Medical charges--are these typical, or reasonable?

In My Humble Opinion
1

Recently I learned that, through just a minor oversight, my doctor’s office neglected to bill me for about nine months, and I now therefore owe nearly $700. I need to mention that I am insured, that this medical practice is in the plan, and I always pay my little $15 or $20 co-payment the day I’m there.

Medical billing bites. I believe that this office is still working with Remington Rand tabulating machines, keypunches, teletypewriters, television-like “terminals”, magnetic tape, and abacuses (abaci?). This practice does not send monthly statements, and when you do get an occasional statement, it is pages and pages of gibberish with no page footing, or monthly balance forwarding, or aging, or any other feature which you would expect in a computer-generated statement programmed any time since, oh, about 1962. I can absolutely believe that they “forgot” to bill me. Or rather, as they put it, they don’t bill for small amounts like eleven or thirteen dollars, but like to let them pile up. It must be like a Christmas present for them, I don’t know.

But to take an example, is the following reasonable and customary? In particular, the gap between what the doctor declares the expected fee to be, and what he accepts from the insurance company? All these occurred in the course of one visit. I don’t remember exactly what the “lab and X-ray” processes entailed. Is it normal for the standard fee to be so much more than what the insurance actually pays, and if it is, should I be concerned about it? If not, is the doctor inflating the price in order to get more from the insurance company? I don’t think he is, because I would imagine that the insurance company agrees to pay a certain percentage up to a certain ceiling, and the provider can’t increase revenue by simply inflating the fee. I also understand that it costs money to make X-rays. But in just these two examples, there are nearly $700 in submitted charges. Of course, they didn’t get half that, and undoubtedly didn’t expect to. There are two more itemizations for the same visit that are much the same. The total submitted charges for that day, just for my visit, were over $1100.00, but the plan paid just over $310.00, and my responsibility was just under $80.00

(Names removed from links to protect confidentiality. Also, Photobucket seems to have become increasingly larded up with animated ads, so I apologize.)

Link 1 - office visit, lab, and X-ray

Link 2 - more X-ray and lab from same visit

FTR, this is in a major metro area on the California coast.

2

I had a clinic that wasn’t billing my procedures and I asked them what was wrong after 3 months. At the time I was there 2 or more times a month. They said they weren’t doing the insurance or billing until they opened their new clinic building. One year after they stopped billing they submitted billing. I had by that time had two insurance companies. Work changed benefits with the first one during this. I lost all insurance coverage at the end. They had to deal with 4 different insurance conditions by that point and I didn’t even have an active account with the insurance companies any longer, so this was one big mess. They had to resubmit and work with my previous insurance companies for a couple years to get it straightened out as best as they could. This was exactly what I expected to happen when they told me they were going not do billing in a timely manner.:mad:

3

My medical bills look similar with the amount the insurance says is reasonable sometimes being a lot less than what the clinic charges. If you’re concerned you can call a few different clinics and ask what they would charge for similar services.

What your billing shows, while not reasonable to me, is similar to charges I’ve seen, and what your insurance will pay would be bargain prices around here.

4

This is really common. I’ve worked in hospitals for over a decade, though not directly involved in doing billing. What happens is that periodically, doctors’ groups/hospitals tell insurance companies what their charges are, insurance companies tell doctors’ groups what they’re going to pay, there’s a bunch of negotiation, and an agreement is reached. You see the results of that printed on your statements.

Or, sometimes it isn’t - I recall a couple of major medical centers around here not taking a major insurance company for a year or so because they could not come to an agreement (different medical centers, different times, different insurance companies).

5

Holy shit your doctor charges $326 for a visit? I hope it’s more than just a routine visit or a visit in which he/she does nothing but write up scripts for all those x-rays and lab work.

The x-rays and lab work seem cheap compared to what I pay, BTW. Conversely, the doctor’s visit is about 3 or 4 times what I pay.

6

Yes. This is called fee scheduling- insurers pay for medical care according to a chart that basically lists the going rate for any given procedure based on the locale and on the staff who perform it.

Usually the fee schedule rate is about 1/2 what the doctor “charges”. Medicaid/Medicare have their own fee schedules which are even lower.

7

Doctor checking in to correct a few misconceptions. First of all-the doctors do not tell the insurance companies what they want to charge. The insurance companies decide what they will pay. Doctors can take it or leave it. Most of it is tied to Medicare. The government decides what Medicare will pay. For next year, for example, the government has decided that costs are expected to increase 2.5%. They are therefore increasing pay by 1.1%, and asking doctors to increase productivity by 1.4%.

IOW, it’s not like any other business where you can charge what you are worth and patients can compare prices. If you want to participate with an insurance then you take their payments, and are prohibited from billing the patient any extra above what the insurance allows. The caveat is that if you charge less than the approved fees then you get paid the lesser amount. Unfortunately, fee schedules seem to change randomly and most doctors contract with 20 or more different plans, including HMOs, PPOs, etc. Therefore, when setting prices the only goal is to make sure that you charge more than the highest paying insurance company. Since reprinting billing forms is expensive, and it really doesn’t matter what you charge since it has no relation to what you are paid, it makes sense to charge at least 10-15% above what you think you will be paid.