Medical Providers vs. Medical Insurance, Who is more at fault?

[Lost_in_the_HTTP]

This might be able to go in Health and Fitness, but nobody reads that section.

Got a letter in the mail today from a major medical 'system' serving this area. We don't have small hospitals any more like we used to. They have all been absorbed by various national or regional corporate level medical systems.

Apparently they are in negotiations with my medical insurance company, also a major national system. They say my insurance company is slow to pay and often denies some claims.

They want me to call customer service at my insurance company and tell them to negotiate with the provider. How is that my duty? Or how is that what customer service is supposed to be doing?

But who is more at fault? When I look at my insurance company page, I see a number of claims for my recent medical event. Something like 30 or 40 separate items. Most have been paid (marked approved), but some have not. Those are either marked denied or only partially approved. But for some of those, there is a duplicate claim marked approved. When I call and ask, it seems they are simple coding errors and needed to be resubmitted differently in order to be paid.

On the hospital patient login account, I see the total of the two stays approaching $80,000.00 for a relatively simple procedure with a minor complication. No major specialized treatment. No ICU or any like it. About 7 days inpatient.

Back to the insurance company account and I see claims submitted for several thousand dollars where only a few hundred was paid as the 'contract amount'. Where did the rest of the bill go?

Are the providers overbilling knowing the insurance will pay a lesser amount?

Are the insurance companies underpaying knowing the hospitals are going to bill higher?

 

[MtnMan]

The problem is the Amurca health care system.

 

[biostud]

For some reason you're the only western country that has this broken system.

 

[dlerious]

Back to the insurance company account and I see claims submitted for several thousand dollars where only a few hundred was paid as the 'contract amount'. Where did the rest of the bill go?

Are the providers overbilling knowing the insurance will pay a lesser amount?

Are the insurance companies underpaying knowing the hospitals are going to bill higher?

The contract amount is what the insurance agreed to pay and provider agreed to accept when they negotiated. A different insurance company might negotiate a different price. What the hospital charges may or may not be based on reality.

 

[Lost_in_the_HTTP]

This is just one example.

Billing Details​

As a reminder, this is not a bill. If you have not already paid the amount shown below, wait until you get a bill from the provider. For a received bill that is higher than the amount shown for "Your Share", click Chat with an Agent at the bottom of your screen.
Amount Billed
$464.10
Amount Plan Approved
$53.22
Plan's Share
$46.48
Your Share
$6.74

Why would they bill $464 when they know the contract only pays $53?

 

[dlerious]

This is just one example.

Billing Details​

As a reminder, this is not a bill. If you have not already paid the amount shown below, wait until you get a bill from the provider. For a received bill that is higher than the amount shown for "Your Share", click Chat with an Agent at the bottom of your screen.
Amount Billed
$464.10
Amount Plan Approved
$53.22
Plan's Share
$46.48
Your Share
$6.74

Why would they bill $464 when they know the contract only pays $53?

Because that's what someone with no plan pays. You got an 88.5% discount for using your plan.

 

[pete6032]

This is just one example.

Billing Details​

As a reminder, this is not a bill. If you have not already paid the amount shown below, wait until you get a bill from the provider. For a received bill that is higher than the amount shown for "Your Share", click Chat with an Agent at the bottom of your screen.
Amount Billed
$464.10
Amount Plan Approved
$53.22
Plan's Share
$46.48
Your Share
$6.74

Why would they bill $464 when they know the contract only pays $53?

The bill amount is just funny money. Nobody pays the bill amount. The huge discount is how all health insurance claims work.

 

[waffleironhead]

The billing amount is just a fake number they made up so you appreciate just how much your insurance is doing for you.

 

[FelixDeCat]

I blame Obama. Costs went to the moon after that went into effect.

But over time I've come to realize we do need more government healthcare choices. Maybe not single payer only, but single plus private on the side if you want to pay extra for it. At my age, I would opt into a government paid healthcare plan but I am not old enough for Medicare.

 

[dank69]

I blame Obama. Costs went to the moon after that went into effect.

But over time I've come to realize we do need more government healthcare choices. Maybe not single payer only, but single plus private on the side if you want to pay extra for it. At my age, I would opt into a government paid healthcare plan but I am not old enough for Medicare.

Lol get rekt

 

[Jon-T]

Don't even worry about about the bill amount. That's just for posting on social media for e-credit.

More than once on reddit I have seen some one post their "bill" (that says not a bill right on it) showing some scary number that elicits hundreds of posts calling for revolution and blood in the streets. Only to scroll down down 25 top level replies to find a followup where the OP says their total out of pocket was 50 bucks.

 

[Lost_in_the_HTTP]

The point of the thread is to explore why both sets of numbers are essentially false. That was for a lab test. Certainly $53 is too low. I can see it being in the $200 range, so why can't they meet in the middle and bill accurately?

 

[Torn Mind]

People go into medicine generally for the money.
People go into insurance jobs generally for the money.

As they are both businesses, they learn to to milk the riches from the system.

And the government providing healthcare is basically a "nicer business" that hates being "nicer" and concocts obtuse ways to dodge their obligation.

 

[dlerious]

The point of the thread is to explore why both sets of numbers are essentially false. That was for a lab test. Certainly $53 is too low. I can see it being in the $200 range, so why can't they meet in the middle and bill accurately?

Because they're "for-profit" companies looking to maximize profits.

 

[pete6032]

The point of the thread is to explore why both sets of numbers are essentially false. That was for a lab test. Certainly $53 is too low. I can see it being in the $200 range, so why can't they meet in the middle and bill accurately?

$53 is too low for your lab test alone, but when you have thousands of patients on your plan getting similar tests, then economics of scale kicks in and the lab still makes money doing the tests at $53 a pop.

 

[Brainonska511]

$53 is too low for your lab test alone, but when you have thousands of patients on your plan getting similar tests, then economics of scale kicks in and the lab still makes money doing the tests at $53 a pop.

Depending on the test, it could be quite cheap to start - for many tests, it's not like they're using some novel chemistry - it's stuff that was figured out decades ago. The expensive stuff for most labs is the equipment and employees; the marginal cost of additional reagents is nominal.

Anyway, EOBs are not bills, and the numbers can seem totally arbitrary and made up. They're basically showing how some chargemaster sheet the hospital creates as baseline pricing gets adjusted based on contracts with payers (eg, insurance companies) and then how cost-sharing is allocated between the insurer and the plan member.

 

[Lost_in_the_HTTP]

Turns out they're both at fault, pointing fingers at each other and could not come to an agreement for '24.

So, I either have to change insurance or providers.

One or both need to hire adults.

 

[Ajay]

Wow. That is just completely ridiculous!


This is the USA - there is too much money in healthcare to leave it to bureaucrats to squander. That's why we don't have a better healthcare system. Maybe if we tried to start a national system 50 years ago it would have worked out. Not a snowball's chance in hell these days.

 

[biostud]

Wow. That is just completely ridiculous!


This is the USA - there is too much money in healthcare to leave it to bureaucrats to squander. That's why we don't have a better healthcare system. Maybe if we tried to start a national system 50 years ago it would have worked out. Not a snowball's chance in hell these days.

You just need politicians who are willing to slowly but steady increase medicaid/medicare coverage.

 

[Lost_in_the_HTTP]

My position:

All licensed medical providers in a state must accept all licensed medical insurance plans in that state.

All licensed medical insurance plans in a state must accept all licensed medical providers in that state.

On areas and amounts that are negotiable, they get X time to work out a deal. If they are unable to, the state steps in sets the terms somewhere between the two.