Best strategy for unreasonable medical charge (from insurance)
October 21, 2017 5:40 PM Subscribe
My 3-year old son had a routine tonsillectomy. It went as planned, and he was out half an hour before we expected. Ahead of time I tried to get the insurance company (ACA plan) to say something about what the cost might be and which of their in network providers we should use. They would provide no information, but suggested we check fairhealthconsumer.org for ballpark figures. That ballpark was $2300. After the procedure, they're charging us $4985, which conveniently happens to be $15 less than the deductible. There's no reason for the charge to be higher than any standard arrangement. I feel screwed and have filed a complaint with the state department of insurance, but my question is in the meantime, should I pay the hospital bill? There's a 10% quick payment discount, which is $500 in this case, so that's worth something, and I don't really anticipate winning much with my complaint.
Oh, yeah. I'm in the United States of America. :)
There's so much more I want to say about this, but I don't know what is even useful or hasn't been said 1000 times before, and better. It's crazy to use a system of insurance as a middleman to buy something you need as routinely as HEALTHCARE. One of the most galling facts is that there are several ENT providers in my area (not major urban) who are in network, and my insurance company has rates for each procedure worked out with them, but they won't tell me what those rates are, so I can't make an informed decision. Maybe if I went to the ENT across the street, it would cost $3k less... who knows?
And my insurance company (may their eyes fall out of their heads) are just obeying their incentives. Of course they use this opportunity to get every penny up to deductible out of me. But I hate feeling trapped, and I want to keep my money, not give it to these vultures.
There's so much more I want to say about this, but I don't know what is even useful or hasn't been said 1000 times before, and better. It's crazy to use a system of insurance as a middleman to buy something you need as routinely as HEALTHCARE. One of the most galling facts is that there are several ENT providers in my area (not major urban) who are in network, and my insurance company has rates for each procedure worked out with them, but they won't tell me what those rates are, so I can't make an informed decision. Maybe if I went to the ENT across the street, it would cost $3k less... who knows?
And my insurance company (may their eyes fall out of their heads) are just obeying their incentives. Of course they use this opportunity to get every penny up to deductible out of me. But I hate feeling trapped, and I want to keep my money, not give it to these vultures.
The insurance company doesn't get your deductible. The hospital or doctor who performed the procedure does. As long as the cost is under the deductible, there's no difference to the insurer in you paying $2300 or $4500. In fact, their incentive would be to keep you from reaching your deductible, because that's when they start having to lay out money for your care.
Price transparency is a huge, structural problem in the US health care industry, for sure. In your case, I would check to make sure the hospital applied the appropriate discounts for your insurer and is not billing your their full charges. You can ask for an itemized bill as well and check to see if there are weird things on there.
Also, unless their billing system is really top-tier, you should expect to get a separate bill from the doctor.
posted by jeoc at 6:12 PM on October 21, 2017 [4 favorites]
Price transparency is a huge, structural problem in the US health care industry, for sure. In your case, I would check to make sure the hospital applied the appropriate discounts for your insurer and is not billing your their full charges. You can ask for an itemized bill as well and check to see if there are weird things on there.
Also, unless their billing system is really top-tier, you should expect to get a separate bill from the doctor.
posted by jeoc at 6:12 PM on October 21, 2017 [4 favorites]
On non-preview, EOB is a great way to make sure you're being charged the correct amount.
posted by jeoc at 6:13 PM on October 21, 2017 [1 favorite]
posted by jeoc at 6:13 PM on October 21, 2017 [1 favorite]
The insurance company doesn’t know how much the doctor and hospital are going to charge ahead of time. The doctor and hospital are the ones you should ask for estimates from. Just for future reference.
As everyone else has said, wait until your insurance company processes the bills before you pay anything. You’ll get notification of this in the mail from the insurance company, and after that the hospital will send you a bill that should match what’s on the paperwork from the insurance company. If it doesn’t match, call the hospital and have their billing department explain it.
Your insurance company has not done anything wrong here.
posted by something something at 6:26 PM on October 21, 2017 [4 favorites]
As everyone else has said, wait until your insurance company processes the bills before you pay anything. You’ll get notification of this in the mail from the insurance company, and after that the hospital will send you a bill that should match what’s on the paperwork from the insurance company. If it doesn’t match, call the hospital and have their billing department explain it.
Your insurance company has not done anything wrong here.
posted by something something at 6:26 PM on October 21, 2017 [4 favorites]
In fact, their incentive would be to keep you from reaching your deductible, because that's when they start having to lay out money for your care.
This. Wait and see what your insurance actually does with that amount.
My three-year-old had a tonsillectomy two weeks ago, and the initial charge from the hospital (before insurance has processed it, obviously) was $6500, if having another figure for comparison helps at all.
posted by anderjen at 6:43 PM on October 21, 2017
This. Wait and see what your insurance actually does with that amount.
My three-year-old had a tonsillectomy two weeks ago, and the initial charge from the hospital (before insurance has processed it, obviously) was $6500, if having another figure for comparison helps at all.
posted by anderjen at 6:43 PM on October 21, 2017
Response by poster: Yes, unfortunately, I've been down these roads already. I got the EOB from the insurance last week and the bill from the hospital today.
According to EOB, hospital charges 7k, insurance picks up 2k, my responsibility is 5k. Got bill from hospital to the same effect.
I asked the hospital about cost before procedure. They threw up smokescreens of bullshit, and after quite a bit of prodding, said nominally 10-12k, but that they would have a lower negotiated rate. This turns out to be the aforementioned 7k. I also asked the insurance company. They said they couldn't know because things could go wrong, there could be extra anesthesia, etc. None of that happened.
jecc and something, unless I'm deeply confused, it makes quite a bit of sense to my insurance for them to leave me to pay everything other than my deductible. I have a 5k deductible and they're demanding I pay 5k. If they picked up a bigger part of the tab, it would cost them money. If they picked up a smaller part of it, I would be spending over my deductible for this particular family member, and they would have to pay more (the hospital would get the same). By assigning me to pay exactly my deductible, they're maximizing my outlay and minimizing their own.
Still not 100% sure if it makes sense to pay the hospital and then fight with insurance company to pick up larger part of the tab or hold out while I complain. I don't really expect to win, but I think the charge is arbitrary and out of line (like 2x) with going rates.
posted by windowbr8r at 7:02 PM on October 21, 2017 [1 favorite]
According to EOB, hospital charges 7k, insurance picks up 2k, my responsibility is 5k. Got bill from hospital to the same effect.
I asked the hospital about cost before procedure. They threw up smokescreens of bullshit, and after quite a bit of prodding, said nominally 10-12k, but that they would have a lower negotiated rate. This turns out to be the aforementioned 7k. I also asked the insurance company. They said they couldn't know because things could go wrong, there could be extra anesthesia, etc. None of that happened.
jecc and something, unless I'm deeply confused, it makes quite a bit of sense to my insurance for them to leave me to pay everything other than my deductible. I have a 5k deductible and they're demanding I pay 5k. If they picked up a bigger part of the tab, it would cost them money. If they picked up a smaller part of it, I would be spending over my deductible for this particular family member, and they would have to pay more (the hospital would get the same). By assigning me to pay exactly my deductible, they're maximizing my outlay and minimizing their own.
Still not 100% sure if it makes sense to pay the hospital and then fight with insurance company to pick up larger part of the tab or hold out while I complain. I don't really expect to win, but I think the charge is arbitrary and out of line (like 2x) with going rates.
posted by windowbr8r at 7:02 PM on October 21, 2017 [1 favorite]
But the reason you have to pay your whole deductible is because that’s how insurance works. You were billed $7000 by the hospital. You have a $5000 deductible. You pay $5000, then the insurance company picks up the rest.
You probably already paid that $15 to some other doctor this year. The rest of your deductible has to be paid when you incur services that cost more than $5000. I understand you don’t think surgery should cost that much, but it does. It’s a fact of life in America today.
posted by something something at 7:43 PM on October 21, 2017 [9 favorites]
You probably already paid that $15 to some other doctor this year. The rest of your deductible has to be paid when you incur services that cost more than $5000. I understand you don’t think surgery should cost that much, but it does. It’s a fact of life in America today.
posted by something something at 7:43 PM on October 21, 2017 [9 favorites]
And I’m not saying you shouldn’t be outraged - the system is outrageous. But everybody involved here is operating correctly within the system, unfortunately.
posted by something something at 8:03 PM on October 21, 2017 [7 favorites]
posted by something something at 8:03 PM on October 21, 2017 [7 favorites]
I'm confused -- was this an in network provider? If so, being in network means that they must accept what the insurance company pays and forgive the difference. The amount that you must pay out of pocket on an in network provider should be a pre-determined fixed amount (i.e. copay) or a pre-determined fixed percentage (i.e. coinsurance).
Unfortunately, if you chose to see an out of network provider when in network providers were available, then you are almost certainly on the hook for everything you have been billed (but could try to negotiate with the provider directly).
posted by telegraph at 8:32 PM on October 21, 2017
Unfortunately, if you chose to see an out of network provider when in network providers were available, then you are almost certainly on the hook for everything you have been billed (but could try to negotiate with the provider directly).
posted by telegraph at 8:32 PM on October 21, 2017
Yeah, count me among the confused. I have a high-deductible health plan, so any health care costs up to $XXXX total over the course of the entire year, I have to cover (usually using my HSA funds), and then insurance kicks in and covers the rest. Once you've paid the $5000 deductible on your plan, insurance should cover you (minus any co-pays) for any other covered medical procedures this year (I would assume).
posted by Aleyn at 9:08 PM on October 21, 2017
posted by Aleyn at 9:08 PM on October 21, 2017
Yes...not wanting to discount your frustration here, it's a terrible system, but there's something not quite cohering in this story. I mean, I guess it's technically possible that you could have a 71.4% co-insurance obligation ($5K out of $7K), but that's an odd figure. And as little regard as I have for insurance companies, I doubt yours has precisely negotiated costs of procedures with the hospital to extract the precise maximum deductible at the precise co-insurance.
For an in-network provider, the calculations should look like this, using example figures:
Hospital fake nominal charge: $10,000
Negotiated in-network charge: $7,000
Fixed co-pay for the procedure, paid by you as you haven't reached your $5K deductible: $1,000
Rest paid by insurance: $6,000
OR
Co-insurance, 20%, paid by you as you haven't reached your $5K deductible: $1,400
Rest paid by insurance: $5,600
It can get more complex with multiple billing items. There might be a separate co-pay for [x] service, bringing costs up. That's where surprises often lurk...
But for the procedure to be billed at $7K, you to pay the full deductible of $5K, and then the insurance to pay $2K would mean you were getting no benefits at all!
posted by praemunire at 9:12 PM on October 21, 2017 [1 favorite]
For an in-network provider, the calculations should look like this, using example figures:
Hospital fake nominal charge: $10,000
Negotiated in-network charge: $7,000
Fixed co-pay for the procedure, paid by you as you haven't reached your $5K deductible: $1,000
Rest paid by insurance: $6,000
OR
Co-insurance, 20%, paid by you as you haven't reached your $5K deductible: $1,400
Rest paid by insurance: $5,600
It can get more complex with multiple billing items. There might be a separate co-pay for [x] service, bringing costs up. That's where surprises often lurk...
But for the procedure to be billed at $7K, you to pay the full deductible of $5K, and then the insurance to pay $2K would mean you were getting no benefits at all!
posted by praemunire at 9:12 PM on October 21, 2017 [1 favorite]
(Oh, I see there are ACA HDHPs, and this could be one...but you're still stuck with the implausibility of the insurance negotiating a charge--which would apply to all patients in the plan--calculated to match what's left of your particular deductible. And if you're in an HDHP, you are openly and freely signing up for a huge share of up-front medical costs, anyway. That's the whole theory of them.)
posted by praemunire at 9:21 PM on October 21, 2017
posted by praemunire at 9:21 PM on October 21, 2017
I get that you're frustrated, but that's how deductibles work. You pay all of the costs until your deductible is met, and then coinsurance kicks in. They're not pulling something nefarious by assigning responsibility to you for your deductible. You have a legal agreement with them, and your deductible is part of that agreement. They can't arbitrarily decide to make you pay more than that or allow you to pay less. So the insurance commission is extremely unlikely to make them pay more.
It's also really hard to know that a "going rate" is, and it varies wildly from market to market. In any case, the number you found online has no relation to what the hospital actually charges or what kind of agreement they have with your insurance company. If you feel like the cost of the procedure was too high, that's an issue to take up with the hospital. You thought the procedure would be $2300, but the hospital told you $10,000 and it was actually $7000. That's certainly distressing, but doesn't have anything to do with the division of financial responsibility between you and the insurance company.
It IS confusing. I have a masters degree in health care administration, which is a thing because our health care system is so labyrinthine and opaque.
posted by jeoc at 9:22 PM on October 21, 2017 [6 favorites]
It's also really hard to know that a "going rate" is, and it varies wildly from market to market. In any case, the number you found online has no relation to what the hospital actually charges or what kind of agreement they have with your insurance company. If you feel like the cost of the procedure was too high, that's an issue to take up with the hospital. You thought the procedure would be $2300, but the hospital told you $10,000 and it was actually $7000. That's certainly distressing, but doesn't have anything to do with the division of financial responsibility between you and the insurance company.
It IS confusing. I have a masters degree in health care administration, which is a thing because our health care system is so labyrinthine and opaque.
posted by jeoc at 9:22 PM on October 21, 2017 [6 favorites]
praemunire, a deductible and an out-of-pocket limit are two different things. With various exceptions, the insured pays all costs until the deductible is met. Then the insurance pays some proportion of the cost and the insured pays the rest until the out-of-pocket limit. Only after that point does the insured stop paying co-pays or co-insurance.
Whatever complaint you have is mainly with this asinine system in general, or with the hospital. The insurance company doesn't appear to have done anything even questionable in your description. They don't get any of the money for your deductible.
posted by grouse at 9:27 PM on October 21, 2017 [2 favorites]
Whatever complaint you have is mainly with this asinine system in general, or with the hospital. The insurance company doesn't appear to have done anything even questionable in your description. They don't get any of the money for your deductible.
posted by grouse at 9:27 PM on October 21, 2017 [2 favorites]
Some people here are conflating deductibles and out of pocket maximums.
A deductible represents an amount the patient must pay BEFORE coverage kicks in. This usually doesn't apply to preventive services and doctor office visits, which are free or have a copay and don't play in to the deductible.
If you get services subject to the deductible (surgery, etc.), then you have to pay the entire amount of the deductible before coinsurance kicks in. Then you are paying only your coinsurance on those services for the rest of the year until you reach your out of pocket maximum. At that point, the insurer pays for all services for the rest of the year. Deductibles and out of pocket maxes reset every year.
It's not clear if the insurer actually paid $2k or if that was just the amount of the discount. Usually you'll see the full charges on a hospital bill, and then separate line items for insurance discounts and insurance payments.
Your insurance company is calculating your amount owed by applying their negotiated discounts to the hospital's charges, seeing how much of your deductible hasn't yet been paid by you, figuring out if you are crossing the threshold between deductible and coinsurance, and then calculating your responsibility as the remaining amount of your deductible plus any coinsurance on amounts above the deductible.
posted by jeoc at 9:47 PM on October 21, 2017 [2 favorites]
A deductible represents an amount the patient must pay BEFORE coverage kicks in. This usually doesn't apply to preventive services and doctor office visits, which are free or have a copay and don't play in to the deductible.
If you get services subject to the deductible (surgery, etc.), then you have to pay the entire amount of the deductible before coinsurance kicks in. Then you are paying only your coinsurance on those services for the rest of the year until you reach your out of pocket maximum. At that point, the insurer pays for all services for the rest of the year. Deductibles and out of pocket maxes reset every year.
It's not clear if the insurer actually paid $2k or if that was just the amount of the discount. Usually you'll see the full charges on a hospital bill, and then separate line items for insurance discounts and insurance payments.
Your insurance company is calculating your amount owed by applying their negotiated discounts to the hospital's charges, seeing how much of your deductible hasn't yet been paid by you, figuring out if you are crossing the threshold between deductible and coinsurance, and then calculating your responsibility as the remaining amount of your deductible plus any coinsurance on amounts above the deductible.
posted by jeoc at 9:47 PM on October 21, 2017 [2 favorites]
Ugh, you're right, I've never had insurance with coinsurance, I screwed it up.
posted by praemunire at 10:14 PM on October 21, 2017
posted by praemunire at 10:14 PM on October 21, 2017
The one thing I find odd is the insurance company's evasiveness about their negotiated rates. My SO's (I continue to be uninsured for various reasons) last couple of companies have had many of them published on their website. (Behind a login, of course, but still available)
Obviously, given the complexity of medical billing, looking up just the charge for the tonsillectomy itself would not provide the whole picture since there are also charges for anesthesia and at least 20 other things, but they certainly should have been able to tell you their negotiated rate with provider x for procedure y is z.
Do make sure they are calculating outlays you've had earlier in the year into the amount remaining on your deductible. It's mildly surprising you would have only paid $200 out of pocket this year when the insured just had non-emergency surgery, though I suppose tonsillectomy is routine enough at this point there may not have been many pre-surgery visits and procedures.
Also make sure you don't put off anything else that comes up before the end of the plan year. Now that the insurance company is paying for most or all of it, it's time to make sure every i is dotted and t crossed, to the extent you can afford the copays or coinsurance and depending on where you are wrt your out of pocket maximum. (which I don't think should be too much more if I'm remembering ACA rules correctly. You may be closer than you think, so check.)
posted by wierdo at 11:20 PM on October 21, 2017
Obviously, given the complexity of medical billing, looking up just the charge for the tonsillectomy itself would not provide the whole picture since there are also charges for anesthesia and at least 20 other things, but they certainly should have been able to tell you their negotiated rate with provider x for procedure y is z.
Do make sure they are calculating outlays you've had earlier in the year into the amount remaining on your deductible. It's mildly surprising you would have only paid $200 out of pocket this year when the insured just had non-emergency surgery, though I suppose tonsillectomy is routine enough at this point there may not have been many pre-surgery visits and procedures.
Also make sure you don't put off anything else that comes up before the end of the plan year. Now that the insurance company is paying for most or all of it, it's time to make sure every i is dotted and t crossed, to the extent you can afford the copays or coinsurance and depending on where you are wrt your out of pocket maximum. (which I don't think should be too much more if I'm remembering ACA rules correctly. You may be closer than you think, so check.)
posted by wierdo at 11:20 PM on October 21, 2017
Others have covered the deductable vs out of pocket stuff. Point is - you can save on the front end (lower costs!) by assuming some risk on the back-end (higher deductible!). And so here you are.
As a person who has thread this needle - some advice : In the future, for a non-immediate surgery, save it until January or whatever. Once your deductible is met, you have the whole year free - so go do all your elective stuff. We used plan all our expensive stuff for one year (colonoscopy, vision, etc) for one year, so as to maximize this benefit.
HDHC insurance can be good plans, you just have to do more work to get everything covered well. Which is to say - any MRI for a bad knee or whatever you've been putting off - get it done now. The deductible has been covered. If you do it next year, you have to meet that deductible, but if you do it this year....
the ins company is on the hook. You fuck them, and you fuck them hard.
posted by Pogo_Fuzzybutt at 11:28 PM on October 21, 2017 [3 favorites]
As a person who has thread this needle - some advice : In the future, for a non-immediate surgery, save it until January or whatever. Once your deductible is met, you have the whole year free - so go do all your elective stuff. We used plan all our expensive stuff for one year (colonoscopy, vision, etc) for one year, so as to maximize this benefit.
HDHC insurance can be good plans, you just have to do more work to get everything covered well. Which is to say - any MRI for a bad knee or whatever you've been putting off - get it done now. The deductible has been covered. If you do it next year, you have to meet that deductible, but if you do it this year....
the ins company is on the hook. You fuck them, and you fuck them hard.
posted by Pogo_Fuzzybutt at 11:28 PM on October 21, 2017 [3 favorites]
Also, on the EOB, it should show an allowed amount for the procedure. This is the negotiated rate. That should match what the hospital is charging before the insurance company's $2000. Make sure you are being billed the negotiated rate, as it sounds a bit high. (I'd expect $7000 to be rack rate on the hospital charge unless there were complications or an overnight stay or it includes literally everything you will be charged)
There is one other minor point of confusion I have. Assuming the procedure is $7000 and you have a $5000 deductible, I'd expect your total owed to actually be around $5400 if you have 20% coinsurance. ($400 being your share of the $2000 over your deductible)
posted by wierdo at 11:53 PM on October 21, 2017
There is one other minor point of confusion I have. Assuming the procedure is $7000 and you have a $5000 deductible, I'd expect your total owed to actually be around $5400 if you have 20% coinsurance. ($400 being your share of the $2000 over your deductible)
posted by wierdo at 11:53 PM on October 21, 2017
Response by poster: wierdo, et al, thanks for the wisdom. (but back to my original question, should I pay and complain, or complain while not paying?)
Four clarifications:
This is a SILVER obamacare plan. Obviously not doing what I wished it would for me, but it's not listed as a High Deductible plan (though the deductible seems high since I'm brushing up against it for routine childhood outpatient procedure.)
I think my particular insurance company is particularly bad - when I say the name to any healthcare provider, the person on the other end of the phone groans audibly. They have a reputation for throwing up roadblocks to payment and requiring doctors to resubmit claims multiple times for crazy reasons, basically hoping for people to quit fighting and just pay larger amounts. For instance, they wouldn't process this claim because it had my son's # on it rather than mine. They forced my doctor to resubmit the claim with my # even though my son was the patient. I asked why they gave him a number if we're supposed to submit with my number... they told me to ask billing. (If that sounds so crazy you don't believe me, believe me, I know.)
For the sake of keeping this simple, I rounded figures slightly. The 5k I'm being asked to pay is $4992. That figure includes $376 in coinsurance. I didn't mention the coinsurance for brevity's sake, but it's already in there. There was basically nothing out of pocket up until this point in the year, because my son required no healthcare because he was healthy. One or two routine checkups. (the tonsillectomy was for sleep apnea, not because of infection.) Also, there was a doctor charge and an anesthesia charge, both of which were exactly what I expected and I paid instantly.
COST: There are several third parties that provide ballpark figures of what a procedure costs in a particular area. The fact is that I'm being billed more than TWICE the HIGH END of the normal cost of the procedure in my area. Hence my getting pissed and fighting it.
So anyway, back to the original question - is the best strategy to pay and fight or fight while not paying?
posted by windowbr8r at 6:01 AM on October 22, 2017
Four clarifications:
This is a SILVER obamacare plan. Obviously not doing what I wished it would for me, but it's not listed as a High Deductible plan (though the deductible seems high since I'm brushing up against it for routine childhood outpatient procedure.)
I think my particular insurance company is particularly bad - when I say the name to any healthcare provider, the person on the other end of the phone groans audibly. They have a reputation for throwing up roadblocks to payment and requiring doctors to resubmit claims multiple times for crazy reasons, basically hoping for people to quit fighting and just pay larger amounts. For instance, they wouldn't process this claim because it had my son's # on it rather than mine. They forced my doctor to resubmit the claim with my # even though my son was the patient. I asked why they gave him a number if we're supposed to submit with my number... they told me to ask billing. (If that sounds so crazy you don't believe me, believe me, I know.)
For the sake of keeping this simple, I rounded figures slightly. The 5k I'm being asked to pay is $4992. That figure includes $376 in coinsurance. I didn't mention the coinsurance for brevity's sake, but it's already in there. There was basically nothing out of pocket up until this point in the year, because my son required no healthcare because he was healthy. One or two routine checkups. (the tonsillectomy was for sleep apnea, not because of infection.) Also, there was a doctor charge and an anesthesia charge, both of which were exactly what I expected and I paid instantly.
COST: There are several third parties that provide ballpark figures of what a procedure costs in a particular area. The fact is that I'm being billed more than TWICE the HIGH END of the normal cost of the procedure in my area. Hence my getting pissed and fighting it.
So anyway, back to the original question - is the best strategy to pay and fight or fight while not paying?
posted by windowbr8r at 6:01 AM on October 22, 2017
I would say you should pay the hospital because (1) as far as I can tell, your complaint is not with them, and (2) I'm afraid you have no basis to complain about your insurance.
As others have said, you have a deductible, which needs to be used up before your insurance coverage kicks in. If it's any consolation, the deductible is now satisfied, apparently. So if you or a family member have any surgeries or other medical procedures going forward (this year), you will not have to worry about the deductible.
The part I am most confused about is whether you used an in-network provider. If you did, the insurance would work differently, and you for sure should find out what happened here.
But if you used an out-of-network provider, my question would be: Why did you do that? It is not difficult to find out who is in-network and who is not. It is usually on the insurer's website, or you could just call them.
Btw, the insurance company really cannot know what the hospital will charge. The hospital, though, should probably have been able to give you a ballpark.
posted by merejane at 10:02 AM on October 22, 2017
As others have said, you have a deductible, which needs to be used up before your insurance coverage kicks in. If it's any consolation, the deductible is now satisfied, apparently. So if you or a family member have any surgeries or other medical procedures going forward (this year), you will not have to worry about the deductible.
The part I am most confused about is whether you used an in-network provider. If you did, the insurance would work differently, and you for sure should find out what happened here.
But if you used an out-of-network provider, my question would be: Why did you do that? It is not difficult to find out who is in-network and who is not. It is usually on the insurer's website, or you could just call them.
Btw, the insurance company really cannot know what the hospital will charge. The hospital, though, should probably have been able to give you a ballpark.
posted by merejane at 10:02 AM on October 22, 2017
Re-reading what you have said and my answer right above, I want to add to and adjust my answer a bit.
First, your thread title is: "Best strategy for unreasonable medical charge (from insurance)."
But - the medical charge is not from your insurance at all -- it is from the hospital. So I can't figure out what your complaint would be with the insurance company.
In the first paragraph, if I understand it correctly, you say that the insurance company is "charging [you] $4985." But the insurance company doesn't charge or bill you anything, and you don't pay them or owe them anything. Rather, the $4985 is the remaining deductible. You are always responsible for the deductible, on an annual basis. It is just a statement of the amount that you are responsible for on all claims (in the aggregate), before the insurance company's responsibility kicks in.
As to the hospital, they gave you an estimate in advance of $10-12 K, but the actual charge was $7K. So -- what is your complaint with the hospital?
At one point, you say: "According to EOB, hospital charges 7k, insurance picks up 2k, my responsibility is 5k. Got bill from hospital to the same effect." The 5K is the deductible, which you are responsible for. So what the EOB says is very straightforward, and it is correct, as is the hospital's bill. There just is no basis for complaining about either the hospital or the insurance company, as far as I can see.
Btw, are the doctor bills not covered by insurance? (You don't need to tell me about that, of course, but you should be clear about it yourself.)
posted by merejane at 10:42 AM on October 22, 2017 [1 favorite]
First, your thread title is: "Best strategy for unreasonable medical charge (from insurance)."
But - the medical charge is not from your insurance at all -- it is from the hospital. So I can't figure out what your complaint would be with the insurance company.
In the first paragraph, if I understand it correctly, you say that the insurance company is "charging [you] $4985." But the insurance company doesn't charge or bill you anything, and you don't pay them or owe them anything. Rather, the $4985 is the remaining deductible. You are always responsible for the deductible, on an annual basis. It is just a statement of the amount that you are responsible for on all claims (in the aggregate), before the insurance company's responsibility kicks in.
As to the hospital, they gave you an estimate in advance of $10-12 K, but the actual charge was $7K. So -- what is your complaint with the hospital?
At one point, you say: "According to EOB, hospital charges 7k, insurance picks up 2k, my responsibility is 5k. Got bill from hospital to the same effect." The 5K is the deductible, which you are responsible for. So what the EOB says is very straightforward, and it is correct, as is the hospital's bill. There just is no basis for complaining about either the hospital or the insurance company, as far as I can see.
Btw, are the doctor bills not covered by insurance? (You don't need to tell me about that, of course, but you should be clear about it yourself.)
posted by merejane at 10:42 AM on October 22, 2017 [1 favorite]
Btw, this article might help clarify things: How Do Health Insurance Deductibles Work?
posted by merejane at 10:50 AM on October 22, 2017
posted by merejane at 10:50 AM on October 22, 2017
Response by poster: Ugh, ok, nevermind.
I understand how deductibles work. I understand what a bill is. I'm full up on lectures about the basics of insurance. Yes, all providers are in-network. I think my insurance company isn't paying as much as they should, and I'm going to argue with them about it. If you don't think that's wise, please go watch cat videos. I was hoping to encounter someone else who had made a similar complaint, however unlikely to succeed, so I could hear from their experience. None of those people are here, so I think it makes sense for me to figure things out on my own.
posted by windowbr8r at 11:41 AM on October 22, 2017
I understand how deductibles work. I understand what a bill is. I'm full up on lectures about the basics of insurance. Yes, all providers are in-network. I think my insurance company isn't paying as much as they should, and I'm going to argue with them about it. If you don't think that's wise, please go watch cat videos. I was hoping to encounter someone else who had made a similar complaint, however unlikely to succeed, so I could hear from their experience. None of those people are here, so I think it makes sense for me to figure things out on my own.
posted by windowbr8r at 11:41 AM on October 22, 2017
I think the way you worded the question may be confusing people - is your main argument that the procedure should never have cost 7k because you've seen sources suggesting it should only be 3k in your area? Your main argument with paying your allocated share of 7k then is that 7k is more than the 3k quoted in the sources you consulted?
Did you ever get an actual quote for the procedure by the hospital carrying out the procedure? I would hazard a guess that if you wanted to pay around 3k you needed to find and use a provider offering you that? As far as I understand (and admittedly my understanding is very limited) the US system relies on all kinds of unclear pricing structures. So it is absolutely possible that a price for a procedure without insurance can be lower than your share with whatever cover you have. If there is some kind of patient advocate reach out to them but the whole system seems to rely on these arbitrary pricing structures so.
posted by koahiatamadl at 11:44 AM on October 22, 2017
Did you ever get an actual quote for the procedure by the hospital carrying out the procedure? I would hazard a guess that if you wanted to pay around 3k you needed to find and use a provider offering you that? As far as I understand (and admittedly my understanding is very limited) the US system relies on all kinds of unclear pricing structures. So it is absolutely possible that a price for a procedure without insurance can be lower than your share with whatever cover you have. If there is some kind of patient advocate reach out to them but the whole system seems to rely on these arbitrary pricing structures so.
posted by koahiatamadl at 11:44 AM on October 22, 2017
Complain to the insurance company and the hospital both. Maybe you're right about your deductible, though $5k seems more like a family deductible for an Obamacare silver plan. I could have sworn they were capped at a bit over $3k per insured.
And unless the doctor and anesthesiologist charges and the doctor's visit to decide the apnea was bad enough to require surgery come to less than $2000, your deductible still isn't being applied correctly, so your insurance company is screwing something up.
Personally, if the insurance and hospital both agree the hospital charge is correct, I'd pay them. If it turns out you paid too much of the cost per your plan documents, your insurance will write you a check relatively painlessly once they have recognized the error. Assuming you have the money, I'd be looking to get that discount. If it is at all financially difficult, I'd ask the hospital to knock off a bit more in exchange for immediate payment. It never hurts to ask, after all.
If the money is a big issue, tell them what you can pay. If it's at least half there's a fair chance they'll take it, but might require some documentation of need for that much of a write off.
posted by wierdo at 12:20 PM on October 22, 2017
And unless the doctor and anesthesiologist charges and the doctor's visit to decide the apnea was bad enough to require surgery come to less than $2000, your deductible still isn't being applied correctly, so your insurance company is screwing something up.
Personally, if the insurance and hospital both agree the hospital charge is correct, I'd pay them. If it turns out you paid too much of the cost per your plan documents, your insurance will write you a check relatively painlessly once they have recognized the error. Assuming you have the money, I'd be looking to get that discount. If it is at all financially difficult, I'd ask the hospital to knock off a bit more in exchange for immediate payment. It never hurts to ask, after all.
If the money is a big issue, tell them what you can pay. If it's at least half there's a fair chance they'll take it, but might require some documentation of need for that much of a write off.
posted by wierdo at 12:20 PM on October 22, 2017
Best answer: When confronted with a large medical bill, I once contracted with a medical consultant who had some kind of secret database of procedural expenses for every provider in my area. The consultant did some kind of also-secret negotiation with the hospital, the end result being that I was charged ~2K less than originally billed, and the consultant took 30% of the savings as their fee.
Perhaps there are still people like that around? My consultant seems to have been bought out by an insurer, however.
posted by aramaic at 12:46 PM on October 22, 2017 [1 favorite]
Perhaps there are still people like that around? My consultant seems to have been bought out by an insurer, however.
posted by aramaic at 12:46 PM on October 22, 2017 [1 favorite]
You say:
You say you understand how deductibles work, but it sounds like you don't.
posted by Winnie the Proust at 12:48 PM on October 22, 2017 [3 favorites]
I think my insurance company isn't paying as much as they should, and I'm going to argue with them about it.If the procedure is subject to your deductible (and surgery usually is), your insurance company will not pay a penny until you have met your deductible for the year. That's how deductibles work. If you have a $5K deductible, then you pay 100% of any procedures that are subject to the deductible, until you've paid $5,000 during a plan year. At that point, for the rest of the plan year, your insurance company covers the cost of procedures that are subject to the deductible.
You say you understand how deductibles work, but it sounds like you don't.
posted by Winnie the Proust at 12:48 PM on October 22, 2017 [3 favorites]
Two ideas for you:
Get the list if ICD 10 codes that were billed. There are multiple different codes that can be used for tonsillectomy. Once you know the exact codes billed then you can search for price comparisons.
Two: Get an itemized statement from the hospital. Look through carefully for any charges that don’t make sense. You can hire people to help you do this but it can be pricey.
If you can afford it without financial strain then pay the whole thing and fight later. If you can’t then set up a ten dollar a month payment plan while you fight it.
posted by SyraCarol at 1:20 PM on October 22, 2017 [2 favorites]
Get the list if ICD 10 codes that were billed. There are multiple different codes that can be used for tonsillectomy. Once you know the exact codes billed then you can search for price comparisons.
Two: Get an itemized statement from the hospital. Look through carefully for any charges that don’t make sense. You can hire people to help you do this but it can be pricey.
If you can afford it without financial strain then pay the whole thing and fight later. If you can’t then set up a ten dollar a month payment plan while you fight it.
posted by SyraCarol at 1:20 PM on October 22, 2017 [2 favorites]
You say: "I think my insurance company isn't paying as much as they should, and I'm going to argue with them about it."
What is the basis of your argument? If you can tell us what you plan to say to them, maybe we can be of some assistance.
Obviously, saying that you think the deductible is too high is a non-starter. You have an insurance plan, and that plan has a deductible. There's no negotiating or arguing against that, right?
You keep referring to comparable rates for this procedure. But that would effect only what the hospital charged, not what the insurance reimbursed. So I guess you could argue with the hospital that they charged too much, given what other hospitals charge. But -- they told you up front what they would likely charge ($10-12K) and then charged less ($7K). So -- again, what exactly would you say to them? What would your response be when the hospital points out that you opted to have your son have this proecdure, knowing that it might result in a $10K charge?
I think you are not finding people here who have made "a similar complaint" because there is no valid complaint to be made. Again, though, if you can spell out what you plan to argue (to the hospital or the insurance company), maybe people who have argued with insurance companies can give you some helpful advice.
Fwiw, I have fought insurance companies, and once won an appeal that ended up in the insurance company sending me a check for $30,000 (rounded). So it can be done. But there has to be a valid argument, and I'm not seeing what yours is.
posted by merejane at 2:53 PM on October 22, 2017 [2 favorites]
What is the basis of your argument? If you can tell us what you plan to say to them, maybe we can be of some assistance.
Obviously, saying that you think the deductible is too high is a non-starter. You have an insurance plan, and that plan has a deductible. There's no negotiating or arguing against that, right?
You keep referring to comparable rates for this procedure. But that would effect only what the hospital charged, not what the insurance reimbursed. So I guess you could argue with the hospital that they charged too much, given what other hospitals charge. But -- they told you up front what they would likely charge ($10-12K) and then charged less ($7K). So -- again, what exactly would you say to them? What would your response be when the hospital points out that you opted to have your son have this proecdure, knowing that it might result in a $10K charge?
I think you are not finding people here who have made "a similar complaint" because there is no valid complaint to be made. Again, though, if you can spell out what you plan to argue (to the hospital or the insurance company), maybe people who have argued with insurance companies can give you some helpful advice.
Fwiw, I have fought insurance companies, and once won an appeal that ended up in the insurance company sending me a check for $30,000 (rounded). So it can be done. But there has to be a valid argument, and I'm not seeing what yours is.
posted by merejane at 2:53 PM on October 22, 2017 [2 favorites]
I think you need to contact the hospital to see if you can reduce your bill. Years ago, when I had a procedure and received a bill that I couldn't afford, I reached out to the hospital and they directed me to their charitable program. I filled out some paperwork and the hospital's charitable foundation covered the portion that my insurance company did not cover. If I recall correctly, the charitable foundation helped people whose incomes did not exceeded 4x the federal poverty line, so you don't necessarily have to be impoverished to receive this help.
Since you just reached your deductible now, I don't think there's anything that insurance company will do for you.
posted by parakeetdog at 3:11 PM on October 22, 2017 [1 favorite]
Since you just reached your deductible now, I don't think there's anything that insurance company will do for you.
posted by parakeetdog at 3:11 PM on October 22, 2017 [1 favorite]
I think my insurance company isn't paying as much as they should
How much do you think the insurance company should pay?
posted by grouse at 4:11 AM on October 23, 2017
How much do you think the insurance company should pay?
posted by grouse at 4:11 AM on October 23, 2017
Best answer: Yes...there are databases out there that show the Usual and Customary rates (UCR) for various procedures based on region. Those rates are usually broken down into columns like 100% UCR, 80% UCR, 50% UCR so that a provider can decide if they want to be at the top end or bottom end of their region (and therefore gives them leverage when negotiating network contracts for insurance). If you can get your hands on that info, it will give you some information about what should have been charged by the hospital. HOWEVER...if the hospital's contract with the insurance company states that they will be reimbursed at 80% of the UCR (for example) instead of listing a specific dollar amount for a specific ICD10 code, then of course the hospital is going to charge the maximum amount possible so they can get as much out of that 80% as possible. You may be seeing that effect in your bill, and why it doesn't match up to the prices you found in your search.
Hospitals and insurance providers don't want to give out how much a procedure costs because of competition...they all try to negotiate the most profitable rates with each other and they don't want another hospital/provider in that area to have the upper hand. (I work in a psych hospital where they negotiate a daily rate for inpatient care as opposed to percentages for each individual service. It's a BIG DEAL to negotiate the highest rate they can get from the insurance company, and that daily rate is kept secret so no one else can use it to ask for a higher rate. Outpatient services are billed in units...1 therapy visit, 1 med management visit, etc. and usually have set reimbursement rates from the insurance company).
The other thing that stuck out to me is that the insurance company initially rejected the bill because it wasn't filed under your ID number (Your insurance doesn't happen to be known by 4 letters instead of a longer name, perhaps?). Look up your policy specifics for your deductible...is it $5000 per individual covered, or does it have a "family deductible"? (i.e. $5000 per individual or $7500 for all family members combined?). I'm wondering if the insurance wanted it filed under your number to mess with the deductible amount somehow? You may have an argument there...but if you haven't met your deductible this year either then the numbers remain the same.
posted by MultiFaceted at 8:38 AM on October 23, 2017
Hospitals and insurance providers don't want to give out how much a procedure costs because of competition...they all try to negotiate the most profitable rates with each other and they don't want another hospital/provider in that area to have the upper hand. (I work in a psych hospital where they negotiate a daily rate for inpatient care as opposed to percentages for each individual service. It's a BIG DEAL to negotiate the highest rate they can get from the insurance company, and that daily rate is kept secret so no one else can use it to ask for a higher rate. Outpatient services are billed in units...1 therapy visit, 1 med management visit, etc. and usually have set reimbursement rates from the insurance company).
The other thing that stuck out to me is that the insurance company initially rejected the bill because it wasn't filed under your ID number (Your insurance doesn't happen to be known by 4 letters instead of a longer name, perhaps?). Look up your policy specifics for your deductible...is it $5000 per individual covered, or does it have a "family deductible"? (i.e. $5000 per individual or $7500 for all family members combined?). I'm wondering if the insurance wanted it filed under your number to mess with the deductible amount somehow? You may have an argument there...but if you haven't met your deductible this year either then the numbers remain the same.
posted by MultiFaceted at 8:38 AM on October 23, 2017
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Don’t pay a provider bill until you see the EOB. Don’t pay more than the EOB says you should.
posted by Huffy Puffy at 6:11 PM on October 21, 2017 [13 favorites]