MRI Billing and Insurance

[easysurfer]

Helping a sister. Her neurologist ordered some tests that requires 2 MRIs.

My question is on the billing and insurance. The insurance covers the neurologist and the hospital the neurologist belongs to. The hospital accepts her insurance. Haven't scheduled appointments yet.

Question is if MRI is done in hospital, then is it safe to assume that since hospital accepts insurance, then good to go? Or might there be a surprise, such as MRI billed differently?

Personal experiences from what you went through welcome.

Thanks.

 

[CardsFan]

In my experience she should be fine, but you may want to confirm that the radiology unit is not a separate entity, and if it is, confirm it is in plan.

On a related note: MRI's, x-rays, CT's, etc are much more expensive in a hospital than at a stand alone imaging center. Some times by factors of 5x-10x. If your sister will need to pay towards a deductible and/or co-insurance, this could be significant.

 

[googily]

You might want to read this story, with a stiff drink, while granting that this is pediatric and so more involved. But still.

https://www.vox.com/policy-and-politics/2017/10/16/16357790/health-care-prices-problem

Excerpt:
Fowler’s parents knew the scan might cost them a few thousand dollars, based on their research into typical pediatric MRI scans. Even though they had one of the most generous Obamacare exchange plans available in California, they decided to go out of network to a clinic that specialized in their daughter’s rare genetic condition. That meant their plan would cover half of a “fair price” MRI.

They were shocked a few months later when a bill arrived with a startling price tag: $25,000. The bill included $4,016 for the anesthesia, $2,703 for a recovery room, and $16,632 for the scan itself plus doctor fees. The insurance picked up only $1,547.23, leaving the family responsible for the difference: $23,795.47.

 

[MichaelB]

Helping a sister. Her neurologist ordered some tests that requires 2 MRIs.

My question is on the billing and insurance. The insurance covers the neurologist and the hospital the neurologist belongs to. The hospital accepts her insurance. Haven't scheduled appointments yet.

Question is if MRI is done in hospital, then is it safe to assume that since hospital accepts insurance, then good to go? Or might there be a surprise, such as MRI billed differently?

Personal experiences from what you went through welcome.

Thanks.

It is possible the hospital bill includes charges not accepted by the insurance company, such as facility fees. Your sister should ask for an estimated cost, and at the same time confirm with the insurer if facility fees are covered.

 

[bingybear]

also make sure she has pre-approval from the insurance company if it is required by her insurance.

 

[youbet]

Helping a sister. Her neurologist ordered some tests that requires 2 MRIs.

My question is on the billing and insurance. The insurance covers the neurologist and the hospital the neurologist belongs to. The hospital accepts her insurance. Haven't scheduled appointments yet.

Question is if MRI is done in hospital, then is it safe to assume that since hospital accepts insurance, then good to go? Or might there be a surprise, such as MRI billed differently?

Personal experiences from what you went through welcome.

Thanks.

Here's how my experience went.........

Doc and hospital were "in network" with my insurance. Went to the hospital and the front desk sent me down the hall to a waiting room. I was greeted there by a tech wearing garb with the hospital's name and symbol. We went through a door and a "walkway" similar to a walkway you would take to board an aircraft. We entered a room (nothing seemed temporary or portable about it) and the MRI was completed. I received a bill from a medical leasing company for the MRI which my insurance would not pay.

Fortunately I was in management at MegaCorp and a friend in HR helped me jump through the hoops to appeal and get it paid, but it was a close call.

Be careful with MRI's! Ask specifically who will bill you. It may not be the hospital whose front door you entered!

 

[easysurfer]

also make sure she has pre-approval from the insurance company if it is required by her insurance.

She isn't too able in mind and body (thus my involvement).

Circling around, got word there will be pre-approval.

Circling around as in having to call and get bounced around. Recording at the registration saying make sure to check with insurance to see if pre-authorization required. Calling insurance, who said, Dr's office needs to call them for pre-authorization. Called Dr's office who said, need to schedule the MRI. Only then can get pre-authorization.

Just got call from the medical assistant of the Doc who said too, that need to schedule the MRI, but no guarantee of 100% coverage. That depends on the insurance. So, in other words, still a dice roll .

 

[Likes_to_Lurk]

also make sure she has pre-approval from the insurance company if it is required by her insurance.

I ran into this earlier this year. Unbeknownst to me, I needed a pre-approval. I ended up cancelling the initial appointment, as the radiology center did not receive the approval in time. My insurance company (Cigna) contracts for an outside service that will compare costs of radiology centers. The insurance co. customer service rep used this for me and gave me costs, names, addresses, etc. The eventual cost was very close to what this service provided.

Do not assume ANYTHING when it comes to hospital billing. Ask lots of questions, take names, etc.

Hospitals often have the highest costs for these kinds of services.

 

[W2R]

Helping a sister. Her neurologist ordered some tests that requires 2 MRIs.

My question is on the billing and insurance. The insurance covers the neurologist and the hospital the neurologist belongs to. The hospital accepts her insurance. Haven't scheduled appointments yet.

Question is if MRI is done in hospital, then is it safe to assume that since hospital accepts insurance, then good to go? Or might there be a surprise, such as MRI billed differently?

Personal experiences from what you went through welcome.

Thanks.

This isn't exactly the same, but anyway I had some CAT scans done when I fainted, hit my head on equipment (at the gym) as I fell, and knocked myself out back in 2015. I went to a private imaging facility, not the hospital, and they took care of everything for me. No problems.

But if I was in your sister's situation, I'd look at the back of my insurance card and call the phone number there, and ask them instead of asking my brother to ask on a forum.

 

[Katsmeow]

Find out if the radiologist is on her insurance. Often, in hospitals they may not be even if the hospital itself is on there. Also find out how the hospital codes it. Who do they send in the charges from? The hospital? The radiologist? Someone else?

My daughter recently had gall bladder surgery. We made sure the facility was in network. Surgeon (in network) wanted her to use an out of network facility and promised they wouldn't charge more than insurance company would pay for in network. We refused as we wanted it to be in network (we had met in network our of pocket max for the year). Anesthesiologist was in network. All was fine.

But, turns out they used some company to put pumpers on her legs during surgery to avoid blood clot. That was out of network and so now DD owes almost $500! Really irritating since we didn't know anything about this.

 

[Bamaman]

Find out if the radiologist is on her insurance. Often, in hospitals they may not be even if the hospital itself is on there. Also find out how the hospital codes it. Who do they send in the charges from? The hospital? The radiologist? Someone else?

My daughter recently had gall bladder surgery. We made sure the facility was in network. Surgeon (in network) wanted her to use an out of network facility and promised they wouldn't charge more than insurance company would pay for in network. We refused as we wanted it to be in network (we had met in network our of pocket max for the year). Anesthesiologist was in network. All was fine.

But, turns out they used some company to put pumpers on her legs during surgery to avoid blood clot. That was out of network and so now DD owes almost $500! Really irritating since we didn't know anything about this.

It was the same when I broke a leg and had to have a brace on my knee. My deductible out of plan was more than I could have purchased the same ones brace online.

I avoid the DR like the plagie. All our doctors there are out of plan and don't even work for the hospital. They are slave labor with outside billing services working for whatever they can get people to pay them.

 

[ExFlyBoy5]

Most of the issues have been covered here, but I will add one that we have dealt with twice.

My DW has an MRI once a year and they must be pre-approved by the insurance company. No issue there. BUT...we did have an issue where the ZIP CODE of the hospital was wrong (they have two campuses, the authorization was for the wrong one) so the claim was kicked back. It seems goofy, but both locations are in Atlanta, just two different ones. Now, we make sure the approval matches the actual place that she goes.

 

[68bucks]

I would contact the insurance company for sure. I fought with mine 3 weeks for an MRI for my shoulder. The orthopedic surgeon I was seeing had an MRI in his office. The insurance company told me I had to go somewhere else they wouldn't cover it there even though he was going to do the surgery and was in network. Wound up having to go to a hospital that cost 3x more than the surgeons office, even though I was on HDHP and they paid none of the cost. Heck it took me 2 weeks just to get a rough idea what it would cost. It was just an MRI seems pretty cut and dried to me to come up with the price. Doesn't seem like it should be so hard and complected to get healthcare. Our system is junk.

 

[Rianne]

There are people working in hospitals that are out of network. A patient has no idea who these people are, what department they work in. When you have blood work, tests, etc. sent out to private or out of network facilities, the whole game changes.

My husband had a knee surgery 100% approved...insurance and double checked with hospital, surgeon, nurses, made sure all was covered. After the surgery our bill showed a "helping hands" surgeon assisted in the surgery which was not approved by us or the insurance. They billed us @ $1000. After about 15 phone calls complaining this was not part of what we agreed to, the original surgeon agreed to pay the extra surgeon.

I'm not even sure how to totally protect yourself from these sneaky underhanded things that happen with health insurance. My dog has better insurance. They paid 90%, no questions for an ER overnight stay for my dog! They even paid for the follow-up after he ate some kind of poison in my neighbors garage.

 

[audreyh1]

I would contact the insurance company for sure. I fought with mine 3 weeks for an MRI for my shoulder. The orthopedic surgeon I was seeing had an MRI in his office. The insurance company told me I had to go somewhere else they wouldn't cover it there even though he was going to do the surgery and was in network. Wound up having to go to a hospital that cost 3x more than the surgeons office, even though I was on HDHP and they paid none of the cost. Heck it took me 2 weeks just to get a rough idea what it would cost. It was just an MRI seems pretty cut and dried to me to come up with the price. Doesn't seem like it should be so hard and complected to get healthcare. Our system is junk.

Yeah - that stinks.

A doctor's office is always going to be way cheaper than a hospital imaging service.

I am often facing decisions about where to have something done since with my high deductible I know I'm going to be paying for it. I'm getting more and more inclined to just pay myself as self-pay if it's out of network.

Visit to dermatologist - oops, didn't get the authorization. Self-pay - $70. Authorization came in. Deductible - $70 copay. Same difference.

Of course the rub is that it may not apply to your deductible (depends). But since I haven't exceeded the deductible in a very long time, it's a wash to me.

I'm finding out more and more that self-pay is sometimes even cheaper than going through the insurance. Some places charge higher rates just to pay for all the extra paperwork for dealing with insurance companies!!!!

 

[Rianne]

Yeah - that stinks.

A doctor's office is always going to be way cheaper than a hospital imaging service.

I am often facing decisions about where to have something done since with my high deductible I know I'm going to be paying for it. I'm getting more and more inclined to just pay myself as self-pay if it's out of network.

Visit to dermatologist - oops, didn't get the authorization. Self-pay - $70. Authorization came in. Deductible - $70 copay. Same difference.

Of course the rub is that it may not apply to your deductible (depends). But since I haven't exceeded the deductible in a very long time, it's a wash to me.

I'm finding out more and more that self-pay is sometimes even cheaper than going through the insurance. Some places charge higher rates just to pay for all the extra paperwork for dealing with insurance companies!!!!

I agree, I've been thinking about self pay except for something extraordinary. I want to look into these catastrophic plans that might be approved for people over 30. Right now, they don't offer them to older people.

 

[Car-Guy]

also make sure she has pre-approval from the insurance company if it is required by her insurance.

+1, been there done that more than once. Also, best to get it in writing (at least email) if possible.

Medical insurance providers are several notches below lawyers in my book, especially when it comes to billing.

 

[Disappointed]

California has a new law, out of network working at the in net work on a patient, the out of network doc must accept what the insurance will pay. Too many surprises in the past, patients got screwed especially in the anesthesia field.

 

[audreyh1]

It seems that there has been a trend of hospitals to negotiate with insurance companies and be "in network", but somehow a bunch of services in the hospital is not billed by the hospital but some third party often magically not in network.

It's just such a yucky thing. I feel like patients are sitting ducks.

 

[MBSC]

I want to look into these catastrophic plans that might be approved for people over 30. Right now, they don't offer them to older people.

If the premium of the cheapest Bronze plan available is more than 8.05% (2018) MAGI, those over age 30 can already claim an affordability exemption and purchase a Cat Plan. These plans are still subject to the ACA OOP limit since they are ACA-compliant.

You can view 2017 Cat Plan premiums here: https://finder.healthcare.gov/

Who can buy a Catastrophic plan

Only the following people are eligible:

- People under 30
- People of any age with a hardship exemption or affordability exemption

Reference: https://www.healthcare.gov/choose-a-plan/plans-categories/

 

[Rianne]

I don't really understand "in network" and how that benefits the insurer. I'm the consumer but I have to check and recheck if the doctor, procedure, hospital, treatment...are in network, are approved, go to deductible or are covered without deductible.

I recently went to ER with abdominal pain the gradually got worse over 24 hours. My pancreatic lipase was high so they immediately did a CT scan with dye. All was ok and it seemed my pain was from a pulled muscle. Looked online at my claim, $10,000 plus some.

Now my primary thinks I have gallstones. She ordered an ultrasound which shows kidney stones clearer than a CT scan apparently. I call my insurance company, innocently and very nice, asked if the ultrasound applies to my deductible, answer, "yes." So I have to pay for the ultrasound since I have not met deductible, "yes." I ask, "How much is the ultrasound?" She said $147.00. The ER visit is completely covered except for $500.

I cannot make sense out of this. My primary was aware of abdominal pain. She could have ordered an ultrasound before the ER visit. Just so happened the pain got so bad and it was nighttime and I thought I was dying. There has to be a better way to diagnose and treat.

 

[FargoI]

Depending upon one's insurance plan, and plans vary widely, all ER services including emergency surgery are covered in full once the patient (insured) pays their ER deductible. Interesting, if one has the ancillary testing performed outside or separate and apart from the ER visit, an entirely different and potentially more consequential set of co pays and deductibles may apply. Also, if the surgery is not classified as emergency surgery concurrent with an ER visit, the patient may be exposed to significant co pays, via insurance, deductibles and maximum out of pocket limits. Think of this as eating at a buffet, versus ordering from the a la carte menu. The buffet (ER visit and all associated services), depending upon your policy, may allow all services including lab tests, radiology, surgery, supplies, etc to be bundled together as all inclusive in the $150, $500 ( whatever) ER deductible. An elective gallbladder removal might otherwise have an out of pocket cost or many thousands of dollars ( e.g. 5, 10, 15k) Hope this makes sense.

 

[MBSC]

Depending upon one's insurance plan, and plans vary widely, all ER services including emergency surgery are covered in full once the patient (insured) pays their ER deductible.

Most states allow out-of-network emergency services to be balance billed. This link lists the states with OON balance billing protections and the extent of those protections.

For clarity, it is based on where the emergency treatment occurs, not where the policy was written.

Only 21 states have direct protections laid out in statute or regulations for consumers who would otherwise face balance billing for care by out-of-network providers in EDs.

Reference: Balance Billing by Providers State Consumer Protections - The Commonwealth Fund

 

[Rianne]

With new ACA plans out, I am better off with the cheapest plan available that also offers HSA account. Deductible and out of pocket are the same according to plan admin. So if I wait until January, do the gallbladder surgery then, my deductible and out of pocket will be fulfilled for the rest of the year. The plan I have now, supposedly a great plan, has a much higher premium with same deductible and out of pocket limits. When I spoke with HI admin. the real issue one needs to consider is OOP and Deductible. With a POS plan vs HMO plan is also important. POS at least gives some relief to OON treatment.

We are meeting with a broker who will break down all the minutia involved in these extremely confusing plans. Go to buy car insurance, life insurance, homeowners insurance, umbrella policy...there are maybe 5 or 6 basic questions that give you the real picture of what you're buying. HI, about 50 questions regarding where you stand in various situations.