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Well it doesn't take much to look at a fixed chart of the alloowede cahrges to know what to pay providers. Its all computerized. He bills what the going rate in his area which is the cash price to anyone comoning in and then has contract with private insurances and medicvare. He of course can refuse to trweat either if he so wants but will olse the contract rights to provide.The fact is mnay are refusing some insurance and a growing number medicare especailly in the specailties that are in demand.Only people who don't actaully pay anything don't care because it effects their premiums ;if double billed.
Moderator cut: rude and hostile
Of course, the provider knows the allowable reimbursement--I explained the reasons why he will bill more, even though he knows that it will not be paid. Moderator cut: rude
Last edited by SouthernBelleInUtah; 11-18-2009 at 02:41 PM..
Why is there such a huge difference between the amount a physician bills Medicare for his/her services, and the approved amount that Medicare will actually reimbuse?
For instance, my husband's cataract surgery: the surgeon submitted a claim to Medicare for $2,600. The Medicare approved amount is $613. Any participating Medicare provider presumably knows what they will actually be paid for their services, so why don't they just submit a claim for the $613 in the first place?
There really is a good reason why medical providers bills more than they know they will be reimbursed. If you read the agreements you sign before treatment and surgery, you will notice you are responsible for all costs, if you insurance fails to pay or if you do not have insurance as you alleged.
Of course, the provider must accept the reimbursement that he contractually agreed to previous before treatment from insurance carriers, either through PPOs, HMOs, Medicare, Medicaid etc. which he agrees to be a provider.
If he does not collect, he can go after you. If you do not pay, he can claim the full cost as a loss or theft on his income.
In addition, the provider knows and hopes that sometimes there are mistakes and he can get overpaid. I have seen in my treatments that many physician also double bill because they know that they can receive that through another mistake. After all it is not up to the provider to enforce the reimbursement rate, it is up to the insurance claim personnel.
I have seen many times they got double payments and over payments. I tried once to make an issue to the carrier but it only caused problems for me--so I do not care---as long as I do not pay double or more than required.
Knowing that people deceive and insurance processors are many times incompetent---why should he not bill more?? It is to his advantage.
Well.. most Big health insurance companies pay doctors according to what Medicare pays. If you have no insurance you might have to pay the $2,600 but if you have health insurance they pay a percentage not the full amt. I had several doctors leave the HMO/PPO because of this percentage.
No private insurance pays 20% more to doctors and 30% more to hospitals than medciare does. Private insurnace has subidised medicare;medicaid and non-insurned for years studies have shown.That includes HMOs and PPOs.That is becasue medicare sets the price they will pay or you can't treat thier patinets and private insurnance gruops bargin a contract.
I tried once to make an issue to the carrier but it only caused problems for me--so I do not care---as long as I do not pay double or more than required.
Please read my earlier post regarding incorrect insurance payments. Your bill right or wrong is something you need to take up with the people who sent it to you, not the insurance company. Look at it this way, say your friend agreed to pay your electric bill for a month or two. But when the bill came and you saw it was in error. Who would you go to for an adjustment of the bill? Your friend or the company that created and sent the bill. Would expect your friend to stand up for you and be your representative? Would he really know whether or not you actually used that amount of electricity the electric company claims you used?
As an insurance claims adjuster, I had people call and ask me to dispute their bills for them. Sometimes the bill really was legit but the claimants were angry with their Provider and wanted to slash the bill out of spite. Or maybe they felt the bill was unfair or too much or whatever. The point is if it's your bill it's between you and the biller. Period. The insurance company cannot play attorney or represent you in your dispute. That is not their job. Nor do they have the legal right to represent you. The insurance company's attorneys couldn't even represent you. It would be a conflict of interest claiming you were over billed so they could pay less.
I know how uncooperative doctors and medical facilities are when it comes to their mistakes, especially their billing mistakes. But nonetheless they are the ones to go after not the insurance company which will pay according to the scheduled amounts allowed for the service based on the HIAA tables, PPO or HMO agreements.
Please read my earlier post regarding incorrect insurance payments. Your bill right or wrong is something you need to take up with the people who sent it to you, not the insurance company. Look at it this way, say your friend agreed to pay your electric bill for a month or two. But when the bill came and you saw it was in error. Who would you go to for an adjustment of the bill? Your friend or the company that created and sent the bill. Would expect your friend to stand up for you and be your representative? Would he really know whether or not you actually used that amount of electricity the electric company claims you used?
As an insurance claims adjuster, I had people call and ask me to dispute their bills for them. Sometimes the bill really was legit but the claimants were angry with their Provider and wanted to slash the bill out of spite. Or maybe they felt the bill was unfair or too much or whatever. The point is if it's your bill it's between you and the biller. Period. The insurance company cannot play attorney or represent you in your dispute. That is not their job. Nor do they have the legal right to represent you. The insurance company's attorneys couldn't even represent you. It would be a conflict of interest claiming you were over billed so they could pay less.
I know how uncooperative doctors and medical facilities are when it comes to their mistakes, especially their billing mistakes. But nonetheless they are the ones to go after not the insurance company which will pay according to the scheduled amounts allowed for the service based on the HIAA tables, PPO or HMO agreements.
The issues I was referring to are when the insurance pays twice for the same visit, procedure or Durable Medical Equipment. This has happen to me on numerous occassions. The medical provider knows that the insurance people make mistake, are incompetent or over worked. They bill double because they hope they will get paid. They do this intentionally. Do not forget I get notices of what the insurance pays and I can see the double billing. If they are stupid, that is their problem.
That is not my problem. That is the insurance carrier problem. It does not cause me any harm, as long as I do not pay double. I am saying I have brought this to the attention of the insurance companies--it is their problem to resolve their own overpayment--not mine. It has nothing to do with my rights, I was just doing the honest thing and telling them they overpaid. Am I also not responsible for notifying the insurance carrier if they are billed for a fraudalent treatment which never occurred??? think about that.
Do you think telling the medical provider, he got paid twice, that he is going to give the money back, of course not. He is going to do nothing but take it to the bank.
It would be the cash customer who'd get screwed over good.
And you can't try to bargain with surgeons. They just might "slip" with the scalpel and say, "Oops, sorry about that. Now don't you regret haggling with me?"
If he does not collect, he can go after you. If you do not pay, he can claim the full cost as a loss or theft on his income.
What's to stop him from just lying that he tried to collected the $600 from the insurance, they failed to pay so he's coming after you for the full $2600. Isn't that more money in his pocket if he can scare you into paying out of your own funds?
Why is there such a huge difference between the amount a physician bills Medicare for his/her services, and the approved amount that Medicare will actually reimbuse?
Two words: Tax writeoff!
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