OT: Doctor Billing.

[TNT.sixpack]

Two issues - first, it sounds like your provider billed you in advance. Merit Health and others do this. I had a visit there and they DEMANDED i pay my $1000 deductible and estimated 20% copay before they'd admit me. Even though they could clearly see on their system that my deductible had been met. Bottom line, they want to keep what they can and apply that to my coinsurance payment after discharge and then simply send me the difference as a credit because they know they're getting paid up front and won't have to worry about billing me after the procedure and then waiting for their money. It sucks, but they can do it. SECONDLY and more importantly, it sounds like you were balanced billed - in fact, i'm willing to bet money. It's illegal and most medical providers aren't even aware of it. Bottom line, if your doctor accepts an assignment of benefits, directing your insurer to pay them directly (which they all do), then they CANNOT bill you for more than your deductible and coinsurance. What happens is many ancillary services (xray, lab, and sometimes the doctor's fee) are contracted to others who are not in-net work with your insurer (the hospital may be in net work, but a lot of people working inside that hospital are not hospital employees and they bill separately for their services). THEY ALL DO THIS. It's part of the new healthcare model at most hospitals. Well in that case, the radiologist or lab may be out of network and they're trying to bill you for what your insurance didn't pay. That's illegal - see Ms. HB95 from the 2020 legislative session which gives the Dept of Insurance authority to step in when that happens. The Commissioner has been all over talk radio for the past 2 years talking about how prevalent it is. To see if it happened, look at your EOB. If it was denied as "out of network" yet your doctor or hospital were in net-work, then there's your answer. Call them up and tell them to see HB95 and zero balance you.

 

[johnson86-1]

Two issues - first, it sounds like your provider billed you in advance. Merit Health and others do this. I had a visit there and they DEMANDED i pay my $1000 deductible and estimated 20% copay before they'd admit me. Even though they could clearly see on their system that my deductible had been met. Bottom line, they want to keep what they can and apply that to my coinsurance payment after discharge and then simply send me the difference as a credit because they know they're getting paid up front and won't have to worry about billing me after the procedure and then waiting for their money. It sucks, but they can do it. SECONDLY and more importantly, it sounds like you were balanced billed - in fact, i'm willing to bet money. It's illegal and most medical providers aren't even aware of it. Bottom line, if your doctor accepts an assignment of benefits, directing your insurer to pay them directly (which they all do), then they CANNOT bill you for more than your deductible and coinsurance. What happens is many ancillary services (xray, lab, and sometimes the doctor's fee) are contracted to others who are not in-net work with your insurer (the hospital may be in net work, but a lot of people working inside that hospital are not hospital employees and they bill separately for their services). THEY ALL DO THIS. It's part of the new healthcare model at most hospitals. Well in that case, the radiologist or lab may be out of network and they're trying to bill you for what your insurance didn't pay. That's illegal - see Ms. HB95 from the 2020 legislative session which gives the Dept of Insurance authority to step in when that happens. The Commissioner has been all over talk radio for the past 2 years talking about how prevalent it is. To see if it happened, look at your EOB. If it was denied as "out of network" yet your doctor or hospital were in net-work, then there's your answer. Call them up and tell them to see HB95 and zero balance you.

Does it make it illegal? I know that's the stance Chaney takes, but it looks like those are provisions that must be included in health insurance policies, which they can make in network doctors agree to, but it's unclear to me how that is binding on out of network medical providers.

I mean, don't get me wrong. It's dirty as **** what providers do as far as basically working to confuse patients into taking services from out of network providers, but I don't see how the change in 2020 fixes it. It seems to have the same fatal flaw as the law did before HB95.

 

[TNT.sixpack]

Does it make it illegal? I know that's the stance Chaney takes, but it looks like those are provisions that must be included in health insurance policies, which they can make in network doctors agree to, but it's unclear to me how that is binding on out of network medical providers.

I mean, don't get me wrong. It's dirty as **** what providers do as far as basically working to confuse patients into taking services from out of network providers, but I don't see how the change in 2020 fixes it. It seems to have the same fatal flaw as the law did before HB95.

It was prohibited before HB95 but the law didn't give any specific state agency purview over it. HB95 simply placed it under the Dept of Insurance to allow that office authority to act on it.

 

[johnson86-1]

It was prohibited before HB95 but the law didn't give any specific state agency purview over it. HB95 simply placed it under the Dept of Insurance to allow that office authority to act on it.

I don't think that's quite right. The Department of Insurance always had the ability to enforce the requirement that insurance companies put that provision in their policy and therefore essentially require that they put an equivalent in their contract with providers. But for out of network providers, there is no contract for the insurance company to put that provision in. And HB95 doesn't appear to have fixed that problem. That's just reading the face of the statute. I may be missing how it works, but it certainly looks like that section deals with mandatory clauses to include in insurance contracts and doesn't give any clear authority for the department of insurance to regulate the costs charged by providers generally.

 

[idog]

you're confusing usual and customary fees with allowable amounts

This is possibly the dumbest thing ever posted on this board, and that's saying something. Is there any other provider of goods or services you can think of that doesn't know their prices and can't quickly provide them if asked?

...and you think you're comment and question are cute bc you are ignorant to how medical billing works.

it's a common mistake. i'll dumb it down for you. your doctor does not determine your coverage, your insurer does. the doctor/facility's usual and customary fees (dollar figure set for each service and procedure) do not affect how much you are liable for unless it is a noncovered service. your insurer determines allowable amounts (dollar figure for set for each service and procedure) and most change annually. i.e. i may charge $165 for a visit but your BCBS may only allow $134. your liability is determined when the claim is submitted based on your policy and the allowable amount(s), not the usual and customary fee(s). so, when you ask how much something is going to cost there is no straightforward answer unless you are not using insurance to cover the service/procedure. the same service/procedure may cost ten different patients ten different amounts, and it is not dependent on the usual and customary fee. so, you need to know what your copays, coinsurance and deductible are and how they are applied for any service/procedure. if you do not then you won't know if you're coverage is being applied correctly by your insurer and collected properly by your provider.

 

[johnson86-1]

...and you think you're comment and question are cute bc you are ignorant to how medical billing works.

it's a common mistake. i'll dumb it down for you.

You don't need to dumb anything down. You need to think about it in the context of the real world and what agreements the provider makes, and not just what providers have internalized as "normal".

your doctor does not determine your coverage, your insurer does.

The doctor determines what they agree to charge. If the provider doesn't know what they've agreed to by contract, how do you expect the insured to? The insured doesn't know how the doctor is going to code things. If a doctor can't tell them what they are going to charge, there is no way for the insured to know.

the doctor/facility's usual and customary fees (dollar figure set for each service and procedure) do not affect how much you are liable for unless it is a noncovered service. your insurer determines allowable amounts (dollar figure for set for each service and procedure) and most change annually. i.e. i may charge $165 for a visit but your BCBS may only allow $134.

AGain, it's the lack of experience outside the medical field showing here. If you have agreed to a contract with an insurer, in the normal usage of the world, you are only charging the insured the amount you agreed to charge with the insurance company. You are using "charge" as essentially a term of art here. That's fine but it causes confusion when you use it out of that context, and is really confusing if you forget that you are not using it in the normal sense of the word. When most providers of service or goods say they are charging somebody, they mean they are either billing or including something on a bill that they intend to get paid. Certainly some companies like to put a charge on a bill and then show a discount, but it's more of the exception.

your liability is determined when the claim is submitted based on your policy and the allowable amount(s), not the usual and customary fee(s).

Depends on the sense that you are using "determined" here. In the sense of "figured out", yes, it is determined after the service. This is what people ***** about. In the sense of "set", assuming there is a contract with the insurance company, the liability is accrued or set at the time service is provided. To the extent there is a disagreement over liability, it may not be settled, but in theory there is a correct answer and the liability still accrues at the time of service.

so, when you ask how much something is going to cost there is no straightforward answer unless you are not using insurance to cover the service/procedure. the same service/procedure may cost ten different patients ten different amounts, and it is not dependent on the usual and customary fee. so, you need to know what your copays, coinsurance and deductible are and how they are applied for any service/procedure. if you do not then you won't know if you're coverage is being applied correctly by your insurer and collected properly by your provider.

And again, it's easy enough to know what the copays and deductible are. But if the provider doesn't know the agreements they are part of with the insurance company, it's really unreasonable to expect the insured to know them. Pretty much all the insured can do is make sure the provider has actually agreed to the contract and is in network. I get providers feel like they don't have a choice on a lot of this stuff; but they shouldn't fool themselves into thinking it's reasonable to expect patients to know what the doctors have agreed to, how they plan to code things, and whether the insurance will pay them. If they can't tell the patient ahead of time what's going to be uncovered, then they should not be surprised when the patient adopts the insurance companies position as far as something being unreasonable or unnecessary.

 

[The Peeper]

Yeah, because the government is so good at running itself, lets get them further involved in the fvcked up health care system. I'm feeling better about the whole situation already**

 

[SaintsDoc]

...and you think you're comment and question are cute bc you are ignorant to how medical billing works.

it's a common mistake. i'll dumb it down for you. your doctor does not determine your coverage, your insurer does. the doctor/facility's usual and customary fees (dollar figure set for each service and procedure) do not affect how much you are liable for unless it is a noncovered service. your insurer determines allowable amounts (dollar figure for set for each service and procedure) and most change annually. i.e. i may charge $165 for a visit but your BCBS may only allow $134. your liability is determined when the claim is submitted based on your policy and the allowable amount(s), not the usual and customary fee(s). so, when you ask how much something is going to cost there is no straightforward answer unless you are not using insurance to cover the service/procedure. the same service/procedure may cost ten different patients ten different amounts, and it is not dependent on the usual and customary fee. so, you need to know what your copays, coinsurance and deductible are and how they are applied for any service/procedure. if you do not then you won't know if you're coverage is being applied correctly by your insurer and collected properly by your provider.

Great answer

 

[idog]

You don't need to dumb anything down. You need to think about it in the context of the real world and what agreements the provider makes, and not just what providers have internalized as "normal".

The doctor determines what they agree to charge. If the provider doesn't know what they've agreed to by contract, how do you expect the insured to? The insured doesn't know how the doctor is going to code things. If a doctor can't tell them what they are going to charge, there is no way for the insured to know.


AGain, it's the lack of experience outside the medical field showing here. If you have agreed to a contract with an insurer, in the normal usage of the world, you are only charging the insured the amount you agreed to charge with the insurance company. You are using "charge" as essentially a term of art here. That's fine but it causes confusion when you use it out of that context, and is really confusing if you forget that you are not using it in the normal sense of the word. When most providers of service or goods say they are charging somebody, they mean they are either billing or including something on a bill that they intend to get paid. Certainly some companies like to put a charge on a bill and then show a discount, but it's more of the exception.

Depends on the sense that you are using "determined" here. In the sense of "figured out", yes, it is determined after the service. This is what people ***** about. In the sense of "set", assuming there is a contract with the insurance company, the liability is accrued or set at the time service is provided. To the extent there is a disagreement over liability, it may not be settled, but in theory there is a correct answer and the liability still accrues at the time of service.

And again, it's easy enough to know what the copays and deductible are. But if the provider doesn't know the agreements they are part of with the insurance company, it's really unreasonable to expect the insured to know them. Pretty much all the insured can do is make sure the provider has actually agreed to the contract and is in network. I get providers feel like they don't have a choice on a lot of this stuff; but they shouldn't fool themselves into thinking it's reasonable to expect patients to know what the doctors have agreed to, how they plan to code things, and whether the insurance will pay them. If they can't tell the patient ahead of time what's going to be uncovered, then they should not be surprised when the patient adopts the insurance companies position as far as something being unreasonable or unnecessary.

there are no hidden or alternate meanings in what i wrote. those are real world terms used in clinics (like mine) on a daily basis. everything i wrote is correct. everything you've written above is incorrect and/or just backpeddling. you don't get it, and that's okay! because you're not the dumbest poster on this board, and that's saying something.

[dictated from my criminal doctor haven separated from the real world and all its applicable knowledge]

 

[tatedog]

Take my word for this:

God help you if someone at a major hospital ever transposes a number entering your insurance information.

My saga is at 9 months and counting.

 

[Trojanbulldog19]

It's all a racket. I had a procedure a few years ago paid the bills thrn got another paid it. Called office to ask if that was it they said yes. Then started getting these text about paying some bill. I didn't pay I thought it was a scam. As all the bills were paid I thought. A month or two later I get a collections lawyer letter for that procedure. Called the place I had it had. Said I was paid up. Come to find out it was for the damn anesthesiologist who bills out s completely different system that we had paid but never contacted me except one bill and then those dumb texts. Chewed out the office where I had procedure done and told them they need to to track outside bills.

From then on I never went there again and only use places that consolidate their bills and don't allow everyone to bill from different places.

 

[Trojanbulldog19]

Merit health is one of the worst. Glad we do don't live around them any more.

 

[johnson86-1]

there are no hidden or alternate meanings in what i wrote. those are real world terms used in clinics (like mine) on a daily basis. everything i wrote is correct. everything you've written above is incorrect and/or just backpeddling. you don't get it, and that's okay! because you're not the dumbest poster on this board, and that's saying something.

[dictated from my criminal doctor haven separated from the real world and all its applicable knowledge]

They are real world terms, but they from the clinic. My point is that while it's fine for you to use terms of art in the clinic and dealing with insurers, those words have meanings outside of the clinic and you don't get to create your own legal regime or vocabulary that binds other people. Since our system is so screwed up by the prevalence of third party payers, it might make sense for the providers to just say "to hell with reasonableness; it's better for me to just treat patients and figure out the costs after the fact", but it is idiotic to blame patients for not knowing the information that you won't provide them (and that only you have).

And you are simply incorrect when you say the provider can't know what a patient owes until after the fact. When you have a patient's insurance, and it is an insurer that the provider has entered into a contract with, the provider could tell what they will charge (in the real world sense, as in what they expect the patient to be liable for) for each procedure. The information is there, and it's only available to the provider. The insured could then know what the insurer should pay of that liability and what they will be responsible for out of pocket. There will be the occasional disagreements over how things should be coded and whether things are necessary or covered, but ultimately it will turn out that somebody was correct and somebody was incorrect on their interpretations.