At work we’re signing up for which medical coverage we want. I’m considering a high-deductible plan with an HSA, but one concern I have is that the doctors will overcharge me before my deductible is met. How can I know that they are charging me the negotiated rate according to my insurance versus the list price?
Often when I get a bill from a doctor, it will show how much they billed the insurance, how much they paid, and how much I’m responsible for. For example, say there is some procedure which my insurance has negotiated a rate of $60. I will see something like this on my bill:
Random Lab Service: $500
Negotiated Rate: $60
Patient responsibility: $6
I’ve had treatments done with my regular insurance which were just part of the deductible. The doctor’s office requested payment when I went in since they knew I had not yet my deductible and they wouldn’t get anything from insurance. My concern is how do I know that the price they are asking is the negotiated price? I would prefer that all bills first go through the insurance company even if I haven’t yet met my deductible. Is that possible?
I’ve got a high-deductible plan with an HSA, but I’ve never had a provider ask me for payment upfront. I can see how collections must be a bitch for them in this situation. I’d call your insurance company and ask them what the negotiated rate is, and whether the doctor is even allowed to request advance payment under the terms of their agreement with the insurance company. And the provider should bill insurance anyway – how will the provider or your insurance company even know whether or when you meet your deductible if they don’t?
I’ve been on a HDHP for the last couple of years, and I’m in complete agreement with Eva. Our firm specifically instructed us to make sure bills were submitted through our insurance company for this very reason. If the bill comes to you from your doctor, send it to your insurance company.
I’ve had the same experience as Eva Luna - was always billed afterwards. The only entity that ever asked for payment up front was a physical therapists office, and even then they were willing to wait until the first bill went through and they found out what the negotiated rate was - then they asked for that amount at each session. When I told them several sessions in that I met my deductible and they were about to start getting reimbursed at 90%, they were fine with just billing me after the fact moving forward.
In my case it was also a PT who asked for payment at the time of service. They seemed to have the information about my deductible amount since they knew I had not yet met it. Pretty much every time I paid, they were able to check and verify that the deductible had not yet been met. Fortunately, I haven’t had to use many services which are paid out of my deductible. I was just extrapolating from that one time and thinking all doctor’s offices would operate that way. If they bill through my insurance, it should be okay.
For me the bills come in after the care, and they list the pre and post negotiated rates.
How are you getting a 90% discount? All my bills have only shown a 30-40% discount on medical care. Pre negotiated may be 160,post was 99. Pre 218 post 168.etc.
That’s very unlikely to work unless there’s already a claim on file for the same service and with the same provider. The negotiated rate depends on a number of variables; including (but not limited to) how the claim is billed, the exact procedure & diagnosis codes, the place of service, and the individual provider’s contract. The CSR you speak to is not going to have access to any of this, neither is their supervisor.
Some insurers do offer a predetermination of benefits as a courtesy, but that usually involved the healthcare provider submitting a written treatment plan with all procedure codes, diagnosis codes, place-of-service codes, NPIs, etc. They can take weeks or months to process (they’re a very low priority & take a back seat to actual claims and preauthorization requests). They also come with a disclaimer that they’re not a guarantee of payment.
What the CSR should be able to tell you is if an network provider can require payment up front (though that can also vary based on their contract). If they do overbill upfront then once the claim process they’re supposed to refund you the difference. Usually providers don’t bill upfront unless it’s a fixed co-pay (which is often listed right on the card for office or ER visits). You should never, ever, ever pay any bill you get from a healthcare provider unless they; a) filed a claim with your insurance, & b) what’s on the bill matches the explanation of benefits you get from you insurance explaining how the claim processed & what you’re responsible for.
I’m a healthcare provider. If I am in-network for you, I am only allowed to collect the negotiated rate. If I mistakenly ask for too much at the time of service, I have to refund the difference. As a provider, I can call your insurance company and because I know the procedure code I will use, I can get a good idea from the CSR what to charge. However, sometimes they are wrong, or your deductible gets met between my call and when I submit the bill, etc. My patients pretty much have to trust me until, as Alphaboi pointed out, they get their EOB and can check.
I agree with the others. I am on a high deductible health plan and it is going be be very high deductible next year to the point where I couldn’t ever hit it unless I had some serious trauma.
It sounds almost useless but it really isn’t. EVERYTHING still goes through the insurance company whether they are paying the bill or not. The doctor sends me a bill usually several months afterward telling me what I really owe. It isn’t uncommon for it to be 1/2 - 1/4 of the ‘rack rate’ or even much less. I just got a bill today that the insurance company will not be paying because I haven’t met my deductible this year. Total cost - $488. I need to pay $47.
Yes, American health insurance really is still really that illogical and confusing. Even high deductible plans will save you a tremendous amount of money even if you haven’t met the deductible and you even have the insurance company on your side even if they haven’t started paying anything yet. If you get overbilled even before you have met your deductible, you can still turn the complaint over to your insurance company and let them deal with it.