Medical insurance

[clh2]

Just venting

Saw a new ob/gyn last week. She thought it would be a good idea for me to have a further screening done. The gyn thought it would cost $300 to $400.

I checked with the billing office. The "cost" for this procedure is $1378. I know this is not the actual cost due to insurance. The office cannot tell me the cost. They said to call the insurance company. The insurance company said they cannot give me this information, I need to get it from the clinic.
All I am trying to figure out is what will my out of pocket be. Because that will determine when/if I get this screening done.

If this is a "consumer-driven" health plan -then why can't I easily get the info I need to make an informed decision?

Just needed to vent. Our financial situation has just dramatically changed, and I am just wanting to make sure there are no surprises.

 

[Pooh2]

I have experienced this recently too. The neurologist's office could not tell me how much the visit would be, I have to have the visit first, then they bill insurance and I find out how much my insurance negotiated, but my deductible is high so insurance is not actually going to end up paying anything. Beyond insane way to run a business!

 

[clh2]

Pooh2- I agree . How can they run a business this way? I have the codes, how would this clinic"not" know what they will be reimbursed?

It almost makes me wonder how bad they want my business.

 

[Marionnette]

Just venting

Saw a new ob/gyn last week. She thought it would be a good idea for me to have a further screening done. The gyn thought it would cost $300 to $400.

I checked with the billing office. The "cost" for this procedure is $1378. I know this is not the actual cost due to insurance. The office cannot tell me the cost. They said to call the insurance company. The insurance company said they cannot give me this information, I need to get it from the clinic.
All I am trying to figure out is what will my out of pocket be. Because that will determine when/if I get this screening done.

If this is a "consumer-driven" health plan -then why can't I easily get the info I need to make an informed decision?

Just needed to vent. Our financial situation has just dramatically changed, and I am just wanting to make sure there are no surprises.

Your insurance company should be able to tell you what your copay or OOP cost for the procedure will be. The doctor's office/clinic has no way of knowing whether you have met your OOP costs for the year yet or if you are close to reaching that amount and the costs of the procedure will put you over.

They've already given you what they know: the cost of the procedure is $1378. This is probably the amount that they will bill your insurance for. The insurance company will then reimburse them in the amount that they have negotiated with the office/clinic minus any amount that you are responsible for. If you have an 80/20 plan (where insurance pays 80% of the cost and you're responsible for 20%) then you would pay 20% of what the insurance company has negotiated as the cost of the procedure up to your annual OOP maximum. If you're in an HMO, you probably only have a copay for the procedure. Your insurance company should be able to tell you what that amount is.

The killer would be if you are going out of network for this procedure. You'll get raked over the coals if the office/clinic is not a participating facility or if you have an HMO and your primary doctor is not capitated to that facility under your plan.

 

[Marionnette]

I have experienced this recently too. The neurologist's office could not tell me how much the visit would be, I have to have the visit first, then they bill insurance and I find out how much my insurance negotiated, but my deductible is high so insurance is not actually going to end up paying anything. Beyond insane way to run a business!

Blame the insurance companies for that.

You have one plan with one insurance company to deal with. The doctor's office has to keep track of multiple plans for each insurance company that they deal with. They can only tell you what the insurance company tells them on their provider website. It's up to the consumer to know what their benefits cover and for how much. Yes, that means dealing directly with your insurance company's customer service people or visiting their patient portal on the web. But it's not because the doctor's office doesn't want to assist you. They are just limited as to what they can see when they get authorization for your care.

 

[clh2]

Your insurance company should be able to tell you what your copay or OOP cost for the procedure will be. The doctor's office/clinic has no way of knowing whether you have met your OOP costs for the year yet or if you are close to reaching that amount and the costs of the procedure will put you over.

They've already given you what they know: the cost of the procedure is $1378. This is probably the amount that they will bill your insurance for. The insurance company will then reimburse them in the amount that they have negotiated with the office/clinic minus any amount that you are responsible for. If you have an 80/20 plan (where insurance pays 80% of the cost and you're responsible for 20%) then you would pay 20% of what the insurance company has negotiated as the cost of the procedure up to your annual OOP maximum. If you're in an HMO, you probably only have a copay for the procedure. Your insurance company should be able to tell you what that amount is.

The killer would be if you are going out of network for this procedure. You'll get raked over the coals if the office/clinic is not a participating facility or if you have an HMO and your primary doctor is not capitated to that facility under your plan.

All I want to know is "what" is the negotiated rate between clinic and the insurance company is based on my insurance is. I have a high deductible plan. I already know that I will need to pay 100% of what the negotiated rate, since I have not paid anything toward the deductible this year. The clinic is in-network, so I know that there will be a discounted cost. Due to our current financial circumstances, just want to know the $$$ before I schedule this screening.

 

[Jeff_G]

Couple of things to try, call the office and ask for the diagnostic / billing codes for the tests and costs, then call the insurance company with those codes and costs and ask for the price.

Call the office and tell them you will be a cash payer and see what the costs will be.

 

[Marionnette]

All I want to know is "what" is the negotiated rate between clinic and the insurance company is based on my insurance is. I have a high deductible plan. I already know that I will need to pay 100% of what the negotiated rate, since I have not paid anything toward the deductible this year. The clinic is in-network, so I know that there will be a discounted cost. Due to our current financial circumstances, just want to know the $$$ before I schedule this screening.

The answer still lies with your insurance company. It's possible that the $1300+ price tag that you were quoted is the negotiated amount and not the customary fee.

 

[clh2]

The answer still lies with your insurance company. It's possible that the $1300+ price tag that you were quoted is the negotiated amount and not the customary fee.

Nope - the $1300+ is the amount that the clinic will bill the insurance company.

I've covered all the suggestions that have been discussed. There is a 20% for people who are self-pay. No additional discount if you pay the day of.

The office is wanting to discuss a payment plan. Of which I clearly indicated I won't know "if" I would need a payment plan, until I know what the amount is.

I have the billing codes (got those yesterday) for what the gyn ordered.

I know that I will be responsible for 100% of the negotiated costs between the insurance company, as I have not met my deductible for this year. I just "need" to know what that $$ amount.

I did call an independent imaging company, and for both the codes that the doctor ordered, the cost would be $255, including for the radiologist to read the resulting images.

I am just hopeful that I have a 3rd interview coming up with a company that I have applied for. I know what their insurance plan is for next year, it is not a high deductible plan, and "in-network" my deductible would be $200. If I get an offer from this company - the decision would be easy-peasy. That is why I am trying to figure out if I should go ahead this year, or wait til next year. I am merely trying to make an informed decision. That is all.

 

[mefordis]

Sorry if you already answered this, but what if you told the office you wish to pay out of pocket now, what would be the price for cash payment? You would be surprised how much the knock off the price if you offer to pay yourself.

I pay out of pocket for my pediatrician (25% off) and it works out well with my FSA. She doesn't take my dh's insurance and the deductible is very high, and my children (thank you God) are healthy so no need for a lot of care.

 

[bearzabout]

We recently went through this. The insurance company needs the procedure codes the doctor's office will use in order to tell you what is covered in a very general statement. It also matters if all the doctors or facilities used are in or out of their network.

That said, my husband's eye doctor told him his cataract operation would cost him $4500 or so out of pocket. His Blue Cross policy had a $1,000 deductible. What the doctor's office neglected to mention was that the price they quoted did not include a "facility fee" charged by the location where the procedure took place. That fee turned out to be $5000! You can't tell me his doctor did not know how much the facility that they worked out of every day charged. He ended up paying $7500 in total - nearly twice what he was told it would cost.

Moral of the story - our health care costs are out of control and insurance is almost useless at this point. But in the end, in my husband's opinion, the results from his procedure were well worth the cost.

He did pay cash to get a colonoscopy. He paid $200. His doctor would have charged $1600 if the paperwork was sent through his insurance. Paying cash can save a bundle.