Apr 23, 2016
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Let's say that I am a PCP, and one of my patients has a high deductible (say, $5,000) insurance plan (HDP). If I assess their symptoms as having a 99212 level complexity, and their insurer pays $25 for a 99212, do I have to take the $25 (which will be coming from the patient of the HDP) or can I charge an amount different than what the insurer reimburses for a 99212, since the insurance company is not paying?

Note: all numbers were totally made up, and probably are not even close to what real world numbers look like. I picked them for simplicity and sake of argument, as I am trying to understand the fundamentals of reimbursement, high-deductible insurance plans, and cash-only medicine.
 

VA Hopeful Dr

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Let's say that I am a PCP, and one of my patients has a high deductible (say, $5,000) insurance plan (HDP). If I assess their symptoms as having a 99212 level complexity, and their insurer pays $25 for a 99212, do I have to take the $25 (which will be coming from the patient of the HDP) or can I charge an amount different than what the insurer reimburses for a 99212, since the insurance company is not paying?

Note: all numbers were totally made up, and probably are not even close to what real world numbers look like. I picked them for simplicity and sake of argument, as I am trying to understand the fundamentals of reimbursement, high-deductible insurance plans, and cash-only medicine.
You can charge less if you want, but that's generally a bad idea. You can't charge more.
 
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goodoldalky

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This is part of the problem with the proliferation of Obamacare and HDHPs. No you cannot bill more than the $25 if that is your in-network rate. Patients pay the premium thinking they have coverage. They may or may not have cash to pay their plan out to meet their deductibles, copays, and coinsurance on top of the premium. However the insurance industry has conveniently placed the responsibility of collecting this money on the physician, which is difficult, expensive, time consuming, and often not possible. The end result is you spend $5 in time and fees to staff and/or collection agencies to get that $25 you are owed.

The way it should work is the health insurance company provides the coverage, they collect any deductibles and copays from the patient, and they ensure full payment to the physicians/hospitals for care provided. My .02.
 

goodoldalky

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And to answer your question this is COMPLETELY different than cash only medicine. In cash only medicine you post a fee schedule and the patient pays up front. In HDHP situations you may give $5K worth of care on a $6K deductible plan and find that out 3 months later and then have a hell of a time collecting after the fact.
 
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