Medical billing and negotiated rates ?

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JohnFiscal
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Medical billing and negotiated rates ?

Post by JohnFiscal » Tue May 15, 2018 9:51 am

I'm comparing two Blue Cross ACA policies for my wife as I commence on Medicare.

One of the parameters listed in the policy descriptions is: "Primary care visit to treat an injury or illness"

"Plan A" provides high deductible and there is no benefit for for this 'event' (as BC calls it) until the deductible is met.

"Plan B" has lower deductible, higher premium, and for this 'event' there is just the copay charge.

Question is, up to my current experience being under employer's health plan is that the insurance has a "negotiated" rate they pay for in-network services, and I/we pay our copay but no more than that. Does this same approach apply in the case of "Plan A" above? by that I mean that even though there is no copay are the particular fees for that visit limited to the negotiated rate with the insurance company?

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Pajamas
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Re: Medical billing and negotiated rates ?

Post by Pajamas » Tue May 15, 2018 10:10 am

Yes, if there were a negotiated rate for the primary care visit, it would apply to you.

This is one of the benefits of dental plans. Even if there is a low annual maximum benefit and you exceed it, you still get the negotiated rates.

sport
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Re: Medical billing and negotiated rates ?

Post by sport » Tue May 15, 2018 10:58 am

Pajamas wrote:
Tue May 15, 2018 10:10 am
Yes, if there were a negotiated rate for the primary care visit, it would apply to you.

This is one of the benefits of dental plans. Even if there is a low annual maximum benefit and you exceed it, you still get the negotiated rates.
Of course, this is true only if the doctor/dentist is in the network of your insurance plan.

JohnFiscal
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Re: Medical billing and negotiated rates ?

Post by JohnFiscal » Tue May 15, 2018 11:25 am

sport wrote:
Tue May 15, 2018 10:58 am
Pajamas wrote:
Tue May 15, 2018 10:10 am
Yes, if there were a negotiated rate for the primary care visit, it would apply to you.

This is one of the benefits of dental plans. Even if there is a low annual maximum benefit and you exceed it, you still get the negotiated rates.
Of course, this is true only if the doctor/dentist is in the network of your insurance plan.
And that is what I was thinking, later on. Thank you both.

This begs the question "what benefit is there to the provider by being 'in network'? " Any thoughts?

rantk81
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Re: Medical billing and negotiated rates ?

Post by rantk81 » Tue May 15, 2018 11:57 am

sport wrote:
Tue May 15, 2018 10:58 am
Pajamas wrote:
Tue May 15, 2018 10:10 am
Yes, if there were a negotiated rate for the primary care visit, it would apply to you.

This is one of the benefits of dental plans. Even if there is a low annual maximum benefit and you exceed it, you still get the negotiated rates.
Of course, this is true only if the doctor/dentist is in the network of your insurance plan.
For dental services, they generally aren't life-or-death emergencies, and you have ample time to plan ahead for getting service. Hence, I would assume nearly all dentists are very generous in their "no-insurance cash discounted" price, as long as you ask ahead of time. In my experience, the cash price for services from dentists I've had, has often been cheaper than the insurance negotiated prices too.

sport
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Re: Medical billing and negotiated rates ?

Post by sport » Tue May 15, 2018 12:15 pm

JohnFiscal wrote:
Tue May 15, 2018 11:25 am
sport wrote:
Tue May 15, 2018 10:58 am
Pajamas wrote:
Tue May 15, 2018 10:10 am
Yes, if there were a negotiated rate for the primary care visit, it would apply to you.

This is one of the benefits of dental plans. Even if there is a low annual maximum benefit and you exceed it, you still get the negotiated rates.
Of course, this is true only if the doctor/dentist is in the network of your insurance plan.
And that is what I was thinking, later on. Thank you both.

This begs the question "what benefit is there to the provider by being 'in network'? " Any thoughts?
I once asked my dentist why he was not in an insurance plan. He told me that if he joined the network, he would get more patients, but he would get paid less for each one. The result would be that he would do more work for no more money. So, of course, he was not interested in joining.

Rupert
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Re: Medical billing and negotiated rates ?

Post by Rupert » Tue May 15, 2018 12:44 pm

JohnFiscal wrote:
Tue May 15, 2018 11:25 am
sport wrote:
Tue May 15, 2018 10:58 am
Pajamas wrote:
Tue May 15, 2018 10:10 am
Yes, if there were a negotiated rate for the primary care visit, it would apply to you.

This is one of the benefits of dental plans. Even if there is a low annual maximum benefit and you exceed it, you still get the negotiated rates.
Of course, this is true only if the doctor/dentist is in the network of your insurance plan.
And that is what I was thinking, later on. Thank you both.

This begs the question "what benefit is there to the provider by being 'in network'? " Any thoughts?
Well I think it's different for doctors and dentists. Many dentists aren't in any networks and don't suffer for it. Even the best dental insurance isn't that great; so most people expect to pay out of pocket for dental work. And the cost of dental work isn't going to bankrupt many people. Implants may be an exception, but that's elective. Health insurance is a completely different animal. Health insurance pays most of the costs of medical care, especially when you stay in network; so people tend to stay in network. And the potential costs of healthcare are astronomical; many people do declare bankruptcy as a result of medical costs. As a result, doctors, in contrast to dentists, have to be in networks to keep a steady stream of patients. There are some exceptions, of course, but those exceptions are mostly limited to certain specialties or concierge care, which mostly targets high-wealth individuals.

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Pajamas
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Re: Medical billing and negotiated rates ?

Post by Pajamas » Tue May 15, 2018 12:47 pm

More than half of doctors are employees now, with no ownership, so they may have limited or no say in it.

If they can avoid it, they often do, as mentioned above. Anesthesiology groups frequently aren't contracted with plans, for instance.

toofache32
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Re: Medical billing and negotiated rates ?

Post by toofache32 » Tue May 15, 2018 11:15 pm

Pajamas wrote:
Tue May 15, 2018 10:10 am
Yes, if there were a negotiated rate for the primary care visit, it would apply to you.

This is one of the benefits of dental plans. Even if there is a low annual maximum benefit and you exceed it, you still get the negotiated rates.
Depends on the state. Most have laws prohibiting insurance companies from doing this.

https://www.google.com/search?q=non-cov ... irefox-b-1

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