000 wrote: ↑Mon Sep 21, 2020 4:57 pm
toofache32 wrote: ↑Mon Sep 21, 2020 4:41 pm
Incorrect. Anyone wonder why someone is charged $525 for eight minutes when the doctor never expects to get paid that much?
Insurance companies contractually require providers and hospitals to have a single fee schedule. The doctor bills $525 to the insurance, insurance pays $200 and the doctor writes off the rest. So why not just bill $200? Because there is an insurance plan out there somewhere that pays (making this up) $525 for that same code. If you bill that insurance $200, they will only pay you $200, not the $525 they would have paid if you had asked for it. So, since insurance requires everyone to have a single fee schedule, everyone gets charged $525, including uninsured patients. To charge uninsured patients less is fraud.
Why do the insurance companies want it this way? Because now they have uninsured patients getting a bill for $525 and say to themselves "dang I need insurance." So the insurance companies use the doctors and hospitals to drive customers back to them.
So, yes, the insurance company is strangely behind the phenomenon of doctors billing high fees which they know they will not get paid.
What you are describing is illegal price fixing. No one involved deserves a pass.
It's fraud to charge uninsured patients less than $525 but not fraud to charge the insurer less than $525? Give me a break.
If physicians were really suffering a net harm from the insurance practices, they could use their massive lobbying power to change it. Guess what? The complexity of the system benefits both physicians and insurers. Just step out of your bubble for a minute and compare the net profits of the medical and medical insurance industry in the US versus most other countries: both are higher.
The way fee for insurance contracts work (the fee for service type) is that by being "in-network", I agree to accept their payment and not balance bill the patient for the difference. Their payment is based on the maximum allowable charge (which is in a big table by procedure/visit code), and what happens is that they will pay whatever I charge, up to the maximum allowable. So if I charge less than the maximum allowable, I'm leaving money behind. I don't want that to happen, so I have to make sure my price is higher than the maximum allowable. These tables vary a lot from insurance to insurance (and change frequently), so it's easier to just make my price is significantly higher than those allowables so as to not miss any outliers. This is why the list price on everything is so high.
The catch is that the government (and private insurers) have rules stating that I have to give them my best price. So if you are uninsured, then i am required to charge you the full price. To do otherwise would be medicare fraud and that is bad.
Of course, I don't expect uninsured patients to pay that price. I'm allowed to accept less (after I've charged them full price). I can also offer a prompt pay discount (after officially charging them full price). But I can't run specials deals and advertise for $20 check ups or whatever, nor can I offer to waive co-pays, bring one kid in get the other half price, etc.
I don't like this system and I wish it could be changed. Doctors are absolutely horrible at lobbying and are completely out maneuvered by insurance, pharmaceutical and hospital systems.
Also of note, by being in-network, I am in now way obligated to see you, it just means that if I charge your insurance, I'm agreeing to their payment.
If I'm out-of-network, you (the patient) are welcome to send my charges to your insurance (where they still pay a maximal allowable), but this often comes out of a different deductible, and as the provider I am allowed to charge you for the difference.