deem as "physician shortage areas".

It does not have to be 2 different providers of the same type. It can be the exact same provider providing the same service at location A for a payment of $100 from medicare on Monday and payment of $110 at location B on Tuesday.

https://www.cms.gov/Outreach-and-Educat ... fctsht.pdf
Yeah but this is 10% of MEDICARE fees. I’m real dollars, this is a 1% difference.

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

Post by CppCoder » Tue Jul 09, 2019 7:42 pm

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!
That's funny. I have Aetna, and they complain if I try to use CVS for anything other than a one off prescription. They want me to use the mail order pharmacy (Express Scripts) first for any maintenance drugs. I wonder if this is a result of using Aetna, essentially, as an insurance administrator, but really having a mega corp self-insured plan underneath the hood.

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

Post by toofache32 » Tue Jul 09, 2019 7:45 pm

CppCoder wrote:
Tue Jul 09, 2019 7:38 pm
I wonder if the internet can "break" this paradigm. Could one setup a website to crowd source medical payment information? Get an EOB, submit your CPT codes, provider, insurance, and negotiated rates. Do some data analytics, and presto, after months, all of this becomes public. Waze for health care costs. You participate because it ultimately helps you too. Company monetizes by...advertising? I think the first rule of internet startups is get eyeballs first, ask monetization questions later...we'll figure out the business model in year 3.

Did I "sign" something during open enrollment that said I wouldn't disclose an EOB? If the website were anonymous, would my insurance know anyway?
How is this different from the Fair Health website?

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

Post by CppCoder » Tue Jul 09, 2019 7:54 pm

toofache32 wrote:
Tue Jul 09, 2019 7:45 pm
CppCoder wrote:
Tue Jul 09, 2019 7:38 pm
I wonder if the internet can "break" this paradigm. Could one setup a website to crowd source medical payment information? Get an EOB, submit your CPT codes, provider, insurance, and negotiated rates. Do some data analytics, and presto, after months, all of this becomes public. Waze for health care costs. You participate because it ultimately helps you too. Company monetizes by...advertising? I think the first rule of internet startups is get eyeballs first, ask monetization questions later...we'll figure out the business model in year 3.

Did I "sign" something during open enrollment that said I wouldn't disclose an EOB? If the website were anonymous, would my insurance know anyway?
How is this different from the Fair Health website?
It's different in that I thought of one independently right now, while, apparently, someone else thought of the Fair Health website and forgot to tell me to visit it before discussing my plan on Bogleheads. :beer I also independently (conceptually) "invented" the Ring doorbell (months?) after them. It was still Door Bot at the point. Oh well, a day late and a dollar short, I guess.

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

Post by toofache32 » Tue Jul 09, 2019 8:03 pm

CppCoder wrote:
Tue Jul 09, 2019 7:54 pm
toofache32 wrote:
Tue Jul 09, 2019 7:45 pm
CppCoder wrote:
Tue Jul 09, 2019 7:38 pm
I wonder if the internet can "break" this paradigm. Could one setup a website to crowd source medical payment information? Get an EOB, submit your CPT codes, provider, insurance, and negotiated rates. Do some data analytics, and presto, after months, all of this becomes public. Waze for health care costs. You participate because it ultimately helps you too. Company monetizes by...advertising? I think the first rule of internet startups is get eyeballs first, ask monetization questions later...we'll figure out the business model in year 3.

Did I "sign" something during open enrollment that said I wouldn't disclose an EOB? If the website were anonymous, would my insurance know anyway?
How is this different from the Fair Health website?
It's different in that I thought of one independently right now, while, apparently, someone else thought of the Fair Health website and forgot to tell me to visit it before discussing my plan on Bogleheads. :beer I also independently (conceptually) "invented" the Ring doorbell (months?) after them. It was still Door Bot at the point. Oh well, a day late and a dollar short, I guess.
Ha. Don’t feel bad because if you can make one big meaningful tweek to the concept then you can take over.

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

Post by jacoavlu » Tue Jul 09, 2019 8:47 pm

Websites offering prepaid cash prices for procedures are becoming more common. For everything from a chest X-ray or simple lab, to spinal surgery and delivery of a child. I’m not sure where OP is located but I bet there’s a site offering such in your region. Perhaps a pedi cards consult may not be available but I guarantee an echo would be. Here’s one site

MDsave.com

As to your original question I for one could pretty easily tell you a contracted rate for my professional services for a particular code if I knew your payer. All of our payer contracts are negotiated as a percentage of the Medicare rate so it’s not too complex. It is that percentage that we negotiate at every contract renewal. Surprise they always want to pay us less that what was on the last contract. Your only leverage against accepting a rate cut as a private practice doc is to go out of network and have patients mad at their insurance for not contracting with their local providers. But most often patients get mad at us for being out of network.

Turbo29
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Re: How to obtain contracted rates for medical procedures?

Post by Turbo29 » Tue Jul 09, 2019 9:19 pm

dm200 wrote:
Tue Jul 09, 2019 1:11 pm

I don't think so - if I am understanding.

You need X, Y and Z medical services. You have the HDHP plan and you go to a facility and providers who are all "in network" for your insurance. You do not tell any of the providers that you have not met the deductible for the year. They submit the claims to your insurance for X, Y and Z. The claims go back to the providers and the providers then bill you for X, Y and Z at the insurance negotiated rates. Isn't this the normal process?
That's how it works at my primary care office. I go, they perform the services and submit to the insurance company. If it's early in the plan year and I haven't met deductibles or out of pocket, I get a bill from them a month later for the full amount at the negotiated rate.

But, when I go to my dermatologist, they are online with the insurance company. I stop at the desk on the way out and they tell me, "You have not met your deductible yet, you owe us $xx.xx, which they collect right there. Later in the plan year when I stop at the desk on the way out, if I have met my deductible and out of pocket, they know that and tell me that I owe them nothing.

Interestingly, Lab Corp is onsite at my primary doctor's office and they tell me at the time they draw blood exactly what they charge will be. They look it up before the needle goes in the vein as they are also online with my insurance company. While Lab Corp does not collect on site, they have me sign a sheet acknowledging that I know exactly what their charge will be.

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

Post by toofache32 » Tue Jul 09, 2019 9:28 pm

Turbo29 wrote:
Tue Jul 09, 2019 9:19 pm
dm200 wrote:
Tue Jul 09, 2019 1:11 pm

I don't think so - if I am understanding.

You need X, Y and Z medical services. You have the HDHP plan and you go to a facility and providers who are all "in network" for your insurance. You do not tell any of the providers that you have not met the deductible for the year. They submit the claims to your insurance for X, Y and Z. The claims go back to the providers and the providers then bill you for X, Y and Z at the insurance negotiated rates. Isn't this the normal process?
That's how it works at my primary care office. I go, they perform the services and submit to the insurance company. If it's early in the plan year and I haven't met deductibles or out of pocket, I get a bill from them a month later for the full amount at the negotiated rate.

But, when I go to my dermatologist, they are online with the insurance company. I stop at the desk on the way out and they tell me, "You have not met your deductible yet, you owe us $xx.xx, which they collect right there. Later in the plan year when I stop at the desk on the way out, if I have met my deductible and out of pocket, they know that and tell me that I owe them nothing.

Interestingly, Lab Corp is onsite at my primary doctor's office and they tell me at the time they draw blood exactly what they charge will be. They look it up before the needle goes in the vein as they are also online with my insurance company. While Lab Corp does not collect on site, they have me sign a sheet acknowledging that I know exactly what their charge will be.
This is all good but the insurance company is not always up to date on how much deductible has been used. There can be a surprising lag of weeks or months until the insurance company updates their info. For example, if you were in the hospital a month before your visit at the doctors office, those claims for the hospital stay may not have been fully processed yet to reflect the changes in your deductible. Especially since almost 20% of all claims are denied the first time and can take many more months to process.

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

Post by rantk81 » Wed Jul 10, 2019 6:55 am

CppCoder wrote:
Tue Jul 09, 2019 7:42 pm
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!
That's funny. I have Aetna, and they complain if I try to use CVS for anything other than a one off prescription. They want me to use the mail order pharmacy (Express Scripts) first for any maintenance drugs. I wonder if this is a result of using Aetna, essentially, as an insurance administrator, but really having a mega corp self-insured plan underneath the hood.
Incredible! And even more weird -- my plan has a program called "CVS Maintenance Choice" where they REQUIRE me to get any maintenance prescriptions from the CVS Maintenance Choice 90-day mail-order. (If I try to fill those scripts in person at a CVS -- be it for 30 or 90 days, they'll outright deny the claim.)

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

Post by rantk81 » Wed Jul 10, 2019 7:21 am

CppCoder wrote:
Tue Jul 09, 2019 7:38 pm
I wonder if the internet can "break" this paradigm. Could one setup a website to crowd source medical payment information? Get an EOB, submit your CPT codes, provider, insurance, and negotiated rates. Do some data analytics, and presto, after months, all of this becomes public. Waze for health care costs. You participate because it ultimately helps you too. Company monetizes by...advertising? I think the first rule of internet startups is get eyeballs first, ask monetization questions later...we'll figure out the business model in year 3.

Did I "sign" something during open enrollment that said I wouldn't disclose an EOB? If the website were anonymous, would my insurance know anyway?
I love this idea!
Have an app that grants you access to the massive database, if you allow it to "link" to your online credentials for your health insurance account where it can crawl all your EOBs for the data! Kind of like Mint/PersonalCapital does for financial accounts.

Of course, this is probably illegal as hell per HIPAA laws, and even if it wasn't, the insurance companies would do everything they possibly could to break the functionality from working seamlessly.

The most frustrating part is, the data is all SOMEWHERE. It's only unavailable to you because it is INTENTIONALLY unavailable to you by the people who have the most to gain by keeping you in the dark.

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

Post by toofache32 » Wed Jul 10, 2019 8:27 am

rantk81 wrote:
Wed Jul 10, 2019 6:55 am
CppCoder wrote:
Tue Jul 09, 2019 7:42 pm
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!
That's funny. I have Aetna, and they complain if I try to use CVS for anything other than a one off prescription. They want me to use the mail order pharmacy (Express Scripts) first for any maintenance drugs. I wonder if this is a result of using Aetna, essentially, as an insurance administrator, but really having a mega corp self-insured plan underneath the hood.
Incredible! And even more weird -- my plan has a program called "CVS Maintenance Choice" where they REQUIRE me to get any maintenance prescriptions from the CVS Maintenance Choice 90-day mail-order. (If I try to fill those scripts in person at a CVS -- be it for 30 or 90 days, they'll outright deny the claim.)
This is probably due to rebates and kickbacks created by a Pharmacy Benefit Manager.
Google "Pharmacy Benefit Manager" to find articles like this one:

https://www.statnews.com/2018/08/27/pha ... od-or-bad/

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

Post by dm200 » Wed Jul 10, 2019 8:43 am

toofache32 wrote:
Tue Jul 09, 2019 9:28 pm
Turbo29 wrote:
Tue Jul 09, 2019 9:19 pm
dm200 wrote:
Tue Jul 09, 2019 1:11 pm

I don't think so - if I am understanding.

You need X, Y and Z medical services. You have the HDHP plan and you go to a facility and providers who are all "in network" for your insurance. You do not tell any of the providers that you have not met the deductible for the year. They submit the claims to your insurance for X, Y and Z. The claims go back to the providers and the providers then bill you for X, Y and Z at the insurance negotiated rates. Isn't this the normal process?
That's how it works at my primary care office. I go, they perform the services and submit to the insurance company. If it's early in the plan year and I haven't met deductibles or out of pocket, I get a bill from them a month later for the full amount at the negotiated rate.

But, when I go to my dermatologist, they are online with the insurance company. I stop at the desk on the way out and they tell me, "You have not met your deductible yet, you owe us $xx.xx, which they collect right there. Later in the plan year when I stop at the desk on the way out, if I have met my deductible and out of pocket, they know that and tell me that I owe them nothing.

Interestingly, Lab Corp is onsite at my primary doctor's office and they tell me at the time they draw blood exactly what they charge will be. They look it up before the needle goes in the vein as they are also online with my insurance company. While Lab Corp does not collect on site, they have me sign a sheet acknowledging that I know exactly what their charge will be.
This is all good but the insurance company is not always up to date on how much deductible has been used. There can be a surprising lag of weeks or months until the insurance company updates their info. For example, if you were in the hospital a month before your visit at the doctors office, those claims for the hospital stay may not have been fully processed yet to reflect the changes in your deductible. Especially since almost 20% of all claims are denied the first time and can take many more months to process.
Yes - I agree.

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

Post by dm200 » Wed Jul 10, 2019 8:45 am

But, when I go to my dermatologist, they are online with the insurance company. I stop at the desk on the way out and they tell me, "You have not met your deductible yet, you owe us $xx.xx, which they collect right there. Later in the plan year when I stop at the desk on the way out, if I have met my deductible and out of pocket, they know that and tell me that I owe them nothing.
BUT - if they determine that you have not met the deductible - do they submit the claim so that the insurance company updates your record? Do you get the correct charges from the Dermatologist? How can the dermatologist know the correct amount?

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

Post by toofache32 » Wed Jul 10, 2019 9:04 am

dm200 wrote:
Wed Jul 10, 2019 8:45 am
But, when I go to my dermatologist, they are online with the insurance company. I stop at the desk on the way out and they tell me, "You have not met your deductible yet, you owe us $xx.xx, which they collect right there. Later in the plan year when I stop at the desk on the way out, if I have met my deductible and out of pocket, they know that and tell me that I owe them nothing.
BUT - if they determine that you have not met the deductible - do they submit the claim so that the insurance company updates your record? Do you get the correct charges from the Dermatologist? How can the dermatologist know the correct amount?
This relates to a game I often played in the insurance world. I would do surgery on a patient, and the patient would be discharged hours or days later. It takes a few days or sometimes weeks for a hospital to gather all their data and submit their claims to the insurance company. The deductible applies to the hospital/doctor/lab, etc that files first. So I would wait about a month to submit my claim to give the hospital time to submit theirs first. Then I was paid from the insurance company (not the patient) and the hospital would have to chase the patient for their $6000 deductible. If I submitted my claim first, then I was the one to chase the patient for their money. As noted in multiple other threads here, it's really difficult to collect deductibles from patients who have agreed to pay those deductibles.

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

Post by dm200 » Wed Jul 10, 2019 9:42 am

toofache32 wrote:
Wed Jul 10, 2019 9:04 am
dm200 wrote:
Wed Jul 10, 2019 8:45 am
But, when I go to my dermatologist, they are online with the insurance company. I stop at the desk on the way out and they tell me, "You have not met your deductible yet, you owe us $xx.xx, which they collect right there. Later in the plan year when I stop at the desk on the way out, if I have met my deductible and out of pocket, they know that and tell me that I owe them nothing.
BUT - if they determine that you have not met the deductible - do they submit the claim so that the insurance company updates your record? Do you get the correct charges from the Dermatologist? How can the dermatologist know the correct amount?
This relates to a game I often played in the insurance world. I would do surgery on a patient, and the patient would be discharged hours or days later. It takes a few days or sometimes weeks for a hospital to gather all their data and submit their claims to the insurance company. The deductible applies to the hospital/doctor/lab, etc that files first. So I would wait about a month to submit my claim to give the hospital time to submit theirs first. Then I was paid from the insurance company (not the patient) and the hospital would have to chase the patient for their $6000 deductible. If I submitted my claim first, then I was the one to chase the patient for their money. As noted in multiple other threads here, it's really difficult to collect deductibles from patients who have agreed to pay those deductibles.
Interesting approach!

It is too bad that folks with these deductible are often "slow" or "no" pay.

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

Post by dm200 » Wed Jul 10, 2019 9:45 am

Back when I had employer insurance, it was very common that the Physicians I would see for me to have a Copay. When I would check in, most of the time the staff would not have a clue what my copay should be. They would ask me. I would say that I did not know - bill me after you file the claim.

I believed that if I volunteered to pay my "guess" of the copay and it was too much - then I might not get the refund.

When billed for the correct copay - I always paid immediately.

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

Post by rantk81 » Wed Jul 10, 2019 9:50 am

dm200 wrote:
Wed Jul 10, 2019 9:45 am
Back when I had employer insurance, it was very common that the Physicians I would see for me to have a Copay. When I would check in, most of the time the staff would not have a clue what my copay should be. They would ask me. I would say that I did not know - bill me after you file the claim.

I believed that if I volunteered to pay my "guess" of the copay and it was too much - then I might not get the refund.

When billed for the correct copay - I always paid immediately.
I've never had an instance where a provider refused to properly reimburse me from an over-payment. In fact, in most cases, the provider's billing department will pro-actively send me a check for a refund, without me ever having to ask them or contact them. This even happened in the case where my insurance company made a payment on a claim nearly a year after the date of service. (For which I already had paid for it out-of-pocket in the prior year.) I do try to stick to doctors who are affiliated with the "large hospital groups" in my city though -- and they all are tied into the same electronic patient portal thing (EPIC Systems MyChart)

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

Post by dm200 » Wed Jul 10, 2019 10:04 am

rantk81 wrote:
Wed Jul 10, 2019 9:50 am
dm200 wrote:
Wed Jul 10, 2019 9:45 am
Back when I had employer insurance, it was very common that the Physicians I would see for me to have a Copay. When I would check in, most of the time the staff would not have a clue what my copay should be. They would ask me. I would say that I did not know - bill me after you file the claim.
I believed that if I volunteered to pay my "guess" of the copay and it was too much - then I might not get the refund.
When billed for the correct copay - I always paid immediately.
I've never had an instance where a provider refused to properly reimburse me from an over-payment. In fact, in most cases, the provider's billing department will pro-actively send me a check for a refund, without me ever having to ask them or contact them. This even happened in the case where my insurance company made a payment on a claim nearly a year after the date of service. (For which I already had paid for it out-of-pocket in the prior year.) I do try to stick to doctors who are affiliated with the "large hospital groups" in my city though -- and they all are tied into the same electronic patient portal thing (EPIC Systems MyChart)
One of my Specialty Physicians at the time was, in my opinion and experience, a medically excellent specialist. However, her office staff was like a revolving door. Administratively a real mess. I did not want to risk it - and have hurdles to climb to get money back.

jayk238
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Re: How to obtain contracted rates for medical procedures?

Post by jayk238 » Fri Jul 12, 2019 10:19 am

ram wrote:
Tue Jul 09, 2019 7:30 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.
I work for a medical facility which has many different geographic locations. Medicare pays 10% more for the exact same thing done at those locations that they deem as "physician shortage areas".

It does not have to be 2 different providers of the same type. It can be the exact same provider providing the same service at location A for a payment of $100 from medicare on Monday and payment of $110 at location B on Tuesday.

https://www.cms.gov/Outreach-and-Educat ... fctsht.pdf
Yeah but thats medicare. Im talking about private insurance reimbursements

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

Post by jacoavlu » Fri Jul 12, 2019 10:24 am

If there is more than one group of providers that are "in network" then certainly charges and payments may be different, for the same procedure or encounter, among different "in network" providers, because different provider groups will have different contracts and possibly different negotiated payment rates with the payer (insurance company).

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

Post by toofache32 » Fri Jul 12, 2019 10:33 am

jacoavlu wrote:
Fri Jul 12, 2019 10:24 am
If there is more than one group of providers that are "in network" then certainly charges and payments may be different, for the same procedure or encounter, among different "in network" providers, because different provider groups will have different contracts and possibly different negotiated payment rates with the payer (insurance company).
I think the fees would be essentially the same among private practice physicians since they are not allowed to actually negotiate the fees. Institutional settings such as university or hospital based practices have the leverage to negotiate higher fees which increases costs. Not to mention facility fees.

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

Post by KingRiggs » Fri Jul 12, 2019 10:44 am

toofache32 wrote:
Fri Jul 12, 2019 10:33 am
jacoavlu wrote:
Fri Jul 12, 2019 10:24 am
If there is more than one group of providers that are "in network" then certainly charges and payments may be different, for the same procedure or encounter, among different "in network" providers, because different provider groups will have different contracts and possibly different negotiated payment rates with the payer (insurance company).
I think the fees would be essentially the same among private practice physicians since they are not allowed to actually negotiate the fees. Institutional settings such as university or hospital based practices have the leverage to negotiate higher fees which increases costs. Not to mention facility fees.
Being "in network" doesn't mean that you can't negotiate fees. It just means that you HAVE a negotiated fee structure with the insurer.

Our practice group has been aggressive with negotiations, resulting in larger fees compared to a similar-sized practice group across town with the same carrier...
Advice = noun | Advise = verb | | Roth, not ROTH

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

Post by toofache32 » Fri Jul 12, 2019 10:58 am

KingRiggs wrote:
Fri Jul 12, 2019 10:44 am
toofache32 wrote:
Fri Jul 12, 2019 10:33 am
jacoavlu wrote:
Fri Jul 12, 2019 10:24 am
If there is more than one group of providers that are "in network" then certainly charges and payments may be different, for the same procedure or encounter, among different "in network" providers, because different provider groups will have different contracts and possibly different negotiated payment rates with the payer (insurance company).
I think the fees would be essentially the same among private practice physicians since they are not allowed to actually negotiate the fees. Institutional settings such as university or hospital based practices have the leverage to negotiate higher fees which increases costs. Not to mention facility fees.
Being "in network" doesn't mean that you can't negotiate fees. It just means that you HAVE a negotiated fee structure with the insurer.

Our practice group has been aggressive with negotiations, resulting in larger fees compared to a similar-sized practice group across town with the same carrier...
In my experience, they will not negotiate fees with individual private practitioners, only really large groups. These are contracts of adhesion.

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

Post by jacoavlu » Fri Jul 12, 2019 10:59 am

independent physicians (such as myself and partners) absolutely can and do negotiate our agreed reimbursement rate (expressed as a percentage of the medicare rate) with each payer we contract with. Being a large group and/or affiliated with a university is not the only means by which to have some leverage in negotiations.

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

Post by toofache32 » Fri Jul 12, 2019 11:22 am

Interesting. Maybe it's regional and depends on how much of a foothold the company has in a certain area. BCBS and Cigna are the 800 pound gorillas in my area. They literally told me to sign the contract or don't since they will not change it. So I didn't.

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

Post by TropikThunder » Fri Jul 12, 2019 11:55 am

jacoavlu wrote:
Fri Jul 12, 2019 10:59 am
independent physicians (such as myself and partners) absolutely can and do negotiate our agreed reimbursement rate (expressed as a percentage of the medicare rate) with each payer we contract with. Being a large group and/or affiliated with a university is not the only means by which to have some leverage in negotiations.
How would you know that you’re really getting a better payment rate than another physician group? Do you share information with competitors? None of this is transparent at any level. If the insurer’s first offer is say 110% of Medicare rate (I have no idea what’s normal), how many practices in your area will just shrug and say “OK” and how many (like you) will say “No, we want a higher rate”. Maybe everyone gets the higher rate but the insurer lets you feel like you won?

I realize how cynical (even conspiratorial) that sounds ...

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

Post by jacoavlu » Fri Jul 12, 2019 1:37 pm

TropikThunder wrote:
Fri Jul 12, 2019 11:55 am
jacoavlu wrote:
Fri Jul 12, 2019 10:59 am
independent physicians (such as myself and partners) absolutely can and do negotiate our agreed reimbursement rate (expressed as a percentage of the medicare rate) with each payer we contract with. Being a large group and/or affiliated with a university is not the only means by which to have some leverage in negotiations.
How would you know that you’re really getting a better payment rate than another physician group? Do you share information with competitors? None of this is transparent at any level. If the insurer’s first offer is say 110% of Medicare rate (I have no idea what’s normal), how many practices in your area will just shrug and say “OK” and how many (like you) will say “No, we want a higher rate”. Maybe everyone gets the higher rate but the insurer lets you feel like you won?

I realize how cynical (even conspiratorial) that sounds ...
I don't know what other groups rates are and we don't share our rates with competitors. We always have an idea, whether from talking to colleagues, practice managers, etc. You also hear things about other people's negotiations, so and so went out of network, so and so took a big cut, etc. You always of course know the rates you get with other payers. So if one is way out of line that's obvious. They always want to pay you less. The things that insurance companies will say in negotiations is sometimes surprising. I've had insurance execs tell me that they'll have my group replaced in my community.

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