Bitten by a Copperhead in Virginia

[Flamingo13]

Regardless of the poster who thought it was unnecessary to go to the hospital - IMO - if I'm bitten by a snake, I'm going to the E.R.

[Anders15]

Originally Posted by Flamingo13

Regardless of the poster who thought it was unnecessary to go to the hospital - IMO - if I'm bitten by a snake, I'm going to the E.R.

Wheres the fun in that? I much rather prefer sitting around and waiting to see if I die or not.

[Flamingo13]

Lol

[stan4]

This is why I hate these kinds of bills.
It's totally fake.
No company really got billed that and no one paid it out.
Unfortunately it's a stupid game that is played...one person asks for some astronomical price so that the insurance people will pay them a fraction of that...lower the price to the actual price, and the insurance company will lowball that price, as well. So you have to start your negotiations higher to get close to the price you want.

The same will happen at your doctor's office...you will see bills for 100 bucks or 200 bucks...they will get paid 20 bucks, I guarantee you.

[stan4]

Originally Posted by Flamingo13

Regardless of the poster who thought it was unnecessary to go to the hospital - IMO - if I'm bitten by a snake, I'm going to the E.R.

Get a stick to bite on and some whiskey.

[sunnydays077]

What happens is the provider that agrees to accept assignment from an insurance company (doctor/hosp signs up to participate with an insurance plan after seeing the insurance plan's terms & fees they will pay for each service) agrees to accept a percentage of what the insurance company deems is the reasonable & customary fee for each code they are billed for. Best way I can sum it up for you:

Your health ins is ABC Insurance. Hospital 123 participates with them meaning they accept their plan & submit the bill on your behalf & wait for payment from ABC Ins.

The billing codes are 12345 & 67890 with descriptions indicating admission, observation, etc. (Of course there will likely be excess of 25-50 codes since EVERYTHING is coded, from guaze & tape they used when they removed your IV to the codes used to bill for the attending physician.)

Say for 12345 ABC Ins says they feel $1000 is the reasonable & customary fee for this service. But the hospital's set price for code 12345 is $1600. This means if you had to pay it, they would expect you to pay $1600 for this service (not really since if they're billing a self pay rather than insured patient the fee is reduced......) but in this case ABC Ins says they pay a % of the reasonable & customary fee. Typically this is 80%, leaving the patient responsible for 20%. ABC would pay $800 of the $1000 billed to them. AND by agreeing to the plan's terms, Hosp 123 cannot bill you for the other $800, only $200 since this is the portion unpaid by the ABC Ins & Hosp 123 agreed to accept $1000 as the reasonable & customary fee for 12345 for every patient using ABC Ins.

Code 67890 has a charge of $10,000 but ABC Ins says no, no, no - our provider agreement says $6000 is reasonable & customary for this service so we'll give you 80% of the $6000 we allow. This means they pay the hospital $4800 for this code & leave you responsible for $1200.

Of course each plan has a maximum out of pocket per year along with other restrictions so you may not be responsible for the thousands & thousands left over after ABC Ins pays their 80% so pull all your plan docs & call your health insurance provider to clarify.

The reason Hosp 123 doesn't just bill the actual reasonable & customary fee is because different companies have different amounts for the reasonable & customary fees allowed. Your neighbor's MNO Ins company may say for code 12345 reasonable & customary = $1200, 67890 reasonable & customary = $7200. At 80% his insurance would net the hospital more since they would see $960 for 12345 & $5760 for 67890 from MNO Ins, leaving him responsible for $400 & $1440.

It's all a game & physicians, hospitals, dentists etc. end up agreeing to accept a range of fees for a certain service rather than just a flat fee. Unfortunately, all this does is confuse the average person that doesn't work in the medical field & have anything to do with billing.

[VRE332]

Originally Posted by sunnydays077

What happens is the provider that agrees to accept assignment from an insurance company (doctor/hosp signs up to participate with an insurance plan after seeing the insurance plan's terms & fees they will pay for each service) agrees to accept a percentage of what the insurance company deems is the reasonable & customary fee for each code they are billed for. Best way I can sum it up for you:

Your health ins is ABC Insurance. Hospital 123 participates with them meaning they accept their plan & submit the bill on your behalf & wait for payment from ABC Ins.

The billing codes are 12345 & 67890 with descriptions indicating admission, observation, etc. (Of course there will likely be excess of 25-50 codes since EVERYTHING is coded, from guaze & tape they used when they removed your IV to the codes used to bill for the attending physician.)

Say for 12345 ABC Ins says they feel $1000 is the reasonable & customary fee for this service. But the hospital's set price for code 12345 is $1600. This means if you had to pay it, they would expect you to pay $1600 for this service (not really since if they're billing a self pay rather than insured patient the fee is reduced......) but in this case ABC Ins says they pay a % of the reasonable & customary fee. Typically this is 80%, leaving the patient responsible for 20%. ABC would pay $800 of the $1000 billed to them. AND by agreeing to the plan's terms, Hosp 123 cannot bill you for the other $800, only $200 since this is the portion unpaid by the ABC Ins & Hosp 123 agreed to accept $1000 as the reasonable & customary fee for 12345 for every patient using ABC Ins.

Code 67890 has a charge of $10,000 but ABC Ins says no, no, no - our provider agreement says $6000 is reasonable & customary for this service so we'll give you 80% of the $6000 we allow. This means they pay the hospital $4800 for this code & leave you responsible for $1200.

Of course each plan has a maximum out of pocket per year along with other restrictions so you may not be responsible for the thousands & thousands left over after ABC Ins pays their 80% so pull all your plan docs & call your health insurance provider to clarify.

The reason Hosp 123 doesn't just bill the actual reasonable & customary fee is because different companies have different amounts for the reasonable & customary fees allowed. Your neighbor's MNO Ins company may say for code 12345 reasonable & customary = $1200, 67890 reasonable & customary = $7200. At 80% his insurance would net the hospital more since they would see $960 for 12345 & $5760 for 67890 from MNO Ins, leaving him responsible for $400 & $1440.

It's all a game & physicians, hospitals, dentists etc. end up agreeing to accept a range of fees for a certain service rather than just a flat fee. Unfortunately, all this does is confuse the average person that doesn't work in the medical field & have anything to do with billing.

Great response. You really dissected the industry for all of us who don't know. Sounds like a lot of wheeling and dealing in the back office. I guess if the insurance companies did not protect themselves, they would be out of business.