Actually, it seems you are suggesting a well established approach of blaming the little guy for what is done to them by the big guys.

I thought that was the 99% think? Didn't know Romney was a 99%'er. Learn something new every day.

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By the way, if Medicare, Medicaid, and the VA have different rates, who sues?

Good question, but it isn't the rate, it is the amount billed. If you bill them all the same amount to each, no issue, if you don't you should expect a call from an auditor to explain why. What they pay, their rate, is their rules based on the patient's eligibility and benefit schedule and the rest must come from the patient, gap insurance, etc.

You seem to be suggesting the doctor charges different amounts based on which insurance company is paying. That is the fraud against the USA if any of those rates are less than what he charges the USA. A disgruntled employee of the doctor can do a whistle-blower suit on the doctor and/or take it to a government prosecutor.

There is an out, but still illegal. Doctor tells patient I'm got to send you a bill for the difference, but don't pay it, I'll write it off as bad debt and won't report it to the credit agencies. Auditors can't find that.

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It isn't that the doctor charges a different amount, it is that the insurance company 'adjusts' different amounts.

If for example on a 90807 charge, the doctor charges say $150. The various billed organizations will pay vastly different amounts - 'adjusting' the billed amount.

In some cases there are no adjustments. In others a modest adjustment (say less than $5), in most cases the adjustment is something between $30 and $50 (Medicare adjusts this by about $45 in our area). Then there are a couple of insurance companies which adjust that $150 bill by as much as $70.

It doesn't matter what gets billed (as far as we're concerned) it is what get's paid. By the way, if an insurance company 'adjusts' the amount *below* what Medicare allows, would that be the insurance company defrauding the government? Just wondering - since there are quite a few insurance plans that do that (not by a large amount -- less than $10 to $15 per visit -- but it obviously would add up big time.


Fair point on what is commonly known as sliding scale I suppose -- but it does exist for patients without coverage who are paying 100% out of pocket.

Take a step back. You are too close.

It isn't that the doctor charges a different amount, it is that the insurance company 'adjusts' different amounts.

The doctor is responsible to get the difference. If they make no attempt then the Doctor commits a fraud. Get the difference up front. This is one reason costs are so high, they have to have a couple of billing staff on hand to find out what will be paid and ding the patient for it before the doctor sees them. Get real here, what about someone who hasn't met the deductible yet? Are you going to see them for free because you didn't verify the insurance?

It is about what the Doctor charges, not what a third party may pay.

If for example on a 90807 charge, the doctor charges say $150. The various billed organizations will pay vastly different amounts - 'adjusting' the billed amount.

In some cases there are no adjustments. In others a modest adjustment (say less than $5), in most cases the adjustment is something between $30 and $50 (Medicare adjusts this by about $45 in our area). Then there are a couple of insurance companies which adjust that $150 bill by as much as $70.

It doesn't matter what gets billed (as far as we're concerned) it is what get's paid. By the way, if an insurance company 'adjusts' the amount *below* what Medicare allows, would that be the insurance company defrauding the government? Just wondering - since there are quite a few insurance plans that do that (not by a large amount -- less than $10 to $15 per visit -- but it obviously would add up big time.


Fair point on what is commonly known as sliding scale I suppose -- but it does exist for patients without coverage who are paying 100% out of pocket.

You keep talking about what insurance pays. That is irrelevant. Maybe the insurance the patient can afford only pays 25%. Why do you insist that it pay 100%?

Consider dental insurance. It may pay 100% on teeth cleanings. It may pay 50% on a filling. It may pay 25% on a crown. It may pay 0% on implants. It also has a yearly dollar cap. Why do you insist it pay 100%? The patient is told what the coverage is before they buy it. The Doctor is not part of that deal.

This even flows down to the IRS level. If the Doctor knows in advance they won't be paid what they billed, then the difference may be a charitable donation or a gift. If they don't know in advance the patient will stiff them, then they can take a bad debt write off. The cold hard truth is the Doctor may owe income tax on it depending on the facts.

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Gary, the deal here is that to be an 'in network' provider, the doctor is *constrained* by the insurance company. That is, yes, there are co-pays, and deductibles for which the patient is responsible. But in addition to this, there is a disallowed amount -- which, as an 'in network' provider, the doctor can not then bill the patient, elsewise the doctor is in violation of the 'in network' provisions.

Note, this very same deal applies with hospitals. If you have ever been a hospital patient (or at least within the past 10 years or so) and have insurance, take a close look at the EOB you get.

When I was in hospital for surgery to remove a cancerous portion of my colon -- this was over 6 and half years ago and I've been declared cancer free ever since (though I went through a 12 month chemo cycle). The hospital (which was 'in network) billed something like $35K (which did not include the surgeon, pathologist, or anesthesiologist). The insurance 'allowed' amount was UNDER $12K -- which the insurance paid (after my deductible). The hospital bill noted the 'adjustments' that the insurance company took.

I am not sure, but perhaps you haven't explored the wonders of medical insurance - a bout with cancer tends to focus one's mind on this sort of thing.

What you are saying is that the doctor is responsible for non-compliance with the in-network insurance provisions. Sounds a tad catch-22 to me. I know a number of other doctos and know the approach I've outlined is in fact common practice.

Gary, the deal here is that to be an 'in network' provider, the doctor is *constrained* by the insurance company.

They are *constrained* by the contract[1] they signed to be in network. BFD. That also makes those 'in network' insurance companies their best customers. The Doctor is required to give Uncle Sam the same or better prices than their best customer. What is so hard about that to understand?

Just because Uncle Sam may be willing to pay more doesn't make it right to charge more. Just because Uncle Sam's system only pays a portion doesn't make it right to jack the charge so Uncle Sam's payment matches. Doing that is fraud. The patient is responsible for any portion Uncle Sam doesn't pay.

There is a very good reason for this as well. If the doctors jack prices to get Uncle Sam to pay 100% of their normal charge then not only are the tax payers dollars being stolen but the survey data on what the average charge for the procedure in an area is distorted. Then the next year it is set too high and medical costs inflate. Since Uncle Sam's rates are public information, private insurance uses the information in setting their rates. More inflation.

It is a viscous cycle all because the Doc knows the patient is broke and can't afford the difference, but the Doc knows the procedure is needed and knows the patient and is willing to do some fraud to get their cash.

That is, yes, there are co-pays, and deductibles for which the patient is responsible. But in addition to this, there is a disallowed amount -- which, as an 'in network' provider, the doctor can not then bill the patient, elsewise the doctor is in violation of the 'in network' provisions.

Note, this very same deal applies with hospitals. If you have ever been a hospital patient (or at least within the past 10 years or so) and have insurance, take a close look at the EOB you get.

When I was in hospital for surgery to remove a cancerous portion of my colon -- this was over 6 and half years ago and I've been declared cancer free ever since (though I went through a 12 month chemo cycle). The hospital (which was 'in network) billed something like $35K (which did not include the surgeon, pathologist, or anesthesiologist). The insurance 'allowed' amount was UNDER $12K -- which the insurance paid (after my deductible). The hospital bill noted the 'adjustments' that the insurance company took.

I am not sure, but perhaps you haven't explored the wonders of medical insurance - a bout with cancer tends to focus one's mind on this sort of thing.

What you are saying is that the doctor is responsible for non-compliance with the in-network insurance provisions. Sounds a tad catch-22 to me. I know a number of other doctos and know the approach I've outlined is in fact common practice.

OBTW, if those in network payments aren't enough, they can always decline to be an in network doctor. I know suicide for a patient mill.



[1]
Appendix A: Payment amount for a Procedure
00001 $XX.XX
00002 $YY.YY
.
.
.

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Gary, for what it's worth, the Medicare allowed amount for a 90807 has increased by about $5 over the course of the past 15 years....

It's not all of the government's fault. They are only in the blame column for inefficiency and ignorance. The rest falls to the hospitals, drug manufacturers and the equipment suppliers and insurance companies.

By the way, when it comes to inefficiency and ignorance -- it is not as if the private insurance companies are exempt from this. And you get the added joy of a bit of avarice.

It's not all of the government's fault. They are only in the blame column for inefficiency and ignorance. The rest falls to the hospitals, drug manufacturers and the equipment suppliers and insurance companies.

interesting article at Cracked by someone that appears to read these forums


http://www.cracked.com/blog/6-things-rich-people-need-to-stop-saying/

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In a rich man's house there is no place to spit but his face.
Diogenes Of Sinope