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High Insurance deductibles and bills you get...

Discussion in 'Topics in Healthcare' started by YouDontKnowJack, Apr 24, 2007.

  1. YouDontKnowJack

    YouDontKnowJack I no something you don't

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    I'm trying to figure this out.

    Insurance companies scam doctors out of reimbursement when they have to pay for some procedure, visit, and other crap.

    I have a $5000 annual deductible which I will never reach.
    The doc checks off a bunch of codes and then bills my insurance company.

    Although my insurance company doesn't pay **** until I reach 5000, will they allow a $4000 office visit bill to go through without blinking an eye? or would that raise a red flag?

    It seems it would be easy to get away with overcharging a patient with a high deductible insurance plan, since insurance companies really have no incentive to deny claims when they're not paying for any of it.

    how does the patient deal with this?
     
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  3. Miami_med

    Miami_med Moving Far Away
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    #1: You should still pay the negotiated rate with the insurance company when the bill is below your deductable. This little pearl is probably what actually makes it worth it to buy any insurance for 95% of people carrying less than catastrophic policies.

    #2: The doctor has to have a reason for checking the box, or it's fraud. That is generally frowned upon and illegal.
     
  4. YouDontKnowJack

    YouDontKnowJack I no something you don't

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    for some office visits, I've paid cash instead of using my insurance, because the doc said they'd bill more if i went with my insurance. I supposedly saved $30 on a $200 bill.

    did I make the right choice? how do i even know if my cash payment was really lower than the insurance negotiated rate?
    Maybe the negotiated rate would've been $140, and I would've then paid $30 more by cash?
    I became suspicious when my last doctor told me to come in for a followup, only to spend 2 minutes with me and charge me another $70. Would $70 have been the negotiated rate had I used my insurance?
     
  5. Tired Pigeon

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    The insurance company is only going to apply what they deem the appropriate amount for the visit or service to your deductible. Therefore, the doc could bill $4000 for an office visit, but if the insurance company says the "usual, customary & reasonable" office visit fee is $60, that's all that's getting applied to your deductible.

    Plus, when your doc bills the insurance company and they don't pay out anything because you haven't met your deductible, guess who the bill comes to?
     
  6. Blue Dog

    Blue Dog Fides et ratio.
    Physician Gold Donor SDN Advisor Classifieds Approved

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    Your doctor has a negotiated fee schedule with your insurance carrier that you have no access to. Your doctor is prohibited by law from discussing his negotiated fees with other doctors. It's entirely possible, in a poorly-run practice, that he doesn't even know what those fees are. If he's savvy, however, he received a fee schedule from your insurance company before he agreed to participate. Lots of doctors don't do this, however. It's virtually certain that he doesn't have immediate access to that fee schedule when he sees you in the office, whatever the case.

    If a doctor offers a discount for cash, he's discounting his own fee schedule, which will be different than the fees used by your insurance company (usually higher). You have no way of knowing if the cash price is less than the amount he would receive from your insurance carrier. Your doctor probably doesn't even know. If you pay cash, they aren't going to bill your insurance carrier (that would be fraud), so the amount you paid will not be applied to your deductible.

    IMO, you're probably better off just paying to have them send the bills in to your insurance company so the charges get applied to your deductible, even if you never reach it.
     
  7. dpmd

    dpmd Relaxing
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    If they bill the insurance company for whatever amount they want, the insurance company is still going to treat it as if it was a claim they pay in terms of applying their usual and customary fee schedule. They will indicate the allowed charges, and everything else should be written off by the provider (assuming they have agreed to the fee schedule-ie they are a participating provider). They will them use a little code to indicate that the entire amount was applied to your deductible (and you never know if you will reach it, I had surgery last year and the allowed charges were definitely more than that). A few months later when all of this is processed, you get a bill from the insurance company for the allowed charges (so it wouldn't matter if they tried to bill for 40 or 4000, if the allowed charge for that visit is 40 you will pay 40). I used to do insurance billing, and 70 seems like it would be high for a followup (but it wasn't for primary care, and it was a while ago). You could probably find out from your insurance company what their usual and customary fees are for some of the typical CPT codes you might need, then you would have your answer.

    Look at this. Most insurers base their U+C fees on medicare payments (a little above or below). The CPT code for what they charged should be on your receipt.
     
  8. Blue Dog

    Blue Dog Fides et ratio.
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    A 99212 is the lowest-complexity physician visit code for an established patient, and reimburses $35 from Medicare (in Virginia). That's generally only applicable for a single, stable chronic problem (by definition, a very uncomplicated follow-up visit). Add a second problem, or if the single problem isn't stable, and the level of complexity (medical decision-making) goes up to 99213 ($57 from Medicare). A new problem, or the management of three or more chronic diseases gets you a 99214 ($87 from Medicare). The highest-complexity follow-up visit, 99215, reimburses around $118 from Medicare. All of this is contingent upon proper documentation according to E&M coding guidelines, of course. It's worth noting that the amount of time spent with the patient isn't really a factor. Any of these visits could conceivably be accomplished in the usual time allotted for an appointment in most practices.

    A $70 charge is around 120% of Medicare for a 99213, which wouldn't be unusual for commercial payer. Just a guess, though. Fees will vary from state to state.
     
  9. YouDontKnowJack

    YouDontKnowJack I no something you don't

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    is the 99212 the same for all types of specialists, or do certain docs get paid more for this code?

    $70 seemed high for a followup cash payment, where all the doc did was take a look ("went through the motions"), and nothing more. he is a dermatologist.
     
  10. dpmd

    dpmd Relaxing
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    I think it is the same regardless of specialty, but different based on where you live. For my area the 99212 gets you 40.55, 99213 = 64.97, 99214 = 98.36, and 99215 = 132.67. It isn't that hard for them to justify one of the higher codes (they get the tech to weigh you and take vitals, then they chart exams on a couple of different things-like heart, lungs, I guess skin in your case). If I were you I would go a head and go through the insurance since it probably would have been around that much anyway (although I might have skipped the follow up, depending on what it was for-making friends with attendings is good).
     

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