Covid Relief: End to surprise medical billing?

[LivingAlmostLarge]

While it is a free economy and folks should be able to "get what they can get", it's a special sort of crook-ed with non-network physicians are benefitting from the hospital being in-network and all of the patient volume that follows, only to bilk the patients for 12X Medicare. Unethical, immoral, and fraudulent are the words that come to my mind.

But it's free market to allow drs right the decision to participate? And who would work in hospitals if they didn't choose? I also thought most dr worked for hospitals not private practice anymore.

[ua_guy]

Living this currently. My daughter had to be taken by ambulance to the hospital at thanksgiving. The Medic said "Which hospital?" I said "ABC...they are in-network with our plan." Of course, we hadn't met our yearly deductible so I'm 100% copay. Got the hospital bill, $4200, reduced to $2400 through my insurance contract. Paid it. Doctor bill? $1400. for CPT code 99205. 1200% of Medicare, no discount. They aren't in the network. I'm fighting it out with them now. I have offered 200% of Medicare, which I believe to be very generous, and they have refused.

Why are you fighting the hospital? Wouldn't it be more fruitful to fight your insurer and have them cover the professional fees as if the provider was "in-network"? You tried to do right and go to an in-network hospital but didn't have a choice in who cared for your daughter.

I just don't see where the hospital should eat the cost or give you a discount. I'm guessing your daughter isn't a Medicare patient, so, why should they apply Medicare rates when that's not the coverage she has?

I don't disagree that the system is broken and the cost of healthcare is astronomically high. But this is what we all deserve allowing a very free market to dictate the terms of healthcare to us.

[Snicks]

It's not up to the PROVIDER to know what your insurance will or will not pay for. That is on YOU

[disneysteve]

Why are you fighting the hospital? Wouldn't it be more fruitful to fight your insurer

He’s not fighting the hospital. He’s negotiating with the doctor who is out of network. The insurer has nothing to do with that.

[ua_guy]

He’s not fighting the hospital. He’s negotiating with the doctor who is out of network. The insurer has nothing to do with that.

The "network" is a construct of the insurance company, so it would seem that the insurance company could agree to pay the doctor as if in-network since the patient didn't have any choice in the matter. They did choose a hospital that was supposedly covered by the insurance plan.

I'm confused...this literally has everything to do with the insurer and their coverage agreement with the patient/insured.

[disneysteve]

It's not up to the PROVIDER to know what your insurance will or will not pay for. That is on YOU

In most cases, it's impossible for you to find out what something will cost. Only the provider has that information. Only they know how much they will bill for a procedure or service. They know what is in the contract they have with your insurance company. You don't have direct access to that information. You need to ask your provider.

It's difficult under the best of circumstances. It's virtually impossible in any sort of emergency situation because you don't have the time to research every piece of the care process. You don't get to pick your ER provider or your anesthesiologist or which medications are given to you in the hospital or which medical device gets implanted in the OR.

Where I work, the fee used to not cover testing like x-rays or labs. Those were billed separately in addition to the visit itself. Insured patients didn't care but cash patients wanted to know how much the chest x-ray would be or what the charge was for a throat culture. We couldn't tell them. We didn't have that information. I asked for it numerous times and was never able to find anyone who could give me a list of charges that I could share with patients. Thankfully, they finally switched to a global fee so now one flat price covers everything. That's far simpler but it still really bothers me that I couldn't get a straight answer to a simple question.

[disneysteve]

The "network" is a construct of the insurance company, so it would seem that the insurance company could agree to pay the doctor as if in-network since the patient didn't have any choice in the matter.

The out-of-network provider chose not to be a part of the network for a reason. They weren't willing to accept what the company was paying in-network providers. The problem is the whole in-network/out-of-network system. What good is ABC Hospital being "in-network" if the providers who work there aren't all in-network? I've even encountered cases where some doctors in one individual practice were in-network but others in the very same practice were not. It's insanely complicated.

ETA: Sometimes a provider is out of network because the insurance company wouldn't admit them for some reason, like maybe they decided they already had enough surgeons on board. So there might be a surgical group that tried to join the network but couldn't.

[ua_guy]

The out-of-network provider chose not to be a part of the network for a reason. They weren't willing to accept what the company was paying in-network providers. The problem is the whole in-network/out-of-network system. What good is ABC Hospital being "in-network" if the providers who work there aren't all in-network? I've even encountered cases where some doctors in one individual practice were in-network but others in the very same practice were not. It's insanely complicated.

I'm talking about it from an appeals standpoint with the insurance company. If the doctor is charging $1000 and insurer only pays $600 since he's out of network, but would have paid $800 if he was in network, the insurance company could decide to pay him $800 instead of $600 since the patient had no say in the matter and tried to do the right thing to get the best coverage by going to that hospital facility. End result is the patient would owe $200 instead of $400. Or if they weren't going to cover anything out-of-network, they could elect to provide some sort of coverage because of the situation.

I just don't see where it's the hospital or provider's responsibility to eat this.

[disneysteve]

I'm talking about it from an appeals standpoint with the insurance company. If the doctor is charging $1000 and insurer only pays $600 since he's out of network, but would have paid $800 if he was in network, the insurance company could decide to pay him $800 instead of $600 since the patient had no say in the matter and tried to do the right thing to get the best coverage by going to that hospital facility. End result is the patient would owe $200 instead of $400. Or if they weren't going to cover anything out-of-network, they could elect to provide some sort of coverage because of the situation.

I just don't see where it's the hospital or provider's responsibility to eat this.

I see where you're going with this. Sure, the insurance company could decide to suspend their policy so it can't hurt to ask. The provider in question could also agree to accept a smaller fee. It can't hurt to ask about that either. It is nobody's responsibility to eat this charge because all parties are abiding by their contracts, but they still might make a one-off exception if you reach the right person who actually has the authority to do so.

Bottom line is to always make the effort to negotiate. Sometimes it will work. Sometimes it won't. It works surprisingly often.

[TexasHusker]

The "network" is a construct of the insurance company, so it would seem that the insurance company could agree to pay the doctor as if in-network since the patient didn't have any choice in the matter. They did choose a hospital that was supposedly covered by the insurance plan.

I'm confused...this literally has everything to do with the insurer and their coverage agreement with the patient/insured.

Our deductible is $7000. So the insurance company isn’t paying anything. But I do get the benefit of their contractual discounts, provided that I pay promptly. The issue is, this is a group of physicians (ER) that are directly benefitting from the hospital’s status as the in-network hospital through patient volumes, and then, in my case, they bill me for 1,235% of what Medicare would allow. Yet we made a decision in good faith in selecting this hospital because it's where our insurance has a contract.

At best, that’s unethical.

[LivingAlmostLarge]

Our deductible is $7000. So the insurance company isn’t paying anything. But I do get the benefit of their contractual discounts, provided that I pay promptly. The issue is, this is a group of physicians (ER) that are directly benefitting from the hospital’s status as the in-network hospital through patient volumes, and then, in my case, they bill me for 1,235% of what Medicare would allow. Yet we made a decision in good faith in selecting this hospital because it's where our insurance has a contract.

At best, that’s unethical.

But are most dr at a hospital in network or is it common to be out of network?

[TexasHusker]

But are most dr at a hospital in network or is it common to be out of network?

It is uncommon. Generally, a hospital requires all of its hospital-based physicians to participate in the hospital's contracted health plans, in order to avoid these very scenarios. It is a really bad look for the hospital.