How much will the surgical practice get for doing a procedure?

August 27, 2013 3:29 PM

Negotiating self pay medical bill. I want to have an idea of how much the surgical practice/surgeon would have been paid if the patient had had insurance. How much will they get if they hire a collection agency? Do they get a percentage or just sell the debit for a fixed price? The patient is being billed 1850.00 self pay for the procedure. The procedure was at a major Boston hospital and the patient is being billed self pay due to a temporary lapse in subsidized insurance. The hospital has already written off the bill. The billing date was sometime around the end of March 2013. The patient has been told by the billing organization that represents the surgeon that they have to deal directly with the surgeon or their practice.
posted by flummox to Work & Money (4 answers total)

This is complicated because there are several different groups that will be charging. The facility will charge for use of its operating room, supplies, and staff. The operating physician will charge for performing the procedure and the anesthesiologist will charge for anesthesia services. Rates for procedures can be widely different based on where it was performed in the country, so prices from the Midwest or South may have nothing to do with it. Lots of hospitals and insurance companies have started posting pricing guides on their websites. There is also the big daddy of insurance, Medicare, and you could look up what they'd pay on the CMS website but it can be difficult to locate.

You'll want to have access to the bill so you can see which CPT procedure codes were billed out, this will help identify what possible payments may be.
posted by Apoch at 5:19 PM on August 27, 2013

Here's the Medicare fee schedule lookup Apoch mentioned. However, if you or the patient don't know much about CPT codes (on the medicare website they're called HCPCS codes), then the results can be confusing. The rates vary depending on locality and modifiers. The modifiers indicate how much the doctor provided. For instance, for an EKG, the doctor may charge a global fee with no modifier (he provided the EKG machine, the office in which the ekg was done, the technician who hooked up the patient to the machine, and his own expertise in interpreting the EKG) or just a professional fee with a "professional only" modifier (all he did was interpret the EKG- someone else owns the equipment and employs the technician). The more information you can get about what codes were billed (including modifiers), the easier it will be to figure out how much Medicare would pay for that service. I would not expect to pay Medicare rates, though. The doctors I know in higher-cost-of-living areas usually charge more than Medicare rates.
posted by dogmom at 6:50 PM on August 27, 2013

Just to address one point, you don't really "hire" collections agencies. With few exceptions, debt is sold at a fraction of its value to the collections agency, which then pursues the debt for itself.
posted by Tomorrowful at 6:59 PM on August 27, 2013

Surgical fees for procedures are pretty standardized and are a hell of a lot lower than people think they are. Gallbladders and appendix removals are 200-300$ tops even with cadillac insurance. Look up the Medicare rate for the procedure then double it to get an idea of the maximum reimbursement (strictly speaking with regards to the surgeon, not all the other crazy bill padding)
posted by hobo gitano de queretaro at 8:07 PM on August 27, 2013