[loudee]

Just got done a presentation for a client. We were going over a HSA with a $3500 deductible and she asked me what would happen if she had a bill for say $1500 and the doctor let her pay it back in 3 installments. Would the full $1500 go to the deductible right away or be allocated towards it $500 at a time?

Lou

[healthagent]

It's all applied immediately. The carrier has no idea, nor cares what your payment arrangement is with the hospital or provider.

Let's say you friend is a doctor and the bill comes to $1,000 - runs through the network, carrier applies it towards the deductible then your friend says "forget about the bill."

The $1,000 is still applied.

[tryan326]

Are you asking or are you just telling us what she said?

[loudee]

Originally Posted by healthagent

It's all applied immediately. The carrier has no idea, nor cares what your payment arrangement is with the hospital or provider.

Let's say you friend is a doctor and the bill comes to $1,000 - runs through the network, carrier applies it towards the deductible then your friend says "forget about the bill."

The $1,000 is still applied.

Thanks John. That's what I thought.

Lou

[Dave020]

I had a case some years ago where the client had a $2500 deductible PPO plan. The hospital waived the deductible and the OOP for the client ($5000) completely since the final bill was almost $1 million pre-NFR (I think around $850,000). As far as the carrier is concerned, the deductible and OOPM is the patient's responsibility and it is up to the provider whether or not they need to be paid it and in what manner.

In you case, the provider would report the $1500 as paid by patient to the insurance carrier, the private arrangement is between the provider and patient only.

[salpro22]

Just try and make sure to teach your client HOW to find the pricing BEFORE they obtain health care services.

John and Dave hit it on the head.....There is nothing stopping consumers from negotiating with health care providers except lack of information and resources. Two things which will be remedied shortly...

[somarco]

Participating providers agree to
accept amounts negotiated with (insert carrier name) as payment in full. The member is responsible for any required deductible, coinsurance, or other copayments. Plan benefits paid to nonparticipating providers are based
on maximum allowable fees, as defined in
your policy.

Nonparticipating providers may balance bill
you for charges in excess of the maximum

allowable fee.

You will be responsible for charges in excess
of the maximum allowable fee in addition
to any applicable deductible, coinsurance,
or copayment. Additionally, any amount you
pay the provider in excess of the maximum
allowable fee will not apply to your
out-of-pocket limit or deductible.

[Dave020]

Pretty much hits the nail on the head, most bets are off in an out-of-network situation.

Has anyone else encountered this kind of thing?....

Subscriber receives outpatient service with non-par provider;
Subscriber submits for credit/reimbursement at OON rate;
Carrier stonewalls claim pending information from provider showing medical necessity of procedure;
Carrier denies claim as medically unnecessary.

I tell clients all the time, stay in-network for things because the par providers know to get pre-auth/pre-cert before they do a procedure. Non-par really don't care and will tell you "I will work with your PPO". Problem is, your PPO may take this kind of action. Anyone else seen that?

[healthagent]

It's more rich when your client plays by all the rules - stays in network for a procedure and get whacked with balance billing from a OON ass't surgeon or anesthesiologist.

Of course, there's no way any client can exercise due diligence in these cases.

[TXINSURANCE]

Of course, there's no way any client can exercise due diligence in these cases.

That is because the contracted rates is a guarded secret that is not posted in the Lobby. It is a shame.

Imagine taking your car in for repair and not knowing the bill until 2 weeks later when you get it in the mail.

Rates should be accessible online, public information, all companies side by side - on Norvax... OK I'll stop.

p.s. My wifes EOB arrived today - she is pregnant and went to the 1st doctors visit for blood work and ultrasound. The total bill was $2500+ - which is a complete joke for labs and ultrasound. Negotiated rate was $754 of which we were responsible for 20% around $150.

It took me 10 minutes to figure out this stupid EOB. It should be IN COLOR and graphical - it looked like it came of of a 1980s computer printer and required a Star Trek decoder (which I luckily had by the way)

The best line of the EOB said - THIS IS THE AMOUNT YOU MAY OR MAY NOT BE RESPONSIBLE FOR.

LOL - OK then when the bill comes I may or may not pay it.

[djs]

Norvax's rates aren't even posted on Norvax....
You're dreaming.... but then, you knew that.

[Dave020]

Originally Posted by healthagent

It's more rich when your client plays by all the rules - stays in network for a procedure and get whacked with balance billing from a OON ass't surgeon or anesthesiologist.

Of course, there's no way any client can exercise due diligence in these cases.

In my experience these situations are quite common. There are always going to be PARE doctors to deal with:

P=Pathologists
A=Anesthesiologists
R=Radiologists
E=Emergency Room Doctors

aka RAPE doctors, they are seldom, if ever, in-network contracted with the carriers.

However, 99.9% of the time the carrier will review these and pay the claim at in-network % of actual bill, at least for my clients.

[somarco]

PARE/RAPE.

I need to remember that.

Like the one I borrowed years ago from a buddy. DAMN coverage.

Drug, alchohol, mental, nervous.

[healthagent]

Originally Posted by Dave020

In my experience these situations are quite common. There are always going to be PARE doctors to deal with:

P=Pathologists
A=Anesthesiologists
R=Radiologists
E=Emergency Room Doctors

aka RAPE doctors, they are seldom, if ever, in-network contracted with the carriers.

However, 99.9% of the time the carrier will review these and pay the claim at in-network % of actual bill, at least for my clients.

We fought and won on both cases where my client's got balanced billed while at in in-network facility - took a while but we won.

[healthagent]

And by the way - won another one about a year back. Any have this happen?

Client went to an in-network doctor - about a month later he gets hit with the bill.

Come to find the doctor is "no longer taking that carrier" which seemed to be simply a personal decision on his part - not contractual since I got confirmation from the carrier that he was indeed still contractually an in-network doctor.

Client back on the phone and the doctor simply said he was fed up with the slow pay and decided to to accept that network. Again, he was still under contract.

It almost got ugly but in the end we won. Doctors simply can't wake up one day and decide to violate their contract.