My EOBs have always stated what the healthcare provider is owed per the insurance price. It shows what was billed (the fantasy number), then the insurance price (or the discount), and patient responsibility (dependent upon an individual’s deductible/copay/oop max).
That's right, only there is no normal physician visit that bills $1300. The absolute highest reimbursement you're gonna get for an outpatient visit - a level 5 evaluation and management first-time patient visit plus double-coding an 'prolonged visit for high complexity care' (some handful of insurers allow triple-coding a G2212) - (a 99205 + G2212 x 2) is 244.99 + something like $30 (I don't recall the G2212 reimbursement off the top of my head, but it's in that ballpark), for a total of about $275. +/- some adjustment for geography.
That's not what patients pay - that's the total allowable reimbursement to the doc via medicare.
I use medicare numbers here because almost all private insurers negotiate as %medicare. If I'm a hot specialty people are willing to pick an insurance plan over (say, cardiology) and there's a shortage of my folks in the area, I might negotiate up to something like 110-120% of medicare. Most of the time I'll be happy to get 105% medicare, and some folks will end up getting something like 95% of medicare.
To hit $1300 there'd have to be:
-A procedure, likely an inpatient or facility service, such as a small outpatient surgery, or an infusion.
- Your doc has an in-house blood work lab and your insurer doesn't cover it, and the bill is actually a lab work bill
That latter bit is a gray area - it's actually barred under the Stark Law, as clinical lab work is considered a Designated Health Service that's barred from self-referral, if it's a third-party lab that they own or co-own. If it's their own actual in-clinic lab, though, I'm unsure of how that works out (I don't run my own lab, so I just know of this second-hand).
If you have a private-information-redacted copy of a 'normal' bill for $1300, I'd be happy to eyeball it - either to let you know something is off and worth appealing, or to learn something new for my self.
You’re more literate than most patients. You’re right, it should list all of the above. I think your post reads (and per other poster, I’m not alone) that you had a $1300 normal outpatient visit, so I read that as you misreading your bill.
You as the doctor actually explicitly signed off on the real price? Not some administrator somewhere? Did you have any real input, or is your relationship to the insurer more like a driver’s relationship to Uber?
When working for a hospital, it’s an admin somewhere. When in private practice, the insurer generally has geographic monopoly, so I sign off on whatever they shove in my face if I intend to accept their patients. The only time I have a real say in price is in private practice for uninsured patients, which is where I set aside a piece of my time for charity care.
lotsofpulp|3 years ago
Is that not true?
johannbok|3 years ago
That's not what patients pay - that's the total allowable reimbursement to the doc via medicare.
I use medicare numbers here because almost all private insurers negotiate as %medicare. If I'm a hot specialty people are willing to pick an insurance plan over (say, cardiology) and there's a shortage of my folks in the area, I might negotiate up to something like 110-120% of medicare. Most of the time I'll be happy to get 105% medicare, and some folks will end up getting something like 95% of medicare.
To hit $1300 there'd have to be:
-A procedure, likely an inpatient or facility service, such as a small outpatient surgery, or an infusion. - Your doc has an in-house blood work lab and your insurer doesn't cover it, and the bill is actually a lab work bill
That latter bit is a gray area - it's actually barred under the Stark Law, as clinical lab work is considered a Designated Health Service that's barred from self-referral, if it's a third-party lab that they own or co-own. If it's their own actual in-clinic lab, though, I'm unsure of how that works out (I don't run my own lab, so I just know of this second-hand).
If you have a private-information-redacted copy of a 'normal' bill for $1300, I'd be happy to eyeball it - either to let you know something is off and worth appealing, or to learn something new for my self.
arkades|3 years ago
User23|3 years ago
arkades|3 years ago