Insurance Q..

brittneycc1982

So today S had her 12 month appt.  I called ahead of time to ask if they would tell me how much I would be paying (insurance covers 80%, including shots).  She told me, "Well, the well visit will be $95 and each shot is $17". At this point she didn't look to see if we even had insurance, she was just giving me the fees.  So I did the math... Ended up paying $32.  BUT everytime I go in there they say "Oh,  you owe $X from the last visit for co-insurance." Wtf? 

My issue is this- The last few statements we've received from our insurance say that they were charged over $100 for each shot! (Remember, she said each shot was $17.) I remember at S's 6 month appt the insurance statement said the doctors office charged them like $500!  That was just for well visit and a couple shots.  Sooo do you think the Dr. office is overcharging the insurance company, which means I have to pay more also!?  There's no doubt in my mind that this happens all the time, but why do I have to pay the 20% that they are over charging? WWYD?

brightning

When in doubt, I call the insurance company and ask lots of questions.

(But even still, I never quite believe what they tell me. I called many times insisting I was being overcharged for my surgery earlier this year. They said emphatically that they charged me the correct amount ... and then I got a huge refund check from the hospital a few months later because I had been overcharged for my surgery.)

Good luck!

brittneycc1982

I will DEFINITELY call then.  I swear I pay for the same visit twice, everytime.

SuwaneeGirl

What they are doing is called "balance billing" and in many states, it's not permitted.

Your doctor's office can charge the insurance whatever it wants on office visits, shots, etc but your insurance carrier has a pre-negotiated rate it will pay the doctor's office.

So let's say the office visit charge billed to insurance is $100, and the pre-negotiated rate the carrier will pay for that office visit is $60. That leaves a balance of $40. Most physicians will write this off because they are not permitted to collect it from the patient. Some, however, will attempt to bill the patient--balance billing.

You can find out if balance billing is illegal in your state by calling your Insurance Commissioner/Department of Insurance. Your EOB (the statement you get from the insurance carrier) may also say something like "the patient is not responsible for charges not paid by insurance except for copay/co-insurance" as well, so check that.

 

Sharon&Paul

SuwaneeGirl:

What they are doing is called "balance billing" and in many states, it's not permitted.

Your doctor's office can charge the insurance whatever it wants on office visits, shots, etc but your insurance carrier has a pre-negotiated rate it will pay the doctor's office.

So let's say the office visit charge billed to insurance is $100, and the pre-negotiated rate the carrier will pay for that office visit is $60. That leaves a balance of $40. Most physicians will write this off because they are not permitted to collect it from the patient. Some, however, will attempt to bill the patient--balance billing.

You can find out if balance billing is illegal in your state by calling your Insurance Commissioner/Department of Insurance. Your EOB (the statement you get from the insurance carrier) may also say something like "the patient is not responsible for charges not paid by insurance except for copay/co-insurance" as well, so check that.

 

No, it does not sound like this. This usually only applies to HMO. It sounds like you have a ppo insurance. I have worked in three states (NY, PA, and MA) and all those states allowed the doctors office to charge their rate. What it sounds like is happening is you doctor's office offers a discount to cash paying (no insurance patients), which is very common. However, because your visit is getting billed through the insurance you are getting billed full price (well 20% of full price). I actually don't have any advise, because I never thought about it. I have always had HMOs and just paid a co-pay. However, I can say all the offices I have worked at bill very similiar to what your office is doing.

SuwaneeGirl

Sharon&Paul:

SuwaneeGirl:

What they are doing is called "balance billing" and in many states, it's not permitted.

Your doctor's office can charge the insurance whatever it wants on office visits, shots, etc but your insurance carrier has a pre-negotiated rate it will pay the doctor's office.

So let's say the office visit charge billed to insurance is $100, and the pre-negotiated rate the carrier will pay for that office visit is $60. That leaves a balance of $40. Most physicians will write this off because they are not permitted to collect it from the patient. Some, however, will attempt to bill the patient--balance billing.

You can find out if balance billing is illegal in your state by calling your Insurance Commissioner/Department of Insurance. Your EOB (the statement you get from the insurance carrier) may also say something like "the patient is not responsible for charges not paid by insurance except for copay/co-insurance" as well, so check that.

 

No, it does not sound like this. This usually only applies to HMO. It sounds like you have a ppo insurance. I have worked in three states (NY, PA, and MA) and all those states allowed the doctors office to charge their rate. What it sounds like is happening is you doctor's office offers a discount to cash paying (no insurance patients), which is very common. However, because your visit is getting billed through the insurance you are getting billed full price (well 20% of full price). I actually don't have any advise, because I never thought about it. I have always had HMOs and just paid a co-pay. However, I can say all the offices I have worked at bill very similiar to what your office is doing.

If the doctor's office is attempting to charge the patient what the doctor's office can't get as reimbursement from the insurance carrier, and the patient has medical insurance that covers the claims, then yes, it is balance billing. Whether it's permitted in the OP's state (by statute or per the policy) or not is the question. That's what I got from the OP's question, since she was asking about why she was being asked to pay what the insurance carrier didn't pay.

 

Sharon&Paul

SuwaneeGirl:

Sharon&Paul:

SuwaneeGirl:

What they are doing is called "balance billing" and in many states, it's not permitted.

Your doctor's office can charge the insurance whatever it wants on office visits, shots, etc but your insurance carrier has a pre-negotiated rate it will pay the doctor's office.

So let's say the office visit charge billed to insurance is $100, and the pre-negotiated rate the carrier will pay for that office visit is $60. That leaves a balance of $40. Most physicians will write this off because they are not permitted to collect it from the patient. Some, however, will attempt to bill the patient--balance billing.

You can find out if balance billing is illegal in your state by calling your Insurance Commissioner/Department of Insurance. Your EOB (the statement you get from the insurance carrier) may also say something like "the patient is not responsible for charges not paid by insurance except for copay/co-insurance" as well, so check that.

 

No, it does not sound like this. This usually only applies to HMO. It sounds like you have a ppo insurance. I have worked in three states (NY, PA, and MA) and all those states allowed the doctors office to charge their rate. What it sounds like is happening is you doctor's office offers a discount to cash paying (no insurance patients), which is very common. However, because your visit is getting billed through the insurance you are getting billed full price (well 20% of full price). I actually don't have any advise, because I never thought about it. I have always had HMOs and just paid a co-pay. However, I can say all the offices I have worked at bill very similiar to what your office is doing.

If the doctor's office is attempting to charge the patient what the doctor's office can't get as reimbursement from the insurance carrier, and the patient has medical insurance that covers the claims, then yes, it is balance billing. Whether it's permitted in the OP's state (by statute or per the policy) or not is the question. That's what I got from the OP's question, since she was asking about why she was being asked to pay what the insurance carrier didn't pay.

 

Actually she said with her insurance she pays 20% and insurance pays 80%, which is why it sounds like she has a ppo (not HMO).