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I didn't say anything about not following contracts.
Here's a friendly hint: you don't have to "say anything" about a related point someone else feels is relevant. Nobody needs your permission. Why are you so argumentative and creating arguments that don't exist?
Back on topic, nobody is arguing contracts should not be followed. You can certainly refuse to pay anything until you get an EOB, but you will find yourself having a more and more difficult time finding a doctor to give you an unsecured loan due to the ever increasing number of deadbeat patients that don't pay their part later. I'm sure you always pay your bills, but many others don't. Many people have said "Not my problem" to this issue. But this becomes everyone's problem even for those who normally pay their bills.
There is nothing wrong with collecting the patient's portion at the time of service. The only people who object to this are deadbeats who never intend to pay anyway.
There is something wrong with ASKING for that money up front. It is against the contract with the carrier. If patients chose to pay, that's on them, but they are not REQUIRED to do so and in fact the insurance company will back them up on their refusal.
And no, most patients will not have a problem finding a doc. This is how the system works. Most docs work for hospitals and most hospitals are too big to want to play this game. Losing an insurance contract would be a big deal for a hospital, and they most certainly can lose it if enough people complained.
I have had this conversation many times throughout my 30 years career, and I find there are many reasons why a patient may pay up front when they don't have to. It isn't a big deal if they do so because they want to. Some like a doc and will do anything to see them. Some are fairly certain they will owe the large deductible later and they like having the time to pay in installments. All very good reasons.
I get the motivation to get as much up front as possible, I have spent my life in the revenue cycle of hospitals. We are always looking for ways to get paid because the less we have to write off to charity (a tax credit paid for by local taxpayers) the better. We certainly love getting that money right off. No dispute there, but we have a myriad of ways to both collect and write off money because it is just a fact of doing business in healthcare, sometimes you won't get paid. It is what it is. Sometimes you get paid, and the money is taken back (say Medicare audits) so you can't even count on the idea that money received is money kept. Even still, we do our best to comply with all contracts because not doing so is an even bigger liability. No large entity wants that risk. There are better ways to manage unpaid balances that flaunting contract rules.
The only caution I would make to patients is that they should be aware that there are plenty of docs who have a hard time with refunding patient money when they have paid too much. If that isn't your issue, great. Then what I am saying isn't about you. There are however plenty of docs who do have this problem and patients should go into it knowing that the docs may breathe down their necks for the money up front, but then the patients can get crickets (silence) when they want their money back.
No need for any patient to take my word for it. Search out refunds on ANY online community that talks about healthcare and payments. Any. You will find stories of people who waited months if not years to get a refund. I have personally participated in the acquisition of private practices where we had to make the purchase of the practice contingent upon the doc paying off all of his/her debts and that included any refunds due to patients. They had excuses from making payroll to remodeling their kitchens to gambling debts for reasons refunds were not issued in a timely manner. Again...If that isn't your issue, great. Then what I am saying isn't about you.
I never spoke to reasonableness. I said it isn't allowed per the contract with the insurance carriers.
If the docs don't like it, take that up with the carriers It isn't the patient's fault that that is the way the system is structured. The doc signed the contract, they know the contract is legally enforceable, they have to follow the rules.
That being said...stupid high deductibles is a problem for the entire healthcare system. Cost shifting to the patient almost always means higher unpaid balances...so a more bankrupt system. No question that they are bad.
But again...most of us don't know enough about the system to push for change that wouldn't involve higher deductibles. Or I think we are finally learning this, but if you would have explained this back in 2009, most people wouldn't have considered deductibles a problem, a barrier to healthcare.
Let's hope we make better decisions for whatever replaces Obamacare.
Can you give an example of a health insurance contract with a physician that forbids collection of the deductible and co-insurance for obstetrical care during the pregnancy?
These OB offices make it clear that the patient responsibility must be paid before delivery.
"Phase One services are billed to your insurance company after delivery. If you do not have insurance coverage or if your insurance deductible is $1000 or more, monthly payments toward your delivery are required and the last Phase One payment must be received during the eighth (8th) month of pregnancy."
"You are responsible for co-pays and/or additional fees for these services, according to your insurance contract. You will need to make a payment of $50 on your first visit and $50 -100 each visit until your deductible/co-insurance amounts are met."
"We require payment of deductibles and co-insurances by the end of your 32 week of pregnancy. We will arrange a payment plan should you need to make payments during the pregnancy."
What doctors are discouraged from doing is waiving copayments and deductibles, as the insurance company considers that a discount of the contractually allowed amount, and the company will set the lower amount as the new allowed amount and will reimburse every claim at the lower rate.
Note that we are not talking about obstetricians who participate with health insurance companies wanting to be paid the entire global fee up front. That would result in the need for a refund to the patient. Non-participating doctors can and do collect the entire fee up front. They then file the claim and the insurance company reimburses the patient directly for out of network coverage. The patient's share of the cost of OB care is not going away. There is no reason for the insurance company to forbid collection of that money during the pregnancy.
Last edited by suzy_q2010; 08-26-2017 at 09:28 PM..
This is carrier specific. It sounds like it's a common trend in your area but I've never seen one of these plans in my area although I'm sure it exists.
My OB's office (in-network) refused to bill my insurance for the prenatal visits I had with them so far (about 3-4 visits). They insisted on me paying out of pocket and claimed that it's because my insurance doesn't cover prenatal care visit. This is not true. I have verified my insurance does cover prenatal visits at 100% without member cost sharing IF the provider bill these as prenatal visit (meaning using pregnancy related codes). So these routine pregnancy visits should have been covered.
I could not think of any reason why they say my insurance won't cover the prenatal visits other than:
1) they intend to bill my prenatal visits as non-pregnancy related;
2) they lied...
What should I do now?
Thanks!!!
It would help to know the exact language in your plan about coverage of maternity benefits.
What you should do now is sit down with someone in the billing office to clarify your coverage and confirm that you have no cost sharing. Make absolutely sure you are not seeing an out of network doctor. The insurance company may claim the doctor is in network when s/he is not. Doctors resign from networks and the insurance companies keep them on preferred provider lists long after they should have removed them.
Prenatal visits are not usually billed separately. Most obstetricians bill a flat fee for maternity service.
Can you give an example of a health insurance contract with a physician that forbids collection of the deductible and co-insurance for obstetrical care during the pregnancy?
They all do.
The very nature of deductibles is such that they are applied by all carriers on a FIFO claims submission basis. First claim for a covered service processed in gets assigned as much of the deductible up to the negotiated allowance as is possible.
The docs aren't allowed to bill in advance for them because they won't have any idea what claims may have come in and hit the deductible over the global period. That is why ALL contracts make the deductible (and coinsurance) only collectible on a post-submission basis.
They are both all calculated based on the allowance assigned to that service for that provider. And that allowance changes for various reasons: type of policy, any pre-admission requirements not satisfied, in-network/out of network, etc etc. Again, this allowance is determined only after a claim is submitted.
If anyone in your family met the max or if you yourself did, your delivery claim would pay with no deductible.
What happens in a lot of cases, the hospital bill comes in first and the deductible is assigned to the hospital, then the OB's claim comes in second and no deductible is assigned. Then the patient is fighting with the OB to get money back so it can be paid to the hospital. Happens all the time.
You are welcome to contact your insurance company and let them explain it. Better yet, report a doc doing this and see what happens.
And yes, LOTS of OBs do this. You have to check if your OB participates, but they largely get away with it because no one complains (mostly because most people don't know the rules), and they feel that a particular OB is perfect is some way or another and they are willing to give in.
It is sad how few people understand this. Too many get taken for a ride.
The very nature of deductibles is such that they are applied by all carriers on a FIFO claims submission basis. First claim for a covered service processed in gets assigned as much of the deductible up to the negotiated allowance as is possible.
The docs aren't allowed to bill in advance for them because they won't have any idea what claims may have come in and hit the deductible over the global period. That is why ALL contracts make the deductible (and coinsurance) only collectible on a post-submission basis.
They are both all calculated based on the allowance assigned to that service for that provider. And that allowance changes for various reasons: type of policy, any pre-admission requirements not satisfied, in-network/out of network, etc etc. Again, this allowance is determined only after a claim is submitted.
If anyone in your family met the max or if you yourself did, your delivery claim would pay with no deductible.
What happens in a lot of cases, the hospital bill comes in first and the deductible is assigned to the hospital, then the OB's claim comes in second and no deductible is assigned. Then the patient is fighting with the OB to get money back so it can be paid to the hospital. Happens all the time.
You are welcome to contact your insurance company and let them explain it. Better yet, report a doc doing this and see what happens.
And yes, LOTS of OBs do this. You have to check if your OB participates, but they largely get away with it because no one complains (mostly because most people don't know the rules), and they feel that a particular OB is perfect is some way or another and they are willing to give in.
It is sad how few people understand this. Too many get taken for a ride.
Deductibles today are so high that many people never meet them. For a healthy pregnant woman, the probability that she has had other medical care that will consume all of a four or five digit deductible is pretty small. It would be simple for an individual patient to track her own deductible and let the OB office know when she has met it. The OB office can also periodically check with the insurance company.
Do you have an example of a contract between an insurance company and an obstetrician that expressly forbids collecting the deductible during a pregnancy?
The very nature of deductibles is such that they are applied by all carriers on a FIFO claims submission basis. First claim for a covered service processed in gets assigned as much of the deductible up to the negotiated allowance as is possible.
The docs aren't allowed to bill in advance for them because they won't have any idea what claims may have come in and hit the deductible over the global period. That is why ALL contracts make the deductible (and coinsurance) only collectible on a post-submission basis.
It is sad how few people understand this. Too many get taken for a ride.
So, my daughter in law has been required to pay $450 a month to her OB office. She has a policy through the exchange.
I was replying to the poster who keeps insisting that it's illegal and that patients are foolish for doing it.
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