Challenging a physician's bill

Non-investing personal finance issues including insurance, credit, real estate, taxes, employment and legal issues such as trusts and wills
quantAndHold
Posts: 5131
Joined: Thu Sep 17, 2015 10:39 pm

Re: Challenging a physician's bill

Post by quantAndHold »

njuser wrote: Mon Sep 21, 2020 12:48 pm
quantAndHold wrote: Mon Sep 21, 2020 10:01 am The system is clearly broken. You’d think doctors, who clearly have a vested interest in the system working properly, would by working to fix it, instead of whining on an Internet forum every time a patient shares their bad experience with the system.
How would you like the doctors to fix it?
What I think doctors should be doing gets into the realm of politics, which we aren’t allowed to discuss here. I’ll just say that my experience is that small groups of committed people can move political mountains, and I don’t see doctors doing much of anything to help themselves except whining on social media about how it isn’t their fault, it’s the broken system. All that whining seems disingenuous.

In this particular case, OP asked the provider up front if they took his insurance. The provider told him yes. My provider checks my insurance online before I go past the reception desk every time I go. What would you expect OP to do at that point, ask the provider to pinky swear?
Yes, I’m really that pedantic.
tibbitts
Posts: 12228
Joined: Tue Feb 27, 2007 6:50 pm

Re: Challenging a physician's bill

Post by tibbitts »

quantAndHold wrote: Mon Sep 21, 2020 3:02 pm In this particular case, OP asked the provider up front if they took his insurance. The provider told him yes. My provider checks my insurance online before I go past the reception desk every time I go. What would you expect OP to do at that point, ask the provider to pinky swear?
Well, in terms of checking online with the insurance company, my insurance says:

After selecting a provider, it is important to reconfirm the network status of the provider or facility.

The insurance company doesn't say how it's possible to do that. But if the same online system is used by a provider to check for coverage, apparently they won't necessarily receive a definitive answer from the insurance company.

So possibly the pinky-swear is the ultimate method of determining coverage.
000
Posts: 3232
Joined: Thu Jul 23, 2020 12:04 am

Re: Challenging a physician's bill

Post by 000 »

EnjoyIt wrote: Mon Sep 21, 2020 8:11 am
000 wrote: Mon Sep 21, 2020 12:19 am
White Coat Investor wrote: Sun Sep 20, 2020 11:57 pm Ahhh...the problems of being in an industry where you don't collect your payment up front or at the time of service. Now nobody is happy. Patient mad because he got a bill and lousy care. Doctor mad because he didn't get paid and forced to try to see patients in 8 minutes. And the insurance company is laughing all the way to the bank.

No wonder doctors are leaving medicine as soon as they can afford to.
Someone's got a nasty case of Tunnelis Visionitis over here!

Quick! Call a doctor!

Oh, wait...
Please explain.
White Coat Investor's post suggested that an insurance company was somehow responsible for (and profiting from) the level of service provided and price charged to a cash patient. This is clearly absurd. The insurance company had nothing to do with the doctor being "forced to try to see patients in 8 minutes", the $525 bill, or the apparent HIPAA violation, despite the claim that "the insurance company is laughing all the way to the bank".

Additionally, the main reason "doctors are leaving medicine as soon as they can afford to" is because the number one reason US doctors choose to enter the profession in the first place is to make a much-higher-than-average income (source: surveys of students at US medical schools).

Hence I believe the White Coat Investor may be suffering from Tunnel Vision, only seeing things from his narrow perspective.
Last edited by 000 on Mon Sep 21, 2020 3:51 pm, edited 1 time in total.
Helo80
Posts: 1781
Joined: Sat Apr 29, 2017 8:47 pm

Re: Challenging a physician's bill

Post by Helo80 »

000 wrote: Mon Sep 21, 2020 3:27 pm
Additionally, the main reason "doctors are leaving medicine as soon as they can afford to" is because the number one reason US doctors choose to enter the profession in the first place is to make money (source: surveys of students at US medical schools).

That does not surprise me at all from personal and direct experience in the field. Gratefully, my line of work has nothing to do with medicine or healthcare at large now.

While high compensation is certainly a factor for going through four years of med school and then 3-5 years of residency + add'l fellowship years, the system is pricing itself further and further out of the reach of average Americans. Median salaries are not rising at the rates healthcare is rising.

That being said, I believe that purely elective cosmetic procedures are going down as plastic surgeons are forced to compete on price. Or, stuff like LASIK and eye corrective surgeries since I think that's 100% elective for most patients that don't want to deal with the cheaper alternative of contacts or glasses.
wfrobinette
Posts: 1413
Joined: Fri Feb 20, 2015 3:14 pm

Re: Challenging a physician's bill

Post by wfrobinette »

stocknoob4111 wrote: Sun Sep 20, 2020 5:27 pm It's the standard price, my doctor charged $240 for my annual checkup as well and he did not do anything at all besides ask me if I was doing my exercise and eating my fruits and veggies. This is why I never go to these things, I only went because my health program at work gave me a $300 bonus for doing it otherwise these "annual physicals" are just a scam.

I visit India every other year and get my comprehensive physical there - costs me about $100 for a full day that includes a battery of tests, full blood panel - pre and post prandial, stress test, ECG, bone density, Liver function, Kidney function, Metabolic function, Chest XRay, Lung function, Dental screening, vision screening, Consult with the doc, Consult with the Nutritionist - yes, all that for $100 in a modern state of the art hospital with the latest and great equipment... as I said healthcare here in the US is a scam.
US healthcare is not a scam. Annual physicals are not a scam either.

You have a crappy doctor is all.

My docs spend plenty of time and give me the appropriate aged based blood tests. Eyes are done elsewhere and so is dental.
yummeemunnkee
Posts: 22
Joined: Fri Feb 16, 2018 10:19 am

Re: Challenging a physician's bill

Post by yummeemunnkee »

njuser wrote: Mon Sep 21, 2020 12:48 pm
quantAndHold wrote: Mon Sep 21, 2020 10:01 am The system is clearly broken. You’d think doctors, who clearly have a vested interest in the system working properly, would by working to fix it, instead of whining on an Internet forum every time a patient shares their bad experience with the system.

I don’t charge my customers up front, either. But my customers know how much things before the service is rendered. It sounds like the guy got billed $500 for his annual “well patient exam,” which is supposed to have a zero copay. I would be mighty upset to the point of finding ways to refuse to pay if that happened to me, too.
How would you like the doctors to fix it? In my plan, it is clearly spelled out that if I go out of network, my plan pays nothing for well care. Everyone gets a summary of benefits from their plan each year that should spell out everything their plan does and does not cover.

The patient and the insurance company have an agreement. In the end, it is up to the patient to follow his insurance companies rules for reimbursement. Ideally, the patient should have checked online or by phone with his insurance company to confirm the doctor being in network. There are thousands of plans and your doctor isn't familiar with every one. In the end, unfortunately, it is up to the patient to make sure he knows his coverage. Read the rules of your plan.

That being said, the doctor will probably negotiate with the patient because most of them are understanding people. Try getting some sympathy from your insurance company.
Agreed. I always check directly with my insurance company if a doctor is in-network before I schedule an appointment since it’s my money I’m paying and ultimately my responsibility.
toofache32
Posts: 2161
Joined: Sun Mar 04, 2012 6:30 pm

Re: Challenging a physician's bill

Post by toofache32 »

000 wrote: Mon Sep 21, 2020 3:27 pm
EnjoyIt wrote: Mon Sep 21, 2020 8:11 am
000 wrote: Mon Sep 21, 2020 12:19 am
White Coat Investor wrote: Sun Sep 20, 2020 11:57 pm Ahhh...the problems of being in an industry where you don't collect your payment up front or at the time of service. Now nobody is happy. Patient mad because he got a bill and lousy care. Doctor mad because he didn't get paid and forced to try to see patients in 8 minutes. And the insurance company is laughing all the way to the bank.

No wonder doctors are leaving medicine as soon as they can afford to.
Someone's got a nasty case of Tunnelis Visionitis over here!

Quick! Call a doctor!

Oh, wait...
Please explain.
White Coat Investor's post suggested that an insurance company was somehow responsible for (and profiting from) the level of service provided and price charged to a cash patient. This is clearly absurd. The insurance company had nothing to do with the doctor being "forced to try to see patients in 8 minutes", the $525 bill, or the apparent HIPAA violation, despite the claim that "the insurance company is laughing all the way to the bank".
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.
Broken Man 1999
Posts: 5275
Joined: Wed Apr 08, 2015 11:31 am
Location: West coast of Florida, inland on high ground!

Re: Challenging a physician's bill

Post by Broken Man 1999 »

What I find interesting is the idea to make the bill lower by reporting a medical person who made a mistake in handing the file of someone else.

That seems rather childish to me.

toofache32, I totally understand why you run your practice the way you do.

Broken Man 1999
“If I cannot drink Bourbon and smoke cigars in Heaven then I shall not go. " -Mark Twain
000
Posts: 3232
Joined: Thu Jul 23, 2020 12:04 am

Re: Challenging a physician's bill

Post by 000 »

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.
potatopancake
Posts: 37
Joined: Fri Jul 13, 2018 4:38 pm

Re: Challenging a physician's bill

Post by potatopancake »

000 wrote: Mon Sep 21, 2020 4:57 pm 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.
Direct primary care (DPC) is on the rise. Cut out the insurance companies. Many of my colleagues love DPC and their patients appreciate the system.
Jags4186
Posts: 5193
Joined: Wed Jun 18, 2014 7:12 pm

Re: Challenging a physician's bill

Post by Jags4186 »

I think it was a poor decision to ask the doctor’s office if they are in-network vs checking on your insurance company’s website to confirm the doctor is in-network. I know, before I show up to a doctor, what the copay will be, if they are Tier 1, Tier 2, or OON providers, etc. Needless to say, I don’t see OON doctors.

Now, that said, I would still complain that they confirmed that you were in-network, the service received was poor, and they did not follow through on the cologuard screening so the physical was never completed. For all those reasons, you would like to know what they can do about reducing the bill.
EnjoyIt
Posts: 4928
Joined: Sun Dec 29, 2013 8:06 pm

Re: Challenging a physician's bill

Post by EnjoyIt »

quantAndHold wrote: Mon Sep 21, 2020 3:02 pm
njuser wrote: Mon Sep 21, 2020 12:48 pm
quantAndHold wrote: Mon Sep 21, 2020 10:01 am The system is clearly broken. You’d think doctors, who clearly have a vested interest in the system working properly, would by working to fix it, instead of whining on an Internet forum every time a patient shares their bad experience with the system.
How would you like the doctors to fix it?
What I think doctors should be doing gets into the realm of politics, which we aren’t allowed to discuss here. I’ll just say that my experience is that small groups of committed people can move political mountains, and I don’t see doctors doing much of anything to help themselves except whining on social media about how it isn’t their fault, it’s the broken system. All that whining seems disingenuous.

In this particular case, OP asked the provider up front if they took his insurance. The provider told him yes. My provider checks my insurance online before I go past the reception desk every time I go. What would you expect OP to do at that point, ask the provider to pinky swear?
As a physician, I hate our medical insurance system. It is complex and difficult to navigate even if you are working within such as us doctors.

I would love to make a stand and make changes but to be honest everything I have ever done generally returns with a backlash. Most of us are employed by corporations and our employers are not interested in those that rock the boat. Those who do are quickly remove and replaced.

It is a shame that a few bad doctors and there are bad doctors out there make the rest of us look bad. If you have some idea on how to beat the insurance industry complex and how a few separatist docs can take down the mega corps while still being able to pay the bills, please share. I am seriously listening. I’ll even take a Private Message if you have some good ideas.

As for the OP, yes you should without a doubt try and fight this bill. As you are aware, having another patients medical records in your hands is a very strong bargaining chip which can cost them a $50k fine if reported. They will bend over backwards to clear this up for you.
A time to EVALUATE your jitters: | https://www.bogleheads.org/forum/viewtopic.php?f=10&t=79939&start=400#p5275418
TropikThunder
Posts: 2587
Joined: Sun Apr 03, 2016 5:41 pm

Re: Challenging a physician's bill

Post by TropikThunder »

Jags4186 wrote: Mon Sep 21, 2020 5:05 pm I think it was a poor decision to ask the doctor’s office if they are in-network vs checking on your insurance company’s website to confirm the doctor is in-network. I know, before I show up to a doctor, what the copay will be, if they are Tier 1, Tier 2, or OON providers, etc. Needless to say, I don’t see OON doctors.
That's just silly, you need to do both. Pretty much every insurance company's website has a disclaimer saying verify coverage with the provider before receiving services. Mine says:
While effort (sic) is made to keep network affiliation information up to date, provider status within a network is subject to change at any time and the information shown may not be accurate or complete. You should confirm directly with your provider their network status before services are received.
If a provider moves to another practice group and doesn't tell the insurance company, how is the insurance company supposed to update their website?
cashmoney
Posts: 370
Joined: Thu Jun 29, 2017 11:15 pm

Re: Challenging a physician's bill

Post by cashmoney »

FIREchief wrote: Mon Sep 21, 2020 1:55 pm What does it mean for a provider to tell you that they "accept your insurance?" It may mean nothing more than that they will see you on the hopes of ultimately being paid by someone. When is comes to private insurance, in close to 100% of the cases the terms "in network," "out of network" and "covered expense" are key. I would never just ask the person at the front desk to confirm my insurance coverage.

The responsibility is on the patient to do their homework:

a) Confirm with their insurance company that the provider is either in network or will be covered as out of network (typically at higher cost to the patient). Either of these will ensure that a lower contracted rate or "reasonable rate" will be charged and covered at some level. If neither of these apply, than the patient will likely be billed exorbitant retail pricing as has occurred with the OP. HMOs typically do NOT have any out of network coverage other than for emergencies. I believe that PPO plans typically do have some level of out of network coverage at higher costs to the patient.

b) Confirm with their insurance company that the procedure is a covered expense. This can be either very simple or complicated beyond comprehension. At times, the best clue I've found is to determine if it is covered by Medicare (even though I'm on private coverage prior to age 65). If Medicare considers it an eligible expense, many times private insurance will mimic that. If it's not a covered expense, insurance will do nothing and, again, the patient will be at the total mercy of the provider.

This is all based solely on my experience, which may be different than what others have experienced. Please share. 8-)


+1
I am a licensed agent for medicare health plans .I explain to people I enroll in PPO to very specifically ask a provider if they are in network or participating with the plan vs asking do you accept the plan.While most providers and especially primary physicians will be transparent about whether they are in network when you make an appointment you will run in to few providers who are not.The onus is always on patient to know before they go.In my experience it has been chiropractors and podiatrist more than any other specialty who sometimes IMHO intentionally say yes we accept that plan just to get the consumers in the door.On the flip side there are some providers who may not be in network on a big insurance company ppo because they dont want to go through the credentialing process to get contracted with plan who will not only accept the plan but will also only charge in network rates for all services.
Helo80
Posts: 1781
Joined: Sat Apr 29, 2017 8:47 pm

Re: Challenging a physician's bill

Post by Helo80 »

Godot wrote: Sun Sep 20, 2020 3:54 pm I'm appalled at a few things, including the fact that any PCP charges $525 for an eight-minute "physical"!
You have every right to be appalled. And it's sad that I have to tell you that you should be grateful that it's "only" $525.... and not some of the outrageous bills people have gotten from hospitals for similar times with physicians.

With hospitals operating on such razor thin margins and sending outrageous bills... there are more of us than them and we all vote.
000
Posts: 3232
Joined: Thu Jul 23, 2020 12:04 am

Re: Challenging a physician's bill

Post by 000 »

I don't think it's a good idea to use the apparent HIPAA violation as a bargaining chip. If it deserves reporting, I would do so irrespective of any other issues.
Topic Author
Godot
Posts: 444
Joined: Fri Jun 08, 2018 3:44 pm
Location: Little Beirut

Re: Challenging a physician's bill

Post by Godot »

Broken Man 1999 wrote: Mon Sep 21, 2020 4:53 pm What I find interesting is the idea to make the bill lower by reporting a medical person who made a mistake in handing the file of someone else.

That seems rather childish to me.

toofache32, I totally understand why you run your practice the way you do.

Broken Man 1999
It's not to "make the bill lower." It's to waive it altogether! The physician and the medical group he works for have not responded to my emails and letters appealing the absurd bill and the promised Cologuard kit. Would you consider that "childish" as well?
Estragon: I can't go on like this. | Vladimir: That's what you think. | ― Samuel Beckett, Waiting for Godot
EnjoyIt
Posts: 4928
Joined: Sun Dec 29, 2013 8:06 pm

Re: Challenging a physician's bill

Post by EnjoyIt »

000 wrote: Mon Sep 21, 2020 6:00 pm I don't think it's a good idea to use the apparent HIPAA violation as a bargaining chip. If it deserves reporting, I would do so irrespective of any other issues.
Realistically accidentally giving the wrong patient records happens all the time in the grand scheme of the US healthcare system. It is a human mistake that can happen to anyone. Either way, if the office is being dishonest and not willing to do right by the OP, then OP has full right to use an alternate bargaining chip.

If this office has unscrupulous practices which we don’t know at the moment, they may balk and give OP a hard time. Otherwise, they should do right by the OP.
A time to EVALUATE your jitters: | https://www.bogleheads.org/forum/viewtopic.php?f=10&t=79939&start=400#p5275418
Helo80
Posts: 1781
Joined: Sat Apr 29, 2017 8:47 pm

Re: Challenging a physician's bill

Post by Helo80 »

EnjoyIt wrote: Mon Sep 21, 2020 6:14 pm Realistically accidentally giving the wrong patient records happens all the time in the grand scheme of the US healthcare system. It is a human mistake that can happen to anyone.

I agree --- mistakes do happen with patient records and sometimes unintentionally verifying that a provider is or is not in-network.

I just wonder if an office sticking to its guns over a $525 medical bill is worth the hassle of dealing with a medical board complaint.

I oddly wish I were OP as I might be resolved to just pay the bill as WCI suggests and then reporting the patient record violation to the appropriate authorities. I pay taxes, just as physicians do, to support these regulatory agencies. The physician's office does not seem to keen on working with OP to sort out these in/out of network provider charges.

I'd probably be viewed as a turd of a patient, but not every physician makes it easy to work with. You all went to medical school. You all know some of the personalities there.
Cyanide123
Posts: 325
Joined: Sun May 05, 2019 9:14 am

Re: Challenging a physician's bill

Post by Cyanide123 »

8foot7 wrote: Mon Sep 21, 2020 10:40 am
White Coat Investor wrote: Sun Sep 20, 2020 11:57 pm Ahhh...the problems of being in an industry where you don't collect your payment up front or at the time of service. Now nobody is happy. Patient mad because he got a bill and lousy care. Doctor mad because he didn't get paid and forced to try to see patients in 8 minutes. And the insurance company is laughing all the way to the bank.

No wonder doctors are leaving medicine as soon as they can afford to.

To the OP, I would generously assume this doctor earns $500 an hour, so eight minutes of his time is worth $67. I would offer to pay that in full settlement of this appointment, disregarding the privacy violation and the lack of follow-up on your requested service as well as the time and expense of sorting out the billing office mistake regarding your insurance, and then find another doctor.
$500/hr? Lol...no. Even a neuro surgeon doesn't make that usually.

Most pcps make 220-240k. The average sits around 230k for a pcp. That definitely isn't 500/hr.
User avatar
8foot7
Posts: 2370
Joined: Mon Jan 05, 2015 7:29 pm

Re: Challenging a physician's bill

Post by 8foot7 »

Cyanide123 wrote: Mon Sep 21, 2020 6:35 pm
8foot7 wrote: Mon Sep 21, 2020 10:40 am
White Coat Investor wrote: Sun Sep 20, 2020 11:57 pm Ahhh...the problems of being in an industry where you don't collect your payment up front or at the time of service. Now nobody is happy. Patient mad because he got a bill and lousy care. Doctor mad because he didn't get paid and forced to try to see patients in 8 minutes. And the insurance company is laughing all the way to the bank.

No wonder doctors are leaving medicine as soon as they can afford to.

To the OP, I would generously assume this doctor earns $500 an hour, so eight minutes of his time is worth $67. I would offer to pay that in full settlement of this appointment, disregarding the privacy violation and the lack of follow-up on your requested service as well as the time and expense of sorting out the billing office mistake regarding your insurance, and then find another doctor.
$500/hr? Lol...no. Even a neuro surgeon doesn't make that usually.

Most pcps make 220-240k. The average sits around 230k for a pcp. That definitely isn't 500/hr.
That's why I said generously -- so that OP can feel good about appropriately compensating the doctor for the value he received.
toofache32
Posts: 2161
Joined: Sun Mar 04, 2012 6:30 pm

Re: Challenging a physician's bill

Post by toofache32 »

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.
Not illegal for insurance companies, they are exempt from federal anti-trust laws via the McCarran-Ferguson Act.

Doctors and hospitals bill $525 to the insurance. But the insurance companies (by contract) pay what they want to and the doctor (by contract) cannot balance bill the patient (if in-network).
toofache32
Posts: 2161
Joined: Sun Mar 04, 2012 6:30 pm

Re: Challenging a physician's bill

Post by toofache32 »

TropikThunder wrote: Mon Sep 21, 2020 5:35 pm
Jags4186 wrote: Mon Sep 21, 2020 5:05 pm I think it was a poor decision to ask the doctor’s office if they are in-network vs checking on your insurance company’s website to confirm the doctor is in-network. I know, before I show up to a doctor, what the copay will be, if they are Tier 1, Tier 2, or OON providers, etc. Needless to say, I don’t see OON doctors.
That's just silly, you need to do both. Pretty much every insurance company's website has a disclaimer saying verify coverage with the provider before receiving services. Mine says:
While effort (sic) is made to keep network affiliation information up to date, provider status within a network is subject to change at any time and the information shown may not be accurate or complete. You should confirm directly with your provider their network status before services are received.
If a provider moves to another practice group and doesn't tell the insurance company, how is the insurance company supposed to update their website?
They don't want to update their website and remove doctors. They want to stuff their list as full as possible so patients will think they have lot's of doctors. A doctor in my practice left to move across the country in 2008. He was still listed on multiple insurance websites for 7+ years. Yes, we notified these insurance companies.
toofache32
Posts: 2161
Joined: Sun Mar 04, 2012 6:30 pm

Re: Challenging a physician's bill

Post by toofache32 »

Broken Man 1999 wrote: Mon Sep 21, 2020 4:53 pm
toofache32, I totally understand why you run your practice the way you do.

Broken Man 1999
The common denominator of all these threads is insurance. They wrote the rules and remain in control by being opaque. Amazing that most people truly believe doctors have a copy of your insurance contract and know what insurance pays for each service. Insurance should be between the patient and the insurance company they are paying. With insurance, there are 3 parties involved. Only 2 care about your health. The other is looking for a way to not pay.

This is why there are no market forces with insurance. I used to be in-network with every plan under the sun. Patients don't realize how insurance removes their leverage if they are unsatisfied. If you were unhappy in my insurance practice, it didn't bother me because your insurance company has 10 new patients waiting to take your place in my practice. And insurance pays the same for those easier patients than for a PITA that takes twice as long.

I got off the hamster wheel and I am now out of network with all insurance. I was tired of getting caught between patients and their insurance. This allows me to tell you exactly what everything costs up front. And there are no surprises and I never ask for more later. No surprise bills. I do your surgery at an in-network hospital so you can use your insurance there.
stocknoob4111
Posts: 1581
Joined: Sun Jan 07, 2018 12:52 pm

Re: Challenging a physician's bill

Post by stocknoob4111 »

Not to derail this topic but just to clarify, IF a doctor is "in network" and the coverage for a procedure is indicated by the policy as 100% does this mean that you can NOT be billed in excess for that procedure?

I ask because I recently visited an in network Dentist (Delta Dental) and all my procedures are supposed to be covered 100%. However on the claim I see that the amount the the doctor billed the insurance is substantially higher than the "Plan Paid" amount. I was under the opinion that an in network coverage is at a pre-contracted rate not whatever the doctor wants to bill. I haven't heard from the Dentist yet since this was only 7 days ago but I was curious. I have never been "balance billed" for in-network coverage before.
toofache32
Posts: 2161
Joined: Sun Mar 04, 2012 6:30 pm

Re: Challenging a physician's bill

Post by toofache32 »

stocknoob4111 wrote: Tue Sep 22, 2020 5:56 pm Not to derail this topic but just to clarify, IF a doctor is "in network" and the coverage for a procedure is indicated by the policy as 100% does this mean that you can NOT be billed in excess for that procedure?

I ask because I recently visited an in network Dentist (Delta Dental) and all my procedures are supposed to be covered 100%. However on the claim I see that the amount the the doctor billed the insurance is substantially higher than the "Plan Paid" amount. I was under the opinion that an in network coverage is at a pre-contracted rate not whatever the doctor wants to bill. I haven't heard from the Dentist yet since this was only 7 days ago but I was curious. I have never been "balance billed" for in-network coverage before.
Dental insurance is a completely different animal. It's not really insurance.
With that being said, dentists and physicians should always bill their regular fees to the insurance. Within a few weeks you will get an EOB from Delta Dental showing the amount billed by the dentist, the amount allowed by the in-network contract, and the amount you owe (nothing if you are correct).
stocknoob4111
Posts: 1581
Joined: Sun Jan 07, 2018 12:52 pm

Re: Challenging a physician's bill

Post by stocknoob4111 »

toofache32 wrote: Tue Sep 22, 2020 6:03 pmthe amount allowed by the in-network contract, and the amount you owe (nothing if you are correct).
It was (and is) my understanding that by being in-network within a network the Dentist (or a doctor for that matter) has already agreed to the pre-contracted rate.

I lifted this from Blue Crosses website but the concept applies to all and is in line with my understand of how "in-network" coverage works. The "balance billing" is done with out of network providers where the doctor collects the difference from their regular charge and what insurance has paid.

When a provider joins our network, they agree to accept our approved amount for their services. For example, a doctor may charge $150 for a service. Our approved amount is $90. So as a Blue Cross member, you save $60.

Note the highlighted - they agree to accept our approved amount (which is what the plan has paid out).
toofache32
Posts: 2161
Joined: Sun Mar 04, 2012 6:30 pm

Re: Challenging a physician's bill

Post by toofache32 »

Yes that's what I just said. Sorry if I wasn't clear.
Last edited by toofache32 on Tue Sep 22, 2020 9:29 pm, edited 1 time in total.
alpha88
Posts: 56
Joined: Sun Feb 17, 2008 8:48 pm
Location: Southern California

Re: Challenging a physician's bill

Post by alpha88 »

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.
Seasonal
Posts: 2141
Joined: Sun May 21, 2017 1:49 pm

Re: Challenging a physician's bill

Post by Seasonal »

alpha88 wrote: Tue Sep 22, 2020 9:16 pmDoctors are absolutely horrible at lobbying and are completely out maneuvered by insurance, pharmaceutical and hospital systems.
US doctors are some of the highest paid in the world, often by a wide margin. For example, https://www.medscape.com/slideshow/2019 ... -6011814#2 and https://journal.practicelink.com/vital- ... worldwide/

US doctors have an effective government enforced monopoly on the practice of medicine, with control over licensing and the ability to have competitors arrested.

That does not sound like being horrible at lobbying or being completely out maneuvered.
Yukon
Posts: 312
Joined: Wed Jan 23, 2008 8:10 am

Re: Challenging a physician's bill

Post by Yukon »

Godot wrote: Sun Sep 20, 2020 3:54 pm
I'm appalled at a few things, including the fact that any PCP charges $525 for an eight-minute "physical"!

Handicap my chances of getting this bill waived, please.
Have you received an explanation of benefits from your insurance company? It shows the itemized charges and services that you received for the $525. I'd be curious how it breaks out.

Patients are ultimately responsible for knowing and understanding their own insurance benefits so chances are slim that you get the entire bill waived but if you understand the itemization you might be able to chip away some.

Sorry to hear of the incompetence!
Don't Work Forever.
student
Posts: 5210
Joined: Fri Apr 03, 2015 6:58 am

Re: Challenging a physician's bill

Post by student »

stocknoob4111 wrote: Tue Sep 22, 2020 5:56 pm Not to derail this topic but just to clarify, IF a doctor is "in network" and the coverage for a procedure is indicated by the policy as 100% does this mean that you can NOT be billed in excess for that procedure?

I ask because I recently visited an in network Dentist (Delta Dental) and all my procedures are supposed to be covered 100%. However on the claim I see that the amount the the doctor billed the insurance is substantially higher than the "Plan Paid" amount. I was under the opinion that an in network coverage is at a pre-contracted rate not whatever the doctor wants to bill. I haven't heard from the Dentist yet since this was only 7 days ago but I was curious. I have never been "balance billed" for in-network coverage before.
My experience with my dentist and Delta Dental is that the dentist will write off the difference but of course the difference was only a few dollars.
User avatar
LadyGeek
Site Admin
Posts: 67130
Joined: Sat Dec 20, 2008 5:34 pm
Location: Philadelphia
Contact:

Re: Challenging a physician's bill

Post by LadyGeek »

I removed an off-topic rant about the health care system. This thread has run its course and is locked (topic exhausted). See: Locked Topics
Moderators or site admins may lock a topic (set it so no more replies may be added) when a violation of posting policy has occurred. Occasionally, even if there are no overt violations of posting policy, a topic (or thread) will reach a point where the information content of the discussion has been essentially exhausted and further replies are much more likely to cause distress to the community than add anything of value.
Wiki To some, the glass is half full. To others, the glass is half empty. To an engineer, it's twice the size it needs to be.
Locked