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Started By
Message
Is this shady? (Medical ins billing)
Posted on 9/16/19 at 8:37 pm
Posted on 9/16/19 at 8:37 pm
I really don't know, but this one was new to me.
We have super high deductible HSA eligible plan. Deductible not met.
Went to make a yearly eye appointment at a new (in network) office for my young daughter and after they looked up our (crummy) insurance coverage, they gave me two options.
1) File with insurance, I will be required to pay $240 up front, then they will file.
2) If we don't file with the insurance I can just pay $140 cash for the appointment.
------------
I'm asking because I do not know, maybe they are doing me a solid. But if my assumptions are correct, the in network price for this appointment will be about $60 and then they will have to refund $180 if that is the case. Free market and all, if that is what they require to be seen, so be it. Just new to me.
We have super high deductible HSA eligible plan. Deductible not met.
Went to make a yearly eye appointment at a new (in network) office for my young daughter and after they looked up our (crummy) insurance coverage, they gave me two options.
1) File with insurance, I will be required to pay $240 up front, then they will file.
2) If we don't file with the insurance I can just pay $140 cash for the appointment.
------------
I'm asking because I do not know, maybe they are doing me a solid. But if my assumptions are correct, the in network price for this appointment will be about $60 and then they will have to refund $180 if that is the case. Free market and all, if that is what they require to be seen, so be it. Just new to me.
16
Posted on 9/16/19 at 8:38 pm to Kingpenm3
quote:
Is this shady?
I don't know. Maybe.
quote:
(Medical ins billing)
Oh. Yeah.
Posted on 9/16/19 at 8:39 pm to Kingpenm3
Not shady.
Posted on 9/16/19 at 8:39 pm to Kingpenm3
quote:
if my assumptions are correct,
Never assume when it comes to insurance. There are always levels of confusion.
Posted on 9/16/19 at 8:40 pm to Kingpenm3
Option 1 you’ll just get a refund check from insurance company. I’ve done this before. But call them and ask just to make sure what they’re doing.
This post was edited on 9/16/19 at 8:40 pm
Posted on 9/16/19 at 8:40 pm to OysterPoBoy
It’s like not going through your car insurance and just getting it done cheaper.
Posted on 9/16/19 at 9:11 pm to Kingpenm3
It's not shady.
Just know that you won't get credit for making payment toward your deductible if you take the cheaper route.
File insurance and you have to pay what the insurance company is contracted to pay the provider which is the $240 since you have not met your deductible.
$140 and no filing is cheaper but you won't get any closer to meeting your deductible.
If you have a 1k deductible you have a choice to make.
If your deductible is like 10k and you'll never meet it anyway, pay the $140.
Not shady. Your choice.
Just know that you won't get credit for making payment toward your deductible if you take the cheaper route.
File insurance and you have to pay what the insurance company is contracted to pay the provider which is the $240 since you have not met your deductible.
$140 and no filing is cheaper but you won't get any closer to meeting your deductible.
If you have a 1k deductible you have a choice to make.
If your deductible is like 10k and you'll never meet it anyway, pay the $140.
Not shady. Your choice.
This post was edited on 9/16/19 at 9:14 pm
Posted on 9/16/19 at 9:16 pm to Kingpenm3
Not shady, but very strange. Insurance allowables are cheaper than a cash price at a medical practice. The cash price is generally 2-2.5x the average insurance/medicare reimbursement. So I cannot understand why your up front payment would be almost twice the cash pay rate.
The only think I can think of is that they are unsure if your insurance will cover anything on the claim, so they are charging you the entire billed amount with the expectation they will be denied and have to transfer the balance to you. But that should only apply if you're out of network. The in network allowable/contracted price would be less than the cash pay.
I would suggest asking the office what CPT codes are generally billed to insurance for an annual exam, then contact your insurance to ask 1) are you in network? 2) what is the allowable/contracted amounts for these codes? The total amount for those codes should be all you have to pay. And it should be less than the cash rate.
The only think I can think of is that they are unsure if your insurance will cover anything on the claim, so they are charging you the entire billed amount with the expectation they will be denied and have to transfer the balance to you. But that should only apply if you're out of network. The in network allowable/contracted price would be less than the cash pay.
I would suggest asking the office what CPT codes are generally billed to insurance for an annual exam, then contact your insurance to ask 1) are you in network? 2) what is the allowable/contracted amounts for these codes? The total amount for those codes should be all you have to pay. And it should be less than the cash rate.
This post was edited on 9/16/19 at 9:17 pm
Posted on 9/16/19 at 9:22 pm to Kingpenm3
here is shady:
Wife gets ready to go in for an out patient surgical procedure. Gets a letter in the mail from BCBS confirming procedure is medically necessary as part of the prior authorization process.
Wife has procedure done and claims are filed with BCBS.
Claims are still pending for a long while so I call BCBS to ask WTF? The woman says it’s now under a board review to see if my plan will cover the procedure and gives me a 50/50 chance.
What the hell was the purpose of the whole exhaustive prior authorization if they weren’t going to at least check it against my insurance plan? Talk about giving a false sense of financial security. It feels like it borders on insurance fraud.
Wife gets ready to go in for an out patient surgical procedure. Gets a letter in the mail from BCBS confirming procedure is medically necessary as part of the prior authorization process.
Wife has procedure done and claims are filed with BCBS.
Claims are still pending for a long while so I call BCBS to ask WTF? The woman says it’s now under a board review to see if my plan will cover the procedure and gives me a 50/50 chance.
What the hell was the purpose of the whole exhaustive prior authorization if they weren’t going to at least check it against my insurance plan? Talk about giving a false sense of financial security. It feels like it borders on insurance fraud.
Posted on 9/16/19 at 10:26 pm to Kingpenm3
quote:
1) File with insurance, I will be required to pay $240 up front, then they will file.
quote:
the in network price for this appointment will be about $60 and then they will have to refund $180 if that is the case.
This is what is throwing me off.
If the in-network estimate is going to be $60, why aren't they just charging you the $60? If it turns out to be more, they can send you a bill.
Or, I can see them charging you a bit more up front, as a deposit of sorts. But 4x?
This is why, despite the incredible power of an HSA account (which you can only get with a HDHP), I still pay a bit more a month and have a PPO plan. The predictability of co-pays is worth it to me.
Posted on 9/16/19 at 11:28 pm to Kingpenm3
New patient code is 92004, I dunno what other tests they plan on doing, a lot of em do semi unnecessary glaucoma tests but I don't know a single Insurance that pays $240 for 92004.
Problem is the question is really hard for the person you asked to answer and as someone else said $240 is probably the about they bill your insurance.
Problem is the question is really hard for the person you asked to answer and as someone else said $240 is probably the about they bill your insurance.
Posted on 9/17/19 at 4:54 am to Kingpenm3
This doesn't sound in network
Posted on 9/17/19 at 6:29 am to LSU Wayne
quote:
Wife gets ready to go in for an out patient surgical procedure. Gets a letter in the mail from BCBS confirming procedure is medically necessary as part of the prior authorization process.
Wife has procedure done and claims are filed with BCBS.
Claims are still pending for a long while so I call BCBS to ask WTF? The woman says it’s now under a board review to see if my plan will cover the procedure and gives me a 50/50 chance.
What the hell was the purpose of the whole exhaustive prior authorization if they weren’t going to at least check it against my insurance plan? Talk about giving a false sense of financial security. It feels like it borders on insurance fraud.
I've gotten letters weeks after having a procedure done from BCBS saying that my prior auth had been approved and the procedure would be covered.
I didn't even know there was a prior auth process involved. Everything was done in-network at approved practices.
When you see that thin envelope from the insurance company in the mail, you can't help but get a little nervous.
Posted on 9/17/19 at 6:45 am to GetCocky11
In my experiences, most medical billing is shady. Went to emergency room once cause I thought I was having a heart attack. It was dehydration. Waited 4 hours was in back for 45 minutes. All they did was hook me up to ekg machine and give me IV. Saw the doctor less than 2 minutes. With insurance they tried to tell me I owed $3000. It was out of state and After multiple phone calls I was able to get the records. There was all kinds of extra charges that ran bill up. Went on for about 6 months. Finally I agreed to pay $500 just to be done with it. I guess they thought that since I worked for a for a fortune 500 company I would have a emergency room copay.
This post was edited on 9/17/19 at 6:47 am
Posted on 9/17/19 at 7:42 am to Kingpenm3
Eye doctors and dentists do that crap all of the time. Dentists are the worst.
Posted on 9/17/19 at 7:45 am to LSU Wayne
quote:
It feels like it borders on insurance fraud.
That's exactly what it looks like
Posted on 9/17/19 at 7:48 am to Kingpenm3
It's not shady, but just another indictment on our back asswards health care industry.
Posted on 9/17/19 at 7:49 am to Kingpenm3
Nah. It's cheaper for them to just get the money now instead of paying people to process the claim, fight with the insurance, get paid 70% three months ftom now, mail you a bill for the other 30%, wait for that to ckne back, etc...
They'd just as soon take less now and be done with it.
They'd just as soon take less now and be done with it.
Posted on 9/17/19 at 8:03 am to Kingpenm3
They are shady and greedy...I'll explain
The doc just showed you hes good at the cash price. But if you file w insurance, he up charges the insurance and you. You pay 75% more AND he gets insurance money.
Doctors (or most of them)are greedy and will overcharge when insurance is available. It's not there fault, they have been conditioned that way.
But yes, your situation where he asks you for MORE cash up front if you file, go to another doc.
The doc just showed you hes good at the cash price. But if you file w insurance, he up charges the insurance and you. You pay 75% more AND he gets insurance money.
Doctors (or most of them)are greedy and will overcharge when insurance is available. It's not there fault, they have been conditioned that way.
But yes, your situation where he asks you for MORE cash up front if you file, go to another doc.
Posted on 9/17/19 at 8:38 am to LSUFanHouston
Not sure about OP's policy, but our medical insurance will only pay for eye exams from an eye doctor (opthalmologist) if there is a medical problem which needs addressing. If it's just a routine exam for glasses, we have to pay for the full cost of the visit. I've been told this every time I see an actual eye doctor, and I think there's even a form they usually have me sign stating that I understand that. They tell me they can file with insurance, but it will usually not be covered since it would be coded as a regular eye exam. (Usually if I'm visiting the eye doctor, it's because of another problem anyway, so our insurance has always covered it and/or applied the cost of the visit to our deductible.)
Alternatively, we have Eye-Med vision insurance. Most of the doctors listed under this policy are optometrists (and are not the same as the medical insurance eye doctors), and for a routine exam at one of those, we pay a co-pay and it's filed with our vision insurance.
Alternatively, we have Eye-Med vision insurance. Most of the doctors listed under this policy are optometrists (and are not the same as the medical insurance eye doctors), and for a routine exam at one of those, we pay a co-pay and it's filed with our vision insurance.
This post was edited on 9/17/19 at 8:41 am
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