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In addition, many CPT codes are bundled codes. Bundled codes are codes that include otherwise separately billed codes. A very common reason for denial of some codes is when the provider tries to unbundle a procedure. The insurer will rightly object. A good SOB will explain this, but in an abbreviated way in the footnotes.
I noticed when I first went on Medicare, that their reimbursement rates seemed to be about a third of the submitted amount, but it seems to vary. But Medicare also reduces reimbursement rates for given health care providers even more for not meeting arbitrary "quality" standards.So a provider can be dinged for not providing documentation that he/she asked each patient all those invasion of privacy questions mandated by CMS.
As I understand it, other third party payers base their reimbursement to health care providers on current Medicare reimbursement rates for a given locale. So one insurance company may reimburse at something like 90% of the Medicare rate, and other at 115% (I think I've seen figures like that for some of the BC/BS policies).
Medicare generally only reimburses providers no more than 30%. It's crazy.
And yes, you are correct that the Medicare fee schedules and rates are the baseline for most other insurance companies. I've seen some contracts, back in NYC, with reimbursement rates as high as 300% of Medicare. That's not the norm, but it happens.
No.. not at all. But I am paying more with insurance than without !!!
I guess that does seem strange, but it sounds like the provider gave you a pretty decent "uninsured"discount. I agree though, the billing figures you gave are very confusing.
I noticed when I first went on Medicare, that their reimbursement rates seemed to be about a third of the submitted amount, but it seems to vary. But Medicare also reduces reimbursement rates for given health care providers even more for not meeting arbitrary "quality" standards.So a provider can be dinged for not providing documentation that he/she asked each patient all those invasion of privacy questions mandated by CMS.
As I understand it, other third party payers base their reimbursement to health care providers on current Medicare reimbursement rates for a given locale. So one insurance company may reimburse at something like 90% of the Medicare rate, and other at 115% (I think I've seen figures like that for some of the BC/BS policies).
I dont know about Medicare but providers can get dinged by the ins co if the patient doesnt follow thru on what the dr recommended. Lets say for example, the dr writes a script for a statin. The patient refuses to fill the script and take the meds. The dr can get dinged for the patient not following the drs order. Even if the patient wants to sign a form saying the dr told me etc and I refuse. The ACA doesnt allow the patient to sign any form. Its ridiculous. Health care and ins stinks in this country, as well as the govt rules.
30% of an unreasonably high number can still be highly profitable. As others have noted, providers, hospitals and docs can charge whatever they want. Their "price" doesn't need to have any connection to reality or what we'd consider to be good business practices.
S. Florida attracts many docs, while having a big medicare population. Are these the lower intelligence docs that don't realize they're getting a bad deal at 30%?
30% of an unreasonably high number can still be highly profitable. As others have noted, providers, hospitals and docs can charge whatever they want. Their "price" doesn't need to have any connection to reality or what we'd consider to be good business practices.
S. Florida attracts many docs, while having a big medicare population. Are these the lower intelligence docs that don't realize they're getting a bad deal at 30%?
"Unreasonably high number" is defined ONLY by market forces, not by you. And not by me. The market will always tell us what is reasonable and what is not. The problem with insurance is that insurance removes market forces. Patients don't CARE what anything costs and doctors don't KNOW what anything costs. There is no longer competition or market forces because the insurance owns the market. They own the money coming in (premiums from patients) and they own the money going out (payments to doctors/hospitals).
I have 2 separate jobs as a surgeon. One is in my private practice and one is in an insurance based institutional practice. In my private practice, I finally quit de-valuing my services and dropped Medicare largely because of their ridiculous rates that barely covered my overhead. I found that patients still come to me and pay my regular fees. My fees are about 4-5x Medicare rates which means I was getting ripped off by Medicare. Within the next year I dropped all other insurance as well.
Being an out of network surgeon allows me to treat more complex cases, and now many of my colleagues in my same specialty refer these cases to me. When I was in network with insurance companies, I would decline the complex cases because they were not insurance cases. An insurance case has to be an easy slam dunk if I am working for a severe discount. For a more complex case that will take 3x as long, require much more follow-up, and carries higher risks....insurance would pay me the same low fee as the easy cases. So what incentive is there to do the more difficult cases? Just pass on them and move on to the easy ones. Patients don't realize they lose their leverage when signing up for insurance....Insurance patients tend to greatly over-estimate their value to a practice. If an insurance patient gets mad and leaves my insurance practice, that's fine because the insurance company has 10 people waiting to take their spot, and pays exactly the same for the other patients. Doesn't hurt me one bit if they "vote with their feet." Again, insurance removes the patient's leverage.
"Unreasonably high number" is defined ONLY by market forces, not by you. And not by me. The market will always tell us what is reasonable and what is not. The problem with insurance is that insurance removes market forces. Patients don't CARE what anything costs and doctors don't KNOW what anything costs. There is no longer competition or market forces because the insurance owns the market. They own the money coming in (premiums from patients) and they own the money going out (payments to doctors/hospitals).
Are you sure about this? Health Care Economists (you're not that, too?) generally say that heath care is a big market failure, where there is no transparency in prices (hence the discussion here). "unusually high number" was not my term, but a previous poster's. Regardless, I see no market mechanism that sets any of the prices in HC, be they drugs, physician services, facility fees and so forth. Patients have no opportunity to compare prices and other factors such as quality. Indeed, the various parts of the HC system have gone to great lengths to hide various quality measures, even though the data is collected.
And of course you blame "insurance". That's the part with which you have the most financial contact, and they have leverage. Patients don't. But employers do, too, as do institutions. And insurance is part of a true market. They don't have unilateral power to dictate prices. You can (and obviously have) walk away from them. That's one thing that makes a market, one where the true price is negotiated between insurer and provider. And not like arbitrary billed prices between provider and patient, where no negotiation is involved, pricing is after the fact, and the patient has no ability to walk away.
Insurance does operate in a competitive marketplace, despite your belief. Insurance "is owned" not "owns". Insurance is owned by its customers - employers for employee based insurance, individual customers for that market, and government agencies for those cases where they administer government programs like medicaid. In each situation, the customer can walk away and go elsewhere, and take their money with them. That's one form of a competitive market.
Gee, I don't think I've seen such unusual concepts since before I started business school decades ago. Then again, my B school education was all about learning how the business world actually operates. I guess some things aren't as obvious as I thought.
I'm out of work and didn't have insurance in 2017. I signed up for Obamacare insurance for 2018. When I didn't have insurance I paid me primary doctor out of my pocket which was a charge of $80.00.
I went to the doctor in April and paid my copay which was $30.00. Why did I just receive a summary of the bill which my doctor charged the insurance company $330.00
This is the break down of the bill.
Office visit $175.00
Routine Physical $50.00
General Medical Service $45.00
Routine Physical $30.00
Routine Physical $30.00
Total $330.00 of which the insurance company paid $167.38
I don't understand how the same service was $80.00 when I didn't have insurance suddenly escalated to $330.00. I asked friends the same question and they stated that a lot doctors will inflate their fees to get the most that an insurance company will pay.
These type of practices are outrageous and the patients are the ones that get hurt in the end. Healthcare services are the WORST !! Everyone and every company just seems to take advantage of the little guy. I'm just so lost for words.
On a side note, the doctor literally spent less than 5 minutes with me. He reviewed my blood work, look at my blood pressure reading (which the nurse took). and that was it !!!
Totally normal, and this is why health care (insurance) is so expensive in this country. The insurance companies are not at fault.
We have been between insurances before, and our doctor charged us the equivalent of what they charge Medicare. It was reasonable. Once you have coverage, all bets are off.
Conversely, have you ever seen how little Medicare ( and i assume other insurers) pay doctors? It’s no wonder they go for as much as they can get.
Yes, this. I have discovered that even with my overpriced Obamacare insurance, I am better off telling the doctor that I am "self-pay" and then pay cash. It is cheaper than putting a claim through insurance!
Are you sure about this? Health Care Economists (you're not that, too?) generally say that heath care is a big market failure, where there is no transparency in prices (hence the discussion here). "unusually high number" was not my term, but a previous poster's. Regardless, I see no market mechanism that sets any of the prices in HC, be they drugs, physician services, facility fees and so forth. Patients have no opportunity to compare prices and other factors such as quality. Indeed, the various parts of the HC system have gone to great lengths to hide various quality measures, even though the data is collected.
And of course you blame "insurance". That's the part with which you have the most financial contact, and they have leverage. Patients don't. But employers do, too, as do institutions. And insurance is part of a true market. They don't have unilateral power to dictate prices. You can (and obviously have) walk away from them. That's one thing that makes a market, one where the true price is negotiated between insurer and provider. And not like arbitrary billed prices between provider and patient, where no negotiation is involved, pricing is after the fact, and the patient has no ability to walk away.
Insurance does operate in a competitive marketplace, despite your belief. Insurance "is owned" not "owns". Insurance is owned by its customers - employers for employee based insurance, individual customers for that market, and government agencies for those cases where they administer government programs like medicaid. In each situation, the customer can walk away and go elsewhere, and take their money with them. That's one form of a competitive market.
Gee, I don't think I've seen such unusual concepts since before I started business school decades ago. Then again, my B school education was all about learning how the business world actually operates. I guess some things aren't as obvious as I thought.
Yes the lack of price transparency is exactly what removes an important aspect of market forces. Patients cannot compare costs and the insurance companies benefit from this lack of transparency. This is precisely an insurance issue because only the insurance company knows what they will pay for a given service. Most are surprised to learn that doctors have no idea what insurance will pay them. This is why the insurance doctors cannot give anyone an accurate estimate of what something costs...because the insurance company determines this and won't tell anyone until after the claim is filed. I do the same procedure with the same codes with the same insurance plan and the reimbursement is vastly different.
Yes the insurance companies DO have unilateral power to dictate prices. They do not negotiate their fees unless you are a university or major hospital system. Private practice doctors are told to "take it or leave it". There is no negotion and this results in contracts of adhesion.
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