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Tangled web of medical insurance


1K Member
10+ Year Member
15+ Year Member
Nov 2, 2000
I got an education on medical insurance today. Hopefully my new knowledge will benefit the prospective dental students on SDN so that they will not be snared by the same mess that has trapped the physicians and other health care providers.

My son broke both wrists in a snowboarding accident in Jaunary. His wrists were reset in emergency, followed up by surgery the next mornting. All of the service providers except for the anesthesiologists have finally been compensated. I got their bill today demanding payment. Thus began my journey into the world of medcial insurance to find out what went haywire.

Well, it seems that the anethesiologists first needed to send the bill to what is called a network provider . The network provider then reprices the bill and forwards it on the the third party adminstrator who then makes a final judgement on how much to pay the service provider. Both the network provider and the third party administrator claimed tht they never got a billing, but the service provider has the denial of claim letter from the third party administrator. The claim was denied because " Coverage was not in effect", yet all of the other service providers (hospital, emergency MD, orthopedic surgeon) were paid. Only the anethesiologists were left out to dry. The anethesiologists must now resubmit the bill.

I guess my gripe is to wonder why there are so many fingers in the pie to process a medical insurance claim. And what is with this repricing jazz? The hosptial bill was discounted by about 20% and the physicians' bills were discounted by about 40%. Now we all know that the service providers and insurance companies are likley involved in a game of three card monty regarding the billing discount issue, but what a waste of time and effort.
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