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Balance Billing
Old 12-23-2013, 09:56 PM   #1
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Balance Billing

The recent "colonoscopy" thread in this section brought something to mind we are preparing to deal with right now.

Wife had a colonoscopy a while back .... in-network gastroenterologist, in-network facility.

So we get our insurance statement today showing that a provider (after doing a little detective work I found out this person is a CRNA) billed $1500 of which the insurance company paid $675 and indicated we would be responsible for the rest ($825).

Per our insurance plan an over age 50 routine colonoscopy is supposed to be covered 100% once every five years so long as it's done in-network. Naturally we had no choice of the anesthetist or even knowledge of who that would be.

Haven't seen a bill from this particular provider yet - but not inclined to just pay it in full if we do get one.

Now I've previously dealt with some balance billing issues when we went through a major medical event some years ago ... but not lately. I don't look forward to going through that again. Some folk say it's your responsibility to check with each provider as to whether they are in-network or not ... but in this situation ... seriously? I could as easily counter that it's incumbent upon each provider to check & see what our insurance pays ... particularly if we are in an in-network outpatient facility.

I would be interested to hear the different forum member's thoughts on this.
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Old 12-23-2013, 10:07 PM   #2
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I faced this issue on a surgery a few years ago. None of the anesthesia people were in network. Around here, they apparently don't join networks.

The one good thing was that our policy provided that certain types of services (I think anesthesia, pathology, maybe a couple of others) would be covered as in network if it done in an in network facility.

That did help some as we were at a point to be reimbursed 100% of in net work versus 60% for out of network. Of course, none of that would have prevented the out of network provider from balance billing us. While they were paid as in network, it was paid at what our carrier thought was the reasonable amount which was much less than what the out of network provider charged.

There were two out of network providers that fell under this. Note that initially the carrier paid at out of network rate. We pointed out the policy provision to pay at in network rate so the carrier then paid more. I was worried about getting a balance bill from the providers, but we never heard a word.

By the way, I did actually try to track down every provider before I had surgery. I was going to ask for someone in network. What I found out was that for certain things there was simply no one in any network at any of the several hospitals in the area. No anesthesiologists were in network at any of the several hospitals. And, so on. However, in calling some of these providers I found that basically they were accepting what the insurer paid if the insurer paid it at in network rates. They didn't have to, but they were.

I actually think this is a situation where it is really unjust since you as a patient have no control over this and you can't just go to another hospital when you have a situation where these types of providers don't join networks.
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Old 12-23-2013, 10:29 PM   #3
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I actually think this is a situation where it is really unjust since you as a patient have no control over this and you can't just go to another hospital when you have a situation where these types of providers don't join networks.
You not only have no control, you are often unconscious when the out of network providers are involved. We are facing this situation currently. The first step is to file an appeal with the insurance company. My second step will be to ask the out of network to write off their balances. Third will be to offer them partial payment.

What recourse does a patient have? What controls are there in place to prevent out of network providers from charging you ten times the going rate for their services and expecting you to pay? This is one of the reasons we are likely to retire outside the U.S. Even in countries without universal health care the health costs are a fraction of the costs in the U.S. and often for higher rated health care systems.
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Old 12-23-2013, 10:50 PM   #4
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It costs your providers nothing if they send you to an out of network provider. Ultimately it's your money and therefore your responsibility. And my insurance tells me that all the time. My providers have done a great job making sure everyone they refer me to is in network, even when they have to find someone they don't usually use. But they're doing it just to be good guys and retain their patient base.

If you use an HMO it should take care of this problem. That was one of the benefits when we used an HMO.
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Old 12-23-2013, 11:06 PM   #5
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Not looking forward to the day when I receive a balance-bill from an out-of-network contract orderly at an in-network facility for pushing my gurney down the hall. (guess they just haven't thought of it or don't have a billing code for it yet)
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Old 12-23-2013, 11:18 PM   #6
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It costs your providers nothing if they send you to an out of network provider. Ultimately it's your money and therefore your responsibility. And my insurance tells me that all the time. My providers have done a great job making sure everyone they refer me to is in network, even when they have to find someone they don't usually use.
Animorph, the part I think you are missing is that for certain hospital based services there may be no one in network at any hospital. A few years ago I was having some surgery and I wanted to track this down and found that for certain providers they simply did not join networks. It didn't matter what hospital you went you, no one was in network. You had no ability to find an in network provider because they didn't exist. Also, FWIW, my in network provider had zero to do with this because these providers were selected by the hospital not my personal surgeon. All of the area hospitals, by the way, contracted for some services with the same provider group. And that group was a member of zero networks.

This was why our policy actually did pay those providers at in network rates. However, this wouldn't keep those providers from trying to balance bill. Nonetheless, in our case, none of them balance billed and they accepted what the insurer paid them, which was at the in network percentage (100% v. 60%) but heavily discounted.
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Old 12-24-2013, 12:00 AM   #7
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retiredatfifty,

The first thing I would check is that the procedure was billed as Routine Preventative. On our insurance plan that is the coding designation that determines that it is covered at 100%. The definition for this is that you had no signs or symptoms of whatever the test is for and that it is a routine screening.

I've dealt with this a few times with bloodwork ordered by DH's doctor. A few years ago his staff was clueless as to getting these things processed correctly. After talking to our insurer I learned how "Routine Preventative" is handled and how it needs to be submitted.

If your colonoscopy was ordered because your doctor suspected something then it's no longer routine preventative.

Not a medical professional here, just a consumer who has asked lots of questions and taken notes.
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Old 12-24-2013, 06:20 AM   #8
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I had the a similar issue, mine was not 'coded as routine' and I got balance billing. Took a few phone calls to get it resolved but finally 100% was piad including the anesthetist.

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retiredatfifty,

The first thing I would check is that the procedure was billed as Routine Preventative. On our insurance plan that is the coding designation that determines that it is covered at 100%. The definition for this is that you had no signs or symptoms of whatever the test is for and that it is a routine screening.

I've dealt with this a few times with bloodwork ordered by DH's doctor. A few years ago his staff was clueless as to getting these things processed correctly. After talking to our insurer I learned how "Routine Preventative" is handled and how it needs to be submitted.

If your colonoscopy was ordered because your doctor suspected something then it's no longer routine preventative.

Not a medical professional here, just a consumer who has asked lots of questions and taken notes.
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Old 12-24-2013, 06:51 AM   #9
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Another aspect of our overly-complex health care system, as how it is covered by the insurer depends in large part on how it is coded by the medical practice, coding differences affect reimbursement rates and place practitioners and insurers in potential conflict, and none of these things are shared with the patient, who ultimately must pay, regardless.

The ACA helps in two ways. First, by requiring no cost sharing for a preventive screening, second by requiring insurers cover out of network providers if no in-network provider is available. Patients may still be stuck with a bill to pay, but it is less likely. This KFF brief looks at the colonoscopy under the new ACA regs http://kaiserfamilyfoundation.files....13/01/8351.pdf and here's a short article, also KFF, on this http://www.kaiserhealthnews.org/Feat...opy-costs.aspx
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Old 12-24-2013, 07:01 AM   #10
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retiredatfifty,

The first thing I would check is that the procedure was billed as Routine Preventative. On our insurance plan that is the coding designation that determines that it is covered at 100%. The definition for this is that you had no signs or symptoms of whatever the test is for and that it is a routine screening.

I've dealt with this a few times with bloodwork ordered by DH's doctor. A few years ago his staff was clueless as to getting these things processed correctly. After talking to our insurer I learned how "Routine Preventative" is handled and how it needs to be submitted.

If your colonoscopy was ordered because your doctor suspected something then it's no longer routine preventative.

Not a medical professional here, just a consumer who has asked lots of questions and taken notes.
Not the case here .... the insurance statement indicates the $650 insurance paid is 100% with no co-insurance amount listed. Were it not Routine Preventive the statement would have told me to pay coinsurance of 15% for in-network & 30% for an out-of-network.

We had some insurance statements like this show up earlier in the year during my ER visit (that's another story) and never received any bill at all from the out-of-network provider. Perhaps that will be the case for this one.

Too bad the whole system can't be more price-transparent for everyone - consumers and providers - on the front-end. But that's getting political ... so I won't go there.
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Old 12-24-2013, 08:13 AM   #11
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BCBSTX created this web page title "Important Message About Hospital-Based Physicians" to assist patients dealing with hospital providers and network issues. I found it very informative looking at my area.

Provider Finder - Important Message
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Old 12-24-2013, 08:20 AM   #12
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BCBSTX created this web page title "Important Message About Hospital-Based Physicians" to assist patients dealing with hospital providers and network issues. I found it very informative looking at my area.

Provider Finder - Important Message
Thanks, very good info to pass on to my daughter who has BCBS under the ACA.
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Old 12-24-2013, 08:33 AM   #13
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Thanks, very good info to pass on to my daughter who has BCBS under the ACA.
This is just for Texas, but maybe other BCBS have created a similar page. I found it on the top level of the "provider finder" page.
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Old 12-24-2013, 08:50 AM   #14
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This is just for Texas, but maybe other BCBS have created a similar page. I found it on the top level of the "provider finder" page.
Yes, we are Texans...
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