OT: T2 has general insurance/billing question

"Phillip J Fry" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

Type 2 for just over a year.

I hope this isn't too off topic. After all, medical expenses and insurance claims are certainly
part of a diabetic's life.

Here's the scenario . . . I am a member of a group insurance plan (woo

hoo!)

Quoted message said:

which utilizes a PPO network. When my insurance plan processes a claim

from

Quoted message said:

a network provider, they of course will only approve/pay pre-contracted amounts for a given
procedure. The rest is classified on the explanation

of

Quoted message said:

benefits as "unapproved" or as a discount to the insured/patient. Does the provider have the legal
right to backcharge these rejected amounts to the patient? It has never happened to me; rather, I
am simply curious. If

indeed

Quoted message said:

they do have that right, then why does it never seem to happen? Instead,

the

Quoted message said:

provider essentially writes off the difference. Sometimes the difference

can

Quoted message said:

be significant. My doctor orders $400 in lab tests on me every 3 months. Only $200 are approved by
the medical plan (of which I pay 20%, and the

plan

Quoted message said:

80%). The rest is a write off for the lab.

I would love some insight.

It really depends on the type of plan you have. I have a similar plan to yours. The Drs. who take my
plan have agreed with my insurance that they will not charge the patient for any excess that the
plan does not pay. Now this doesn't mean that they don't try to charge it however! I went round and
round with one Dr. and she was so insistent that I finally paid the amount she told me I owed. She
claimed she had called my insurance and this was what I owed. Turns out, I paid her $129 and some
change over and above what I should have paid her. Took me 6 months to get it back from her. I've
also had some strange looking bills for small amounts from various Drs. that came to me nearly a
year after the office visit. This happened a couple of years ago. I suspect they were overbilling me
and they figured that since it was such a small amount, I would just go ahead and pay it. And indeed
this is what I did. I was just so ill at the time, I didn't feel like trying to sort it all out.
Since then, my insurance company has a website where I can access my account information almost
instantly. Now I can look things up and I know for sure what I owe and what I don't. I no longer
have to sort through all my paperwork to see what happened.

--
Type 2 users.bestweb.net~jboveOpen ↗

Phillip J Fry said:

Type 2 for just over a year.

I hope this isn't too off topic. After all, medical expenses and insurance claims are certainly
part of a diabetic's life.

Here's the scenario . . . I am a member of a group insurance plan (woo hoo!) which utilizes a PPO
network. When my insurance plan processes a claim from a network provider, they of course will
only approve/pay pre-contracted amounts for a given procedure. The rest is classified on the
explanation of benefits as "unapproved" or as a discount to the insured/patient. Does the provider
have the legal right to backcharge these rejected amounts to the patient? It has never happened to
me; rather, I am simply curious. If indeed they do have that right, then why does it never seem to
happen? Instead, the provider essentially writes off the difference. Sometimes the difference can
be significant. My doctor orders $400 in lab tests on me every 3 months. Only $200 are approved by
the medical plan (of which I pay 20%, and the plan 80%). The rest is a write off for the lab.

I would love some insight.

In general, it depends on the contract that the lab or other provider has with the insurer.
In most cases, the billed amount is just hot air. The provider would be shocked if anyone
ever paid that amount. There can be exceptions. For instance, on Tricare, the insurance pays
a fixed percentage of the amount it believes is somehow correct, and the patient pays the
remaining percentage of the contract amount, providing that the provider has agreed to
accept tricare. If there is no such agreement, the provider gets to charge 15% more. Under
some circumstances, the provider can charge much more. Except for Medicare, Medicaid, and
related government-pay programs, there is no universal answer. In most cases of private
insurance the I have encountered, there was a stated amount (in some cases, zero) that the
patient was to pay.

I would suggest that you contact member services or its equivalent at your insurer.

Speaking only for myself,

Joe Durusau

Phillip J Fry wrote in message ...

Quoted message said:

Type 2 for just over a year.

I hope this isn't too off topic. After all, medical expenses and insurance claims are certainly
part of a diabetic's life.

Here's the scenario . . . I am a member of a group insurance plan (woo

hoo!)

Quoted message said:

which utilizes a PPO network. When my insurance plan processes a claim from a network provider,
they of course will only approve/pay pre-contracted amounts for a given procedure. The rest is
classified on the explanation of benefits as "unapproved" or as a discount to the insured/patient.
Does the provider have the legal right to backcharge these rejected amounts to the patient? It has
never happened to me; rather, I am simply curious. If

indeed

Quoted message said:

they do have that right, then why does it never seem to happen? Instead,

the

Quoted message said:

provider essentially writes off the difference. Sometimes the difference

can

Quoted message said:

be significant. My doctor orders $400 in lab tests on me every 3 months. Only $200 are approved by
the medical plan (of which I pay 20%, and the

plan

Quoted message said:

80%). The rest is a write off for the lab.

I would love some insight.

The concept of a "network provider" means the provider signed a contract with the group
insurance plan. The terms of the contract are such that the provider discounts his services,
and you will not be billed for the discount.

The penalties for going "out of network" in my plan are considerable. Since there's no contractual
discount, "somebody" has to pay the full shot. In my plan, I pay the difference between the typical
negotiated rate and the "out-of-network" rate. This I know for a $289 fact.

This is an example of a grievous flaw in the U.S. Health Care system. It means that those least able
to pay get stuck with the maximum possible bills.

Regards
Old Al

"Phillip J Fry" <[email hidden]> wrote in message news:<[email hidden]>...

Quoted message said:

Type 2 for just over a year.

I hope this isn't too off topic. After all, medical expenses and insurance claims are certainly
part of a diabetic's life.

Here's the scenario . . . I am a member of a group insurance plan (woo hoo!) which utilizes a PPO
network. When my insurance plan processes a claim from a network provider, they of course will
only approve/pay pre-contracted amounts for a given procedure. The rest is classified on the
explanation of benefits as "unapproved" or as a discount to the insured/patient. Does the provider
have the legal right to backcharge these rejected amounts to the patient? It has never happened to
me; rather, I am simply curious. If indeed they do have that right, then why does it never seem to
happen? Instead, the provider essentially writes off the difference. Sometimes the difference can
be significant. My doctor orders $400 in lab tests on me every 3 months. Only $200 are approved by
the medical plan (of which I pay 20%, and the plan 80%). The rest is a write off for the lab.

I would love some insight.

I am with a Cigna PPO. The providers are contracturally prohibited from charging this back to the
patient. By accepting the insurance the providers agree to accept these amounts.

The differences can be truly staggering. I had a hospital stay with a pre-discount cost of
$28000+ and it came down to $14000+. My wife had outpatient surgery and it was about $9000,
discounted to $900.

Phillip J Fry said:

Type 2 for just over a year.

I hope this isn't too off topic. After all, medical expenses and insurance claims are certainly
part of a diabetic's life.

Here's the scenario . . . I am a member of a group insurance plan (woo hoo!) which utilizes a PPO
network. When my insurance plan processes a claim from a network provider, they of course will
only approve/pay pre-contracted amounts for a given procedure. The rest is classified on the
explanation of benefits as "unapproved" or as a discount to the insured/patient. Does the provider
have the legal right to backcharge these rejected amounts to the patient? It has never happened to
me; rather, I am simply curious. If indeed they do have that right, then why does it never seem to
happen? Instead, the provider essentially writes off the difference. Sometimes the difference can
be significant. My doctor orders $400 in lab tests on me every 3 months. Only $200 are approved by
the medical plan (of which I pay 20%, and the plan 80%). The rest is a write off for the lab.

I would love some insight.

Think cars.

The list price that the lab posts is like the sticker price (msrp) on a car. No one really pays it.
The insuror is like a fleet buyer, bidding a price that they are willing to pay for a large
quantity. The greater the quantity they are willing to buy, the better price they can negotiate. The
contract between the insuror and the insured (your "policy"😉 defines whether (1) the provider can
bill the difference between the sticker price and the contracted price back to the patient, and
whether (2) they can actually collect it.

For pharmaceuticals, eg, a common contract pays the negotiated price and allows the pharmacy to
charge the policy holder a flat $5 per scrip (copay).

Cash payors who request a discount will get, typically, 25% - 35% discount from "msrp".

Re: T2 has general insurance/billing question

This is an example of a grievous flaw in the U.S. Health Care system. =A0 It means that those least
able to pay get stuck with the maximum possible bills. Regards =A0=A0Old Al

i take that as a middle class working male correct?

case

the case, minus a few cans!

IF YOU CAN'T SWIM DON'T JUMP IN wrote in message <22662-3F9F2A28-430@storefull-
2115.public.lawson.webtv.net>...

Re: T2 has general insurance/billing question

Quoted message said:

This is an example of a grievous flaw in the U.S. Health Care system. It means that those least
able to pay get stuck with the maximum possible bills.

Quoted message said:

Regards Old Al

i take that as a middle class working male correct?

case

Close enough. Middle class, retired male.

Lotsa work, 43 years to be exact.

Regards
Old Al

CID said:

Phillip J Fry said:

Type 2 for just over a year.

I hope this isn't too off topic. After all, medical expenses and insurance claims are certainly
part of a diabetic's life.

Here's the scenario . . . I am a member of a group insurance plan (woo hoo!) which utilizes a PPO
network. When my insurance plan processes a claim from a network provider, they of course will
only approve/pay pre-contracted amounts for a given procedure. The rest is classified on the
explanation of benefits as "unapproved" or as a discount to the insured/patient. Does the
provider have the legal right to backcharge these rejected amounts to the patient? It has never
happened to me; rather, I am simply curious. If indeed they do have that right, then why does it
never seem to happen? Instead, the provider essentially writes off the difference. Sometimes the
difference can be significant. My doctor orders $400 in lab tests on me every 3 months. Only $200
are approved by the medical plan (of which I pay 20%, and the plan 80%). The rest is a write off
for the lab.

I would love some insight.

Think cars.

The list price that the lab posts is like the sticker price (msrp) on a car. No one really pays it.
The insuror is like a fleet buyer, bidding a

Oh, yes they do pay the whole amount. We the uninsured pay the sticker price. The uninsured have no
bargaining power. I speak of experience.

Quoted message said:

price that they are willing to pay for a large quantity. The greater the quantity they are willing
to buy, the better price they can negotiate. The contract between the insuror and the insured (your
"policy"😉 defines whether (1) the provider can bill the difference between the sticker price and
the contracted price back to the patient, and whether (2) they can actually collect it.

For pharmaceuticals, eg, a common contract pays the negotiated price and allows the pharmacy to
charge the policy holder a flat $5 per scrip (copay).

Cash payors who request a discount will get, typically, 25% - 35% discount from "msrp".

Since when? I tried my darnest to have my GP reduce the price of lab work, without success. I also
tried to get the pharmacy to give me a discount for script, again without success.

_____________________________________________
tcainternet.comindex.htmlOpen ↗

Hi_Therre said:

Quoted message said:

The list price that the lab posts is like the sticker price (msrp) on a car. No one really pays
it. The insuror is like a fleet buyer, bidding a

Oh, yes they do pay the whole amount. We the uninsured pay the sticker price. The uninsured have
no bargaining power. I speak of experience.

[censored]. No third party payors pay sticker price with the exception of unapproved and unneeded
procedures and supplies that are required by legislative action.

I am also uninsured. I pay sticker price for most drugs (although I do shop for the lowest sticker
price, and that varies big time) but I never pay sticker price for physician, lab, hospital,
eyeglasses, or ambulance services. If yer experience is otherwise, you either lack the basic skills
or are clearly unwilling to negotiate with providers.

Quoted message said:

Quoted message said:

Cash payors who request a discount will get, typically, 25% - 35% discount from "msrp".

Since when? I tried my darnest to have my GP reduce the price of lab work, without success. I also
tried to get the pharmacy to give me a discount for script, again without success.

Yer GP can't reduce the price of lab services (unless he owns the lab) any more than the Chevy
dealer can reduce the price of your Sony TV. Deal with the GP on his fee, with the lab on their
charges. Shop pharmacies and you'll find better prices.

Alternatively, just roll over and take it. But stop whining.

"oldal4865" <[email hidden]> wrote in message news:<[email hidden]>...

Quoted message said:

IF YOU CAN'T SWIM DON'T JUMP IN wrote in message <22662-3F9F2A28-430@storefull-
2115.public.lawson.webtv.net>...

Re: T2 has general insurance/billing question

Quoted message said:

This is an example of a grievous flaw in the U.S. Health Care system. It means that those least
able to pay get stuck with the maximum possible bills.

Quoted message said:

Regards Old Al

i take that as a middle class working male correct?

case

Close enough. Middle class, retired male.

Lotsa work, 43 years to be exact.

Regards
Old Al

I understand that you think this is a flaw in the system - but a flaw for who? It often times is a
provider of service who does not get paid for providing service. It is unfair that those who can't
afford to pay end up paying the most - I agree there - but the amount of money, and time it takes a
provider of service to collect on the services provided even further discounts what he/she does
receive from insurance companies. In order for a provider to be able to provide the level of care
that he/she does there needs to be some kind of leveling factor. Where else can you go, get
services, and then tell the business providing service to try and collect from someone else and if
there is a bill left over then send me a bill? --S

CID said:

Hi_Therre said:

Quoted message said:

The list price that the lab posts is like the sticker price (msrp) on a car. No one really pays
it. The insuror is like a fleet buyer, bidding a

Oh, yes they do pay the whole amount. We the uninsured pay the sticker price. The uninsured have
no bargaining power. I speak of experience.

[censored]. No third party payors pay sticker price with the exception of unapproved and unneeded
procedures and supplies that are required by legislative action.

I am also uninsured. I pay sticker price for most drugs (although I do shop for the lowest sticker
price, and that varies big time) but I never pay sticker price for physician, lab, hospital,
eyeglasses, or ambulance services. If yer experience is otherwise, you either lack the basic skills
or are clearly unwilling to negotiate with providers.

You can reduce lab, eyeglass costs. Well tell me how you do this O Great One? Two weeks ago I paid
about $160 at Walmart's VisionCenter for exam and lenses. There was no way they would reduce the
cost, I tried without success.

Quoted message said:

Quoted message said:

Quoted message said:

Cash payors who request a discount will get, typically, 25% - 35% discount from "msrp".

Since when? I tried my darnest to have my GP reduce the price of lab work, without success. I
also tried to get the pharmacy to give me a discount for script, again without success.

Yer GP can't reduce the price of lab services (unless he owns the lab) any more than the Chevy
dealer can reduce the price of your Sony TV. Deal with the GP on his fee, with the lab on their
charges. Shop pharmacies and you'll find better prices.

The clinic where the GP works owns the lab. Hell will freeze three times before they reduce their
costs. I know of no clinic in town that will reduce lab costs for anybody. I know of many others who
have also tried and failed. Why don't you clue us in how you do it?

You appear to have the magic touch, clue us in.

Hi_Therre said:

CID said:

Hi_Therre said:

>
>The list price that the lab posts is like the sticker price (msrp) on a car. No one really pays
>it. The insuror is like a fleet buyer, bidding a

Oh, yes they do pay the whole amount. We the uninsured pay the sticker price. The uninsured have
no bargaining power. I speak of experience.

[censored]. No third party payors pay sticker price with the exception of unapproved and unneeded
procedures and supplies that are required by legislative action.

I am also uninsured. I pay sticker price for most drugs (although I do shop for the lowest sticker
price, and that varies big time) but I never pay sticker price for physician, lab, hospital,
eyeglasses, or ambulance services. If yer experience is otherwise, you either lack the basic
skills or are clearly unwilling to negotiate with providers.

You can reduce lab, eyeglass costs. Well tell me how you do this O Great One? Two weeks ago I paid
about $160 at Walmart's VisionCenter for exam and lenses. There was no way they would reduce the
cost, I tried without success.

Quoted message said:

Quoted message said:

>Cash payors who request a discount will get, typically, 25% - 35% discount from "msrp".

Since when? I tried my darnest to have my GP reduce the price of lab work, without success. I
also tried to get the pharmacy to give me a discount for script, again without success.

Yer GP can't reduce the price of lab services (unless he owns the lab) any more than the Chevy
dealer can reduce the price of your Sony TV. Deal with the GP on his fee, with the lab on their
charges. Shop pharmacies and you'll find better prices.

The clinic where the GP works owns the lab. Hell will freeze three times before they reduce their
costs. I know of no clinic in town that will reduce lab costs for anybody. I know of many others
who have also tried and failed. Why don't you clue us in how you do it?

You appear to have the magic touch, clue us in.

I also got my last glasses at Wal-Mart. I showed them the scrip and told them what I wanted for
lenses and frame. They gave me a price. I politely said I really wanted to do business with them but
I could do better elsewhere. The supervisor was called and I was offered a 20% discount.

If the GP is referring lab business to his own clinic's lab, he has a conflict of interest. Pick
another lab and tell yer GP to send the lab work there. Eliminates the unnecessary lab work and
makes you, not the GP, the buyer.

"mike gray, CID" <[email hidden]> wrote in message news:<[email hidden]>...

Quoted message said:

Hi_Therre said:

CID said:

Hi_Therre wrote:

>>
>>The list price that the lab posts is like the sticker price (msrp) on a car. No one really
>>pays it. The insuror is like a fleet buyer, bidding a
>
> Oh, yes they do pay the whole amount. We the uninsured pay the sticker price. The uninsured
> have no bargaining power. I speak of experience.

[censored]. No third party payors pay sticker price with the exception of unapproved and unneeded
procedures and supplies that are required by legislative action.

I am also uninsured. I pay sticker price for most drugs (although I do shop for the lowest
sticker price, and that varies big time) but I never pay sticker price for physician, lab,
hospital, eyeglasses, or ambulance services. If yer experience is otherwise, you either lack the
basic skills or are clearly unwilling to negotiate with providers.

You can reduce lab, eyeglass costs. Well tell me how you do this O Great One? Two weeks ago I
paid about $160 at Walmart's VisionCenter for exam and lenses. There was no way they would
reduce the cost, I tried without success.

Quoted message said:

>>Cash payors who request a discount will get, typically, 25% - 35% discount from "msrp".
>
> Since when? I tried my darnest to have my GP reduce the price of lab work, without success. I
> also tried to get the pharmacy to give me a discount for script, again without success.

Yer GP can't reduce the price of lab services (unless he owns the lab) any more than the Chevy
dealer can reduce the price of your Sony TV. Deal with the GP on his fee, with the lab on their
charges. Shop pharmacies and you'll find better prices.

The clinic where the GP works owns the lab. Hell will freeze three times before they reduce
their costs. I know of no clinic in town that will reduce lab costs for anybody. I know of many
others who have also tried and failed. Why don't you clue us in how you do it?

You appear to have the magic touch, clue us in.

I also got my last glasses at Wal-Mart. I showed them the scrip and told them what I wanted for
lenses and frame. They gave me a price. I politely said I really wanted to do business with them
but I could do better elsewhere. The supervisor was called and I was offered a 20% discount.

If the GP is referring lab business to his own clinic's lab, he has a conflict of interest. Pick
another lab and tell yer GP to send the lab work there. Eliminates the unnecessary lab work and
makes you, not the GP, the buyer.

Usually a Provider will reduce his prices to what the insurance companies allow. Often times you
would just need to write a letter to the office and explain your situation. MOST physicians are
understanding about these charegs.