Doctors, Dentists and insurance - A RANT

[iNTeNSeBLue98]

Why do I fork out money for health insurance and dental insurance?

Exhibit A : I had an dental exam, full mouth x-rays, 7 restorations and one cleaning (not all at once. ) billed at the total amount of $1095 Mind you, not all services are fully covered. The restorations for example are covered 80%, a cleaning is supposed to be 100% coverage. I also had a deductible of $150. To date I have paid $315 and yet I carry a balance of $235. The restorations and the cleaning were billed at rates considered by my insurance to exceed the "usual and customary" amounts for the procedures. I called both the insurance company and the dentist for explanations - the insurance company averages the billing for the area in which we live, the dentist claims some other insuance companies pay their rates as billed. The restorations were billed from $115 to $149 per tooth!

Exhibit B : I switched pediatricians for my now 12 year old DD. I knew she was due for a checkup and scheduled an appointment, knowing she would need a current physical on record if she planned to join sports next school year. I paid a $20 copay (whatever happened to the $10 copays?) I received the insurance statement showing me what the doctor charged. $130 for an exam? She had her weight, height and blood pressure measured, then the doctor examined her ears, nose and throat and looked at a rash on her arm. She also got a tetanus booster, billed at $26 and there was an administrative fee for $8! Again the charges were above the "norm" and I'm left with a balance of $20. The $8 fee was either for a copy of the immunization record I requested so I would have an updated copy at home, (I can't remember 12 years of immunizations every fall when I fill out the forms for school and Girl Scouts); or, it was for, as it states on the bill, "immunization administration", yet I can't imagine a separate billing for the nurse to inject a needle in less than a minute.

I feel like I'm being overcharged for these services because the doctors aren't willing to accept the amounts that these insurance carriers have agreed to pay. Are they trying to collect more money for their services by doing this and leaving an amount due, payable by the patients? We are not ill people who need to see a physician routinely. It almost wouldn't benefit me to have insurance, but for "what if..."

My company pays about have our benefits, leaving me (and one child) a biweekly payment of $80 for health and dental insurance. I just don't get it. when will (or should) the government step in and fix this? I know- that is a topic suitable for the debate board.

I'm through ranting, resumie posting.

 

[CJMickeyMouse]

I feel your pain... and I am on the other side of the counter! LOL!

I can't speak for Doctors and Dentists specifically, but I can say that we do not accept many insurance cards because they pay less than our ingredient cost for a prescription!!!

Those that accept ALL insurance are more than likely gouging their cash paying customers to make up the difference!

I don't know what the answer is..... but insurance companies are becoming more and more of a nuisance!!!

 

[HoneyPooh]

If the doctor is "participating" with the insurance carrier they are bound by that contract to charge you only the contracted "allowed" amount the insurance carrier specifies and they have to write-off the difference between the billable amount and the allowed amount. If the doctor is not participating they can accept the insurance payment and bill you for the remaining balance. They will still charge the co-pay at the visit and then bill you for the balance after they receive the EOB (Explanation of Benefits) from the insurance carrier with their payment although some are now collecting full payment from the patient because insurance carriers sometimes pay the patient when the doctor isn't participating and an awful lot of people never pass the money along to the doctor). Are the doctors you are seeing participating doctors in your coverage? If they are they are LEGALLY bound to charge you only the contracted amount, if they are not participating they are not legally bound. You should ALWAYS see participating doctors. The $8 administration is most probably the administration of the injection. They do need to pay the cost of a nurse ($$$) for the time they have her scheduled in the office to do injections etc. You got off cheap with that one, when I did medical billing the practices I billed for charged anywhere from $10 - $20 for each shot Once again, if your doctors are participating and your coverage says that the fee for the administration of the injection is not billable, they can't charge you, but if they are not participating they can charge you for it. If your doctors are participating I would send a written letter to your carriers explaining that your doctors are charging you the non-allowed amount. If they are not participating you are stuck with the bills The doctors should have given you a complete run-down of what your charges would be before the work was done. I work in an oral surgeons office and we write up a contract showing exact prices for each procedure and what the patients liability will be if they have coverage we do not participate with.

 

[Jenn Lynn]

My DH is a Doctor and obviously the majority of his salary comes from insurance.

He has told me before how much they (Doctor) charge and how much they have to write-off. It really is amazing to me how much it really is (the write-off.)

I really don't know a whole lot about insurance (that is DH's area ). It really confuses me!

 

[mtemm]

we had the worst time with insurance when I was pregnant with Daniel. Found out I was pregnant in june 2001. knew the dr. I wanted, and holy cow she was in our health book! woo-hoooo! called our insurance co. just to make sure, they said no problem. made the first appointment for july, double checking with dr.s office. Yep, no problems. My insurance co and told me to call them after my first appointment. I did. All is great, right?

Fast forward to October, after many appointments, U/S, unexpected amnio, and I get a letter from the insurance company stating that the dr. and hospital are no longer part of the plan, dating back to june. HELLOOOOOOO!!!!!!!!!!

I was hysterical thinking of the bills, the fact that I worked so hard to make sure everything was fine. My husband finally took over and we were able to get the insurance company to pay as if everything was in network. I think because we weren't notified of the change and I was in my 2nd trimester. And the fact that my dr. was still in the new book, still on their website. In fact, I think she still is. Every month we got a statement saying they were only covering 60%. Every month my dh had to call and get it adjusted, not easy until he got one supervisor's name and actual extension.

It got worse. I was put on bedrest for PIH in late December. They hospitalized me 2x, and released me only if I could have a visiting nurse come 2-3x a week to check on my pressure. Well, get this, our insurance company wasn't big in our area (dh worked for a national company) and they didn't have any visiting nurses on their books to do this, not for over 50 miles. The nurse we were put in touch with from the hospital worked her butt off, as did everyone we came in contact with. Our insurance orginally told someone that I'd just have to stay in the hospital. Um, gee, wouldn't that be more money out of their pocket?

Finally in the end it worked out. Basically our nurse told us she wouldn't charge us the remaining 40% (they would only cover 60% because no network nurses). Thankfully there were so many problems in the end that the insurance co. supervisor just approved everything, and the nurse got all of the money.

so yes, I know your pain when it comes to dealing with insurance!

(gee, this got long, didn't it?)

 

[Mskanga]

You people are talking about my insurance?
I have a dental insurance that everytime I use it , I have a hell of a problem trying to get them to pay.
I know very well what my benefits are, and I get sick and tired of having to explain to the insurance company reps how it's supposed to be, the last time I went as far as getting the person who sold the policy to us ( working for them ) and THAT person had to tell them what the real benefits were ( the ones I know ) only then they accepted that they have a mistake on the way they input my insurance info in their system!
I have so much fun doing someone else's job and not getting paid for it.
I'm thankful that we have insurance , but the government should really step in and do something about the health system.

 

[4greatboys]

If you have a PPO, HMO or POS you dr has a contract with the insurance company for a specified contracted rate. On these types of planes the dr or dentist cannot bill you for the extra amount over the contracted rate.
If you have a plan that pays a percentage--line 80% reasonbable and customary then the dr may bill you for whatever your insurance company does not pay.

 

[AirForceRocks]

If you have a plan that pays a percentage--line 80% reasonbable and customary then the dr may bill you for whatever your insurance company does not pay.

Even that depends on the insurance carrier. For example, with TriCare Standard (military plan), doctors that "accept" it cannot charge you more than reasonable and customary, and the insurance picks up the 80%. They can't bill the patients for anything more than the 20%, plus the full amount for any procedures not covered by TriCare.

 

[Mskanga]

Originally posted by 4greatboys
If you have a PPO, HMO or POS you dr has a contract with the insurance company for a specified contracted rate.

That is exactly what I have and I know the dentist ( who is a participating dentist ) is supposed to accept the agreed amount on his contract. I can NEVER get someone from the insurance company give out the right information, of course when DD went for 2 fillings a month ago, I was slapped with the $80 per each tooth, I told them it was wrong and they insisted on me paying that. First of all they are supposed to submit the claim first and then the insurance company will tell them how much I'm supposed to pay and how much they will pay. Of course the dentist office don't want to do that , but they had to because it was part of his contract with the insurance company. It turned out I only had to pay $47 per tooth, not $80 like they wanted me to.
The funny thing is that the dentist office looked at me like I was an idiot , because THEY had called and verified my benefits, as you can imagine after I paid them what I owed them, I will never go back there again, my old dentist in NJ has signed up with this insurance now and I'm going to him.

 

[4greatboys]

Olga many drs and dentists do things like that. One problems is on insurance verification--many CS reps give out incorrect info. I was a supervisor in an Imaging Facility for several years before I became a sahm and we new the benefits of certain plans better than the reps-that worked for ins company--ever did.
Claims is a good place to start since they pay the claims. Try to get hold of someone who can give you contracted rates so you have some idea of what your looking at.
I recently got a demand letter from my Ob/Gyn's office that I had a $100 balance I better pay within 10 days. Boy talk about steaming mad.
First of all I never rec'd any bills. The balance was from 1999 when I had a mc, the insurance company--a HMO stated my office visit was not an allowable charge. In this case my HMO said no then the drs office should not have billed me. Actually they didnt since that time I had Evan in 2000 and Connor 2002 ad never heard another word about that balance,
I called the girl in the office (I know her, she is a doofus) and voice my displeasure. She tried to blame it on my dr but he hired HER to the the billing, billing she had not done for me in years.
I told her she needed to show me the EOB (explanation of benefits) from the insurance company and if it said member responsible (and it wont) I would pay. That has been weeks and she has not called me back about it.

 

[PamOKW]

On the flip side, you can see why the doctors and dentists are going nuts. Can you imagine the time and costs they face to follow this insurance maze....for a variety of different companies?! It's a wonder they have time to practice medicine. In reality, they can't do it. They have to hire people just to handle the insurance claims.

Some doctors in our area have just "said no". They don't take insurance at all. We live in a wealthy area and some of them now have practices where people pay a very high fee to "belong" to the practice and receive certain benefits like appointments on demand. They then pay for their care without insurance.

I don't think a government health program is the answer but there needs to be some type of greater control over insurance company profits.

 

[Pin Wizard]

These insurance companies stink! Mine dropped ALL OB/GYN's in our county! Either you pay out of pocket, or you go to the next county. And none of the all of about 3 endocrinologists in town are on the plan. I had an appointment with one about 30 minutes away. Before I could get in for an appointment they called and said they no longer participate with my plan and cancelled my appointment. I haven't been to an endocrinologist since! My son goes to a pediatric endo 45 miles away because they're fantastic. For a peds endo, I asked his pediatrician if there's anyone closer. He said he wouldn't go to any of them! (Having worked in the local hospital 8 years, I tend to agree with him!) I'm thrilled with DS's doc but hate the travel. I may end up with an endo in his doctor's office building. Health care STINKS!

 

[CJMickeyMouse]

Originally posted by PamOKW
On the flip side, you can see why the doctors and dentists are going nuts. Can you imagine the time and costs they face to follow this insurance maze....for a variety of different companies?! It's a wonder they have time to practice medicine. In reality, they can't do it. They have to hire people just to handle the insurance claims.

Exactly!! The claim is submitted 3-4-5 times.... for one 'error' or another.... and then they tell you that the check has already been sent weeks ago...... to the patient!!!! It gets really, really old!

 

[Mskanga]

In my case no checks are ever sent to me, unless I submit a copy of my cancelled check or a receipt. But the truth is even when I call, I'm given the wrong information, and everytime I have to correct the representative. The always tell me, you are using PA doctors....so what? I'm allowed to use anyone I want nationwide as long as they are participating dentists! I actually demanded for them to fax me a copy of the fee schedule for the procedures, so now when I go in, I know exactly what I have to pay.
Hopefully after this last time it won't happen again.
It all boils down to insurance companies not training reps properly. The first time they gave me a doctor who was a participating dentist and I found out a month after the services were done, that the doctor that saw my children was not a participating dentist, the participating dentist had not been working in that office for over a year but they were still giving out the information, so who paid for that? they tried to make me pay, but because the dentist also failed inform me of that, he had to agree to take what the insurance paid, eventhough they paid more because they also made a mistake.

 

[iNTeNSeBLue98]

Well now. I knew I'd get some folks fired up. Thanks for the responses.

We have Blue Cross Custom Blue PPO for our health insurance. I checked with the doctor to make sure they accepted the plan before making an appointment for DD. I was burned by them (BC-CBPPO) three years ago when they didn't cover DD's 9 year well-visit. I unexpectedly was billed $50 inaddition to the co-pay for an annual visit. This was a surprise after 3 years with Aetna/US Healthcare, with which I was fortunate not to have had any problems. Why in the world would you not cover a well-visit for a nine-year-old child? Since I left the bill go to collection that pediatric office won't see her again- that's why I had to take her somewhere new. It really ticks me off the way doctors aand hospitals charge for the little things. Isn't the nurse paid to be in the office? Why does she need to be paid to administer an innoculation? Maybe they should be on commission or get incentives based on the nu,ber of immunizations the give to patients.


For dental insurance, we have Reliance Standard. I don't know much about them, and others in my office have not had any problems with their dental claims or so-called overbilling. My immediate supervisor suggests I go elsewhere, but after so many years of not seeing a dentisit, then finding this practice with a very nice staff...

I'm not ready to go through that again. I wasted so many years not seeing a dentist because I didn't have any coverage. I couldn't afford to pay out of pocket. I haven't see a doctor regularly since my daughter was born because I either didn't have insurance, my physician's office at the time was not participating (with US Healthcare) in the new insurance my company offered or because my company changed insurance companies three times in the 10 years I've been with them, making it awkward to return to the office I once actually iked going to. I still haven't gone back, even though I keep promising myself that I really should go for an exam. It's just so aggravating.

I will be calling both insurance companies on Monday to get the contracted rates as suggested by 4greatboys. I will check Blue Cross's directory for the new Ped's office to see if they are "in-network". I really feel like I'm being taken advantage of and I'm not about to let them walk all over me. I have little spare cash flow as it is. DD needs to see a dentist and I refuse to take her until my services are paid in full (or otherwise taken care of).

 

[LadyAurora]

I hate insurance companies! Luckily, we no longer do business with this one...but DH and I had signed up in August. In October I went to the OB/GYN for "female problems"....ended up with a bill of around $758.00. Then the insurance company denies the whole claim, citing that I should read my exclusions and restrictions. I read that book back and forth so many times! They said reproductive organs were not covered for 6 months frm the beginning of the policy. What? That was not in the terms! I even had my salesman call and argue, but we got nowhere. I asked the "customer service" person...what if I was in a car wreck and damaged my reproductive organs? Too bad?
Also...same company...my husband had to ride to the hospital in the ambulance one night for chest pains. The bill is $850.00, insurance max is $250.00. What a big difference! Do they even look at what it really costs to ride in an ambulance?
That's my rant on insurance companies.

 

[CarolA]

On your doctor. It sounds like he needs to take the write off. If it is a PPO, he probably has signed the contract.

On Dental, I have the WORST teeth in the world and I go to a Dentist who is NOT a participant in the Aetna plan since the local participating dentist tried to give me valium when I got upset that he was getting ready to drill the WRONG tooth! I wind up paying a lot of it.

As for the goverment stepping in. Go visit with someone on Tricare and/or Medicare. That will make your skin crawl. At least you were able to get someone from Blue Cross on the phone.