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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?
Because that is the price that they submit to insurance and cash customers. But medicare will soon be paying even less ;so good he got the surgery now.Many alos think like many countries they will not pay for both eyes until one goes to basic blindness. W are spoiled and use to get most surgeries we want it seems.
The problem I see comig is that they are cutting 300 million in medcaire spending and news agnecies are say a increase of 15% to 110.00 per month in medicare premium. I don't have medicare yet but it seems oddd to cut payments and raise premiums.
I'm guessing they charge everyone else $2,600 because Medicare pays only $613. That is, everyone else subsidizes the low Medicare payment. It's likely that when Medicare cuts the payment to say $500, the bill will go up to $3,000 to make up for it.
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.
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. If he only billed the reimbursement rate, he could only claim that as a loss and he could not inflate it latter doing his taxes. If he makes an agreement with you to take less to satisfy the debt, he can still claim the balance as a loss on his taxes. Also, if hes uses credit collection, then he sells the debt to collection agencies. Then it makes more sense for him to have the debt higher because he will sell it at a discount.
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 may an issue to the carrier but it only cause 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, stupid and are crooks---why should he not bill more?? It is to his advantage.
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.
I have seen many times they got double payments and over payments. I tried once to may an issue to the carrier but it only cause problems for me--so I do not care---as long as I do not pay double or more than required.
The problem here is that the insurance companies consider the bill as your bill for your services rendered. Even if you tell them you didn't receive these services, they can't go after the doctors for you because only the patient can correct his or her own bill. If the insurance company does ask for a refund back from the doctors, the doctors will refund them and then go after the patient for the entire billing. If and when the bill is corrected, then and only then will the patient get the refund. An insurance company will refund or adjust a payment but it's the patient who has to demand those changes in the billing are made from the doctor.
Sounds crazy I know but I saw it time and time again when I was working as an insurance claims adjuster. People would call and tell me they had been overcharged or they were billed for services never given and I would have to tell them that they had to deal with the doctor's office since they received (or did not receive) the service. If we did ask for reimbursement from the doctor it would be the patient's responsibility to pay until things got straightened out. I would recommend that if anyone is billed incorrectly, they take it to the source that did the billing rather than expecting the insurance companies to negotiate for you. They are required by their contract (your insurance policy) to pay bills sent to them on behalf of their Insureds and do not have grounds to question the accuracy of the bill.
The good news is that there are now businesses that have sprung up as advocates for the patient's billing or over-billing and will do the negotiation on the patient's behalf.
Doctors are supposed to base their payments on the HIAA, Health Insurance Association of America's UCR (Usual and Customary) amounts or the going rate in any given area. The problem is neither the insurance companies nor the medical profession are required by law to either charge or pay these amounts.
In other words, the sky's the limit for the medical charges and the amount paid for those charges is up to the insurance companies. Blue Cross for example has various contracts with various medical providers as to what will be accepted as payment as long as they charge an agreed upon amount. They were doing this long before PPO's became popular. They don't use the government HIAA-UCR guidelines.
Medicare is a different animal. They will pay what they will pay. The doctors can charge over and above UCR and do in hopes that the supplemental coverage most people have will pick up the balance. But that can be tricky. The doctors will often overcharge to get the amount for which they are actually aiming.
Sounds like a mess? It is. I had to deal with it for 30 plus years.
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