Medical insurance discount for procedure not covered?

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OnTrack
Posts: 776
Joined: Wed Jan 20, 2016 11:16 pm

Medical insurance discount for procedure not covered?

Post by OnTrack »

Under ACA individual (not employer) a scan is covered, but only every 2 years. The doctor wants a scan after one year. I’m fine with paying out of pocket, but I would like to know if I can still get the in-network price? How does that work? Based on the previous EOB for the scan, the discounted price for having insurance was about 25% of the price submitted to the insurance company.
kd2008
Posts: 958
Joined: Sun Feb 15, 2009 6:19 pm

Re: Medical insurance discount for procedure not covered?

Post by kd2008 »

It varies from plan to plan, and facility to facility. In our case, the plan processed the claim with the insurance discount, and then said not covered, and the remainder amount as patient responsibility. So it counted against our deductible and out of pocket max. YMMV.
InMyDreams
Posts: 1341
Joined: Tue Feb 28, 2017 11:35 am

Re: Medical insurance discount for procedure not covered?

Post by InMyDreams »

Ask the scan provider what their cash price is - might even be less than your insurer's listed price! Regardless, definitely negotiate the price in writing before the procedure.
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ResearchMed
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Joined: Fri Dec 26, 2008 11:25 pm

Re: Medical insurance discount for procedure not covered?

Post by ResearchMed »

Is there any possibility that your health care provider, the one wanted another scan sooner, could request some sort of exception (or appeal of a denial) or such to have it covered as "medically necessary"?

RM
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runninginvestor
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Joined: Tue Sep 08, 2020 8:00 pm

Re: Medical insurance discount for procedure not covered?

Post by runninginvestor »

ResearchMed wrote: Thu Sep 22, 2022 1:08 pm Is there any possibility that your health care provider, the one wanted another scan sooner, could request some sort of exception (or appeal of a denial) or such to have it covered as "medically necessary"?

RM
I would also agree to ask your provider.

OP:
If you haven't, or your provider hasn't, submitted a prior authorization for this, you should do that. If this is one of the preventive services that are supposed to be covered, it may be the case where the diagnostic is covered as a preventative service (so 100% covered) every n years, but if you need testing more frequently it may be covered under your normal diagnostic and imaging cost sharing limits.
mcamp18
Posts: 50
Joined: Mon Mar 19, 2018 8:34 pm

Re: Medical insurance discount for procedure not covered?

Post by mcamp18 »

Google MD Save to get discount prices on medical tests. Prior to Medicare I had a high deductible health insurance plan. I used MD Save for an ultrascan and paid 50% of what I would have paid at a local hospital.
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