How Does Medical Billing Really Work?

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An Inside Look at Medical Billing

We hear every day how healthcare costs and insurance premiums are rising and how America is by far the most overpriced country when it comes to paying the price of being healthy. What we don’t hear, though, is the story behind all of it.

Who decides what we pay? How do they ever expect us to pay for most of this? Is there any relief available for those who know they will never be able to pay an enormous hospital bill?

 

Doctor’s Offices

medical-billing-advocate_168769055Many are quick to blame the first person they think of – usually the well-paid doctors. The truth is, though, many doctors don’t know how much they get paid when you come in for an office visit.

This is because:
(1) many doctors don’t process their own billing, and
(2) insurance companies pay based on their own algorithms.

They have a willingness to pay a certain number of dollars for certain types of procedures. So, when the doctors send a bill to the insurance company, they will typically add to the actual cost to ensure they get adequate payout.

Here is a good example:

A patient goes to see their doctor, and the doctor suspects that the patient has strep throat. The doctor does the test and bills the insurance company minus any co-pay the patient is responsible for.

The insurance company already has a formula for calculating what they will pay for that strep test. So no matter what the doctor actually bills, as long as the doctor is participating, the insurance company will pay up to their maximum. So, if the bill is $250, and the insurance company’s maximum payout for the test is $125, the doctor will receive payment in the amount of $125 and will be forced to forgive the rest.

If the bill the insurance company receives is $75, they will not pay their maximum payout of $125, they will pay the full $75 that the doctor’s office asked for.

So you can see why many doctors won’t know how much money they’re getting out of a visit with a patient until they are reimbursed from the insurance company. You can also see how this game of sorts is played back and forth between insurance companies and doctors.

It’s a negotiation; the doctor starts off billing what he or she thinks they should get, but the end result could be considerably less.

medical-billing-advocate_185011487This poses a problem when it comes to cash pay patients, because patients are billed at the same high rates unless a cash price is previously negotiated.

The difference is that patients don’t usually know that they have the option to negotiate, and they definitely can’t choose how much of the bill they would like to pay, as insurance companies do.

This information alone is proof that the prices of healthcare are not set. They are inflated and filled with erroneous charges. Medical bills push more people into bankruptcy than all other financial hardships combined.

Moreover, the same office can bill the same charges to one insurance company and one unrelated patient for the same service, but the insurance company pays many times less than the patient, while the patient faces potential financial ruin.

 

Hospitals

Hospitals typically see approximately a ten percent reimbursement, so it makes sense that they would bill at least ten times more than what they were expecting. Also, hospitals generally have the same go-to plan when sending bills to insurance companies – only to a much higher degree.

medical-billing-advocate_126693332David Belk, MD has attested to the fact that the bill doesn’t really have much to do with what the hospitals actually expect to get paid, and he gave a printout as an example of a hospital bill for a two-day stay. The bill was over $20,000, of which the insurance company paid a little more than $2,000. That’s only 10 percent! The hospital “adjusted” the rest, subtracting over $19,000 at the request of the insurance company, thus zeroing out the balance.

Another example given by Dr. Belk was a three-day stay in the hospital for a Medicare patient. The total of this bill was $30,000, but Medicare paid only $6,000. The patient was left with 20 percent of the charge Medicare accepted, so they had to pay $1,100 and the other $23,000 was completely wiped out.

Different insurance companies compensate at different levels based on their algorithms, which are calculated by number of days, types of services, diagnoses, and so on. Medicare covers more services than private insurance, but private insurance premiums are still on an apparent continuous incline.

As with doctor’s offices, if a patient doesn’t have insurance, they still get an over-inflated bill. Many hospitals do not seem to take into consideration that an uninsured person might not be able to afford these high fees.

Even if you are able to negotiate with the hospital directly, and they give you a “break” by cutting the charges in half, you’re still paying many times over what the facility would have received from an insurance company.

medical-billing-advocate_150090437Here is an example of how flexible these charges actually are. A man who was out of town, who already suffered from heart disease, began having chest pain, which was later diagnosed as a heart attack. The woman who was with him took the initiative to call the insurance company before taking him to the hospital.

The insurance company gave the authorization, but the hospital they went to did not have the ability to do the angioplasty, so the patient was transferred to another facility. After the husband spent three days in ICU at the second hospital, the couple received a bill for more than $80 thousand.

The insurance company stated that it would not cover the charges from the second facility because they did not give permission for his transfer. It took a few phone calls, and the insurance company finally settled with the hospital for many times less than the $80 thousand.  If this couple had not been diligent in their research, that bill could have ruined their entire financial livelihood.

 

A few sobering health care facts:

  • There are far fewer hospitals today than there were even ten years ago, and those hospitals aren’t operating anywhere near capacity.
  • The criteria that must be met before an insurance company will pay for a hospitalization is stricter than ever before, and fewer people are being hospitalized as a result – even those with illnesses that would have warranted hospitalizations just a few years ago.
  • Hospitals cost much less to operate than in years past. Technology has streamlined many procedures, providing faster, more efficient methods and faster healing times, decreasing the length of time many patients have to stay in the hospital.  Surgeries that used to be major procedures are now done in outpatient settings or with shorter stays in the hospitals.
  • Some ailments that used to require surgery can now be treated on an outpatient basis, and some can even be treated with over-the-counter medication.
  • Many other diseases that used to be considered serious are now treated with a pill or with at-home remedies.

Bottom line: Hospitalizations have decreased dramatically; patients can be treated faster, better and more efficiently than ever, saving the hospital money, yet the cost of medical bills continue to rise.

 

What can we do?

Since it is obvious that healthcare really isn’t as expensive as we are often told, and the cost is consistently rising, we have but a few options to help right now. First of all, we can demand price transparency and get explanations for why we are going to be billed so much.

Another option is to forego hospitals who consistently charge erroneous amounts in favor of smaller settings whenever possible, such as with diagnostic imaging and blood work. Also, check around for discounts. Since so many doctor’s offices and hospitals are billing for more than the payment that they expect, it is likely that if you ask before a service, you can get a nice price break that will make much more sense to your wallet and to the healthcare numbers in general.

Lastly, look for a medical billing advocate to help you if you have any questions or uncertainties. Medical Billing Advocates of America can ensure that you receive only “True & Accurate” charges and “Fair & Reasonable” prices.

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40 responses to “How Does Medical Billing Really Work?”

  1. Joshua says:

    How do you contact the President of a Hospital? I fell and broke my wrist. Even though I had VA insurance, they refuse to pay so I am considered a “self pay” patient. They have a total of $60,000 in charges for less than a day of being in the hospital, not being able to find me in the hospital, breaking HIPAA laws and making me stay hours later because a doctor had to “sign me out.” The finance office isn’t budging on the payment and the cost is crazy even by hospital standards. I want to go above just talking to one incompetent person. Where do I go?

  2. sara says:

    Of course, from the end of the provider, what we are talking about is that they are not actually being paid what they SHOULD be getting paid by the insurance companies, and those deficits reduce quality of care to the client. When providers can not meet their overhead (It’s expensive to have a private practice!) because insurance companies pay them less than they SHOULD be paid, it ends up affecting everyone. So, instead of acting like the doctors and therapists should not charge what they charge, we should be demanding that our insurance companies pay rates that are based on nationwide standards. A therapist in Montana should not be paid less than one in California and insurance companies should stop playing games with their ability to stay in practice.

  3. sarah says:

    Hello,

    we are a lab that does TKI testing and we want to be able to bill a patient’s insurance instead of the customer….can you point me in the right direction as to where to start this process.

  4. Rose says:

    So I went to pain management to get my regular appointment.. They Billed the Bill that was left over that my insurance did not cover… I get to my appointment and find out I have this bill that I did not know I had… They refused to see me, and I got the bill the same day that I got refused to be seen … How is this fair.. I have bad disks, in my back and neck, and all that did was pull me off the narcotics they put me on to control the pain.I offered to run home and get a check, and they refused and told me it would be two weeks before they could see me again.. So I said I have half on me and I can pay the rest when I get home, and still they refused….Seriously, this is messed up.. There should be laws somewhere that protect people in the amount a time should be able to be collected… Pulling someone off a scheduled narcotic like that is just dangerous, and the amount of billing time was unfair, and unreal… What is worse is I offered to pay in two different methods because I had the money.. Wrong, Wrong, Wrong… Obama Care act Sucks.

  5. Sue says:

    Had a CT scan at a hospital, insurance was charged 7600.00. Insurance cut it way down and paid about 1600.00. My portion was 2600.00. The hospital will not negotiate with me and cut the bill at all. Just offering me a 36 mo. payment plan. They say they already discounted with the insurance company and won’t negotiate further. Is there anything I can do to get it reduced.

  6. Tiffany says:

    Hi!
    I have a family member who had a serious, but not life-threatening issue that required an emergency room visit. He was checked into the ED and was never asked to see insurance information. After being examined by the doctors, if was imperative that he have an immediate upper G.I. procedure. The patient was in getting anesthesia when someone from registration finally approached his wife to get the insurance information. Now they are saying the hospital was out of his coverage and therefore insurance will not pay anything. Shouldn’t the insurance information have been gotten at the time of registration, therefore letting the patient know whether or not his care would be covered? Again, it was a serious, but NON-life threatening issue, so he could have gone to another medical facility for care had he of known.

  7. Bridget says:

    Question: I know an elderly lady living in an Assisted Living facility. She pays via Social Security, Medicare & Medicaid. The ambulance service is billing her $25 for a wheelchair ride from the ambulance to her room following an ER visit after she fell and got hurt. Medicare and Medicaid has denied payment for this. Shouldn’t they write it off at this point?
    Instead they are demanding payment. She only gets $66 of her social security each month and most if that goes to co-pays for medications, leaving her no money to buy clothes or anything else. What can she do?
    Thanks!

  8. Diana Manwaring says:

    I have Medicare Part A only and can’t get any other insurance because I can’t afford it. Even with Obamacare, which is a big fat joke. I signed up for financial aid at my primary care doctor because I am now self pay. I think they will rip me off.

    The financial aid table says that, based on my income, my discount will be 80 percent off the bill. But I just realized that if one doesn’t have insurance, then I was supposed to stop providing more information, sign the form and that I would be charged the Medicare fee schedule rate.

    I think that the discount table was for what would be paid after insurance. But I have Part A only. Not B. This is sooooo confusing.

    My original bill was for $170. I paid $20 in cash at the time as I didn’t know what the total would be, and they said that would be fine. Well, 20 percent of $170 is $34. My balance due should be $14 if I go by that income table, but they want me to pay $85 more! How come?

    I have Medicare Part A only. I can’t get part B because I couldn’t afford the late signup penalty and I can’t find any other insurance, so I am stuck. I have a multitude of health problems, including a history of cancer, and diabetes, so I shouldn’t just drop my doctor but I may have to.

    I’m still trying to reach them. I thought that I would finally be able to see my doctor but if they want me to pay over $100 each time I will have to give up and go to an ER whenever I need something.

    How can they do this to me?

    I could scream. My day is ruined and I am very very worried about how this will turn out.

  9. Mark says:

    What I am experiencing is not that the medical office bills the insurance then forgives the rest, but that whatever the insurance company won’t pay is coming back to us. How does this work and do I have any rights? Is this standard? How can a person make a wise decision if they don’t even know what their costs are going to be until later on? Thank you!

  10. Eric says:

    Hi Pat!

    Thanks for the article! One section that caught my eye was:

    “If the bill the insurance company receives is $75, they will not pay their maximum payout of $125, they will pay the full $75 that the doctor’s office asked for.”

    I have an HDHP through Aetna ($5,000 deductible, Aetna pays 80% after the deductible is met). June of 2015 I spent the night in the emergency room due to Lyme disease from a tick bite. When I received the EOB from Aetna, I was shocked to see that the “Member Rate” came to a total of $9,606, while the actual “Amount Billed” came to only $5,529.

    Once my deductible was figured in, using Aetna’s “Member Rate”, rather than the actual “Billed Amount”, the total amount that I owed came to $4806. When the amount I owe is figured out using the Billed Amount, I would owe $3,991.

    Also, the “Plan Pays” is stated on the EOB as $4,800, which is based off the more expensive Member Rate. However, when I see the actual bill from the hospital, it clearly shows that Aetna only paid $722. If Aetna were to pay out based on the actual Billed Amount, Aetna would end up paying more, while I would pay less. So even though Aetna wanst me to pay based on the Member Rate, they are only paying the hospital based on the Billed Amount.

    I filed an appeal with Aetna in July 2015. In August I received a letter from Aetna stating that I “should not be responsible for more than 20% of the Billed amount.” The letter went on to say that the appeal was sent for further review. I called Aetna several times, and it was not until Janurary of 2016 that I finally received a notice that Aetna decided to hold me responsible for the “Member Rate”. I was furious at this point, because I had to complete my 2016 benefits selection at work by November. I chose Aetna again (over Highmark’s HDHP, which I had before and did not have this problem) because, based on the letter I had received from Aetna, I thought they were helping me through this problem.

    Now I am facing an uphill battle with Aetna trying to pay the Billed Amount rather than the more expensive Member Rate. It feels like Aetna will not base the payment off the Billed Amount becuase it will force Aetna to pay more. I am also frustrated because I am commited to paying for Aetna HDHP for the rest of the year until I can switch for my 2017 benefits. This has been a frustrating experience.

    Do I have any other options? I cannot understand Aetna’s logic in forcing a customer to pay more.

    Thank you!

  11. lyssa says:

    I was recently in a car accident, my doctor submitted my bills to my insurance company, my insurance paid the negotiated amount leaving me the balance, which is fine. However, I have a pending lawsuit, my doctor is submitting the original charge to my lawyer after he has accepted the negotiated amount from the insurance company. Is this legal?

  12. darlene says:

    For an outpatient procedure, according to my insurance EOB; the hospital was “paid according to a negotiated amount”, $0 and my amount owed is $0. Does this mean that the “negotiated” payment is something done during the insurance & hospital contracting, hence the hospital got paid a contract lump sum for accepting their policy holders for claims? Now, the hosptial has resumbitted the same claim, but, broke down 1 charge into two and “requested this denial of coverage notice”. So, now the insurance EOB is trying to say we owe a large amount even tho the same code and total charge was submitted on both hospital claims. How can our insurance change it if it’s still the orginal “paid according to a negotiated rate”?

  13. Sabrina says:

    How long after a visit does a medical practice/provider have to bill either the insurance of the patient? I received a bill more than a year after the service was provided…

  14. Zequek says:

    Dealing with medical bills seems really stressful. It kind of seems like you’ll be better of if you’re doing your research and know what options you have. That’s generally helpful for most things.

  15. Jasmine says:

    Hello, I’ve never had to deal with insurance before because I was on my parents plan. Now that I have my own insurance through work I’m not sure of many do’s and don’ts. A few weeks ago I had my gallbladder taken out. My surgeons office billed both my primary and secondary insurance for my appointments so my copay for visits are very small. Today I received a bill from the hospital for the actual surgery stating that I owe over $13,000. It looks as if they only billed my primary insurance who only paid $1,500! However I know that part of my coverage states that my annual deductible is only $1,000. Who do I contact? Do I call the hospital to see if they billed right or call my insurance company first? I can’t afford to pay $13,000!!!!

  16. Joseph says:

    My wife had an appendectomy a little over a month ago and was discharged on the third day. We have not received an “initial” bill yet, although the hospital, in this case the Community Hospital of Monterey Peninsula here in CA says on their website that, we should see an initial bill about 10 days after discharge. My wife called this morning and was told that they were in the process talking with our insurance and was orally quoted on the phone for $62,000 for the surgery and 2.5 days’ stay at the hospital over a month ago. My question is if we have the right to see an initial “before-insurance” bill first? Still shocked here. Thanks much.

  17. Tracey says:

    i PAID IN FULL FOR THE BILL FOR A SURGERY CENTER IN THE AMOUNT OF $4650. THE CENTER BILLED MY INSURANCE AND RECEIVED $4650 FROM MY INSURANCE SO NOW THEY HAVE $9,300 AND THEY WILL NOT CUT ME A CHECK FOR THE MONEY PAID TO THEM BY THE INSURANCE COMPANY. INSTEAD THEY ARE NOW KEEPING ALL OF IT THUS COLLECTING DOUBLE. THEY REFUSE TO LISTEN. HELP

  18. Susan G says:

    I understand that doctors have a long time to file a claim. My question is why do they wait? One of mine just billed insurance 5 months after my surgery. Thanks

  19. Janet says:

    I learned a lesson the hard way. My physical therapist recommended I have a flat plate x-ray of my knee and lower back d/t chronic knee pain. I went to St. Elizabeth’s Hospital Medical Center ER referral facility and had the digital x-rays taken. To say I was shocked when I received the EOB for more than $1800, of which Aetna approved more than $1100, is an understatement. I contacted Aetna, where the representative informed me that if I had gone to a “free-standing” radiographic provider instead of a “hospital,” my out-of-pocket expense would have been “much cheaper.” This “hospital” IS a free-standing facility and does not have in-patient beds. From now on I will always ask for an estimate of cost before agreeing to the service. Had I known that Aetna would allow such an egregiously high amount relative to other providers of the same service, I’d have gone elsewhere. Was making monthly payments until the hospital decided I wasn’t paying enough, stopped sending the statements and sent the bill to collections.

  20. Mele says:

    I recently went out of network(no one in network for the device my neurologist recommended ) for a sleep apnea mouth guard. I was told and have a receipt for the consultation that there was no charge for the consultation. I also have their handwritten notes with the ‘billable amount’ for the device, the insurance codes, and with their calculation of what it would likely cost me after they consulted with my insurance company.
    Now I have been billed $ 254 for the consultation and they have billed my insurance company nearly $500 MORE than what they quoted that they would bill for the device.
    My insurance company has not yet completed the EOB and I have not been billed for the device yet but I’m very concerned about what they will expect me to pay given the above facts. So far they have billed my insurance about $ 800 more than what they quoted me.
    I don’t know if this constitutes insurance fraud, unethical behavior or what. But what can I do?

  21. Leslie says:

    What are your thoughts on insurance companies being able to sell over state lines? Would this lower rates in insurance and price fixing?

  22. Dave says:

    So my question is what does the the facility or provider do with that “wiped out amount”? Is that something they right off and tax payer end up paying for it anyway?

    Maybe if doctors didn’t have to pay so much for medical school and they didn’t have to all drive a Mercedes their office overhead wouldn’t be so high and they could simply bill what they are contracted to receive for the service. Just a thought…

  23. Dr. T says:

    Dave,

    So you think that doctors don’t deserve to drive Mercedes or whatever luxury cars our hearts desire, and that we could afford, JUST so that we can keep our overheads low enough to be happy to make a quarter on the dollar, or less, when accepting contracted rates from in-network insurance companies? You think that if we’ve spent decades upon decades studiously poring over textbooks, training to save lives, that we don’t deserve to make a bit more money than most and be able to enjoy the finer things in life that we’ve worked so hard for? Meanwhile, CEOs of insurance companies enjoy ever-increasing bonuses and perks, year after year, by ripping off doctors. How is this fair? And who is going to want to become doctors in the future to continue to save lives?

  24. Melissa says:

    Hello,
    Our son had outpatient surgery in July 2016, he had 7 teeth removed and 3 caps put on. He is afraid of dentist, and we tried doing the procedures in office (which would have taken at least 4 different appt.) He freaked out, so that’s why we choose surgery. He has medical insurance and I have dental through my employer. We needed medical to help with the hospital bill and the dental insurance would cover most of the dental bill. At first the claim was denied with the medical insurance cause someone at the hospital filed it as dental, and we don’t have dental in the medical insurance. Also he is Autistic, which the insurance confirmed he would be covered. Had to appeal the claim with insurance which was changed. So a 7,000 plus bill down to 2,400. Ok I can deal with that. Before we received a bill the hospital was calling to make payment arrangements. I told them I needed to get the EOB from the insurances first and an itemized bill from them. I wanted to be sure everything that was charged was correct. Well the dental insurance paid for extractions and the caps, but I noticed on the hospital itemized bill they were also charging for extractions and caps. The dentist preformed the procedure. Not a dental surgeon at the hospital. My question is can both the dentist and hospital charge for the same thing if the dental insurance paid for the extractions to the dentist?

  25. Katherine says:

    I still have a medical bill for 9,272 dollars when my boyfriend paid 850 at my check up apt and 12 hundred dollars for the doctor. And the price still us high. I can’t afford to pay for it.

  26. Denise says:

    My husband had a colonoscopy at our in network hospital. They contract with an out of network anesthesiologist (which he was not aware of). Our insurance company paid a small portion of the bill and has turned the remainder over for collections. I am told by our hospital that there were no other options for anesthesiologist in our area and that the full amount should be paid by our insurance company. What is our recourse?

  27. Teena says:

    Aloha, I pay cash upfront and then I’m supposed to Bill Medicare myself but the problem is my nurse practitioner only gives me handwritten carbon receipt that Medicare won’t accept. Is she required to give me a receipt so that I can file a claim legitimately? I’ve been seeing her for over two years and I pay $75 every two weeks. Now she’s quitting her practice to work at a hospital and won’t call me back at all. I’ve given her grace on this because I’m limited on Physicians where I live on Maui.thanks.

  28. Ephesha says:

    Hi,my son was walking home from school.He waited to cross the street and stood in the street too far and a car ran over the top of his sneaker. I took him to the hospital where Xray’s were performed and there was no swelling or bruising. We were sent home. I later received a bill from the hospital for $1500.00. I called the insurance company and was told the bill was paid. I called the hospital also. The person from the insurance company even called the hospital on my behalf to let them know that the health insurance paid the bill. The insurance specialist was told by the hospital that in order for them to close the claim would be if I got a form notarized stating that I don’t have auto insurance and that no one in my household has auto insurance. I’m having a hard time finding that form online and I live in NJ

    • says:

      Hi, Ephesha. Thanks so much for reaching out. Could you give us a call so that we can get more information? 855-203-7058

  29. Nikhil says:

    Hello,
    We were recently blessed with our 1st child who was born in May :-). I recently received an Explanation of Benefits or EOB form from the Health Insurance Company (purchased through the MA Health Connector – Annual Premium approx. $8000) for providing newborn care. I noticed that the Provider (hospital where our child was born) billed the insurance company for a total amount of approx. $2500. I was SHOCKED, to say the least, when I noticed that the insurance company “ALLOWS” a provider to charge approx. $18,500 for newborn care services. That said, the EOB listed that I was responsible for $3000 (my deductibles and co-insurance) and that the insurance company paid the provider the remaining $15,500. I understand that the insurance companies and providers have pricing contracts, but the practice of paying a provider more than they are charging for services provided makes no sense at all! I would be better off to have paid the provider directly out of pocket and not go through the insurance. I can’t seem to get my head around this situation.

  30. cheryl says:

    i spoke to business department before i make a surgery appointment.
    they gave me a set price for total 4 procedures (self pay)
    i asked them repeatedly if that is the total amount I really have to pay for..
    total price for 4 procedure was 20,000 dollar. so each procedure costs about 3000-4000.
    i agreed with the payment and had the surgery done. now they are sending me ridiculous amount of bills.
    they are saying its really a 11,000 each procedure and since I paid 3000 upfront each procedure i have to pay rest of the bills from 11,000..
    i even have set price list with the names of “stuff”? they used during surgery sent to me.
    i showed it to them and they couldnt say anything about it.
    can they do this? is there something i dont really understand about this whole bill thing?
    they even resent the ultrasound bills that I already paid for.

    PS// those price list i received was without the doctor’s fee. it was price list given from hospital business department. not from the physician’s office. I paid those amount directly to the hospital.

    • says:

      Hi, Cheryl. Thank you so much for reaching out. We would be happy to go over your bills with you and make sure they are accurate and fair. Could you give us a call? Our Consumer Division can be reached at 855-203-7058. Thanks!

  31. Penny says:

    I was in an auto accident and had C6-7 ACDF and Posterior cervical fusion C3-C7, my employer sponsored BCBS AL paid for the surgery and all other procedures related to the auto accident. Per BCBS AL because I am located in Florida BCBS FL made the termination to pay 100% of the hospital bill without taking any discounts or negotiated rates. I contacted the hospital and they were even surprised BCBS made the payment. All other procedures associated with the auto accident (MRI’s, surgeons, anesthesiologist, etc.) were paid at a discount or negotiated rate this includes procedures done by the same hospital that the surgery was done. It took BCBS 5 months to pay the bill and only paid after they were notified I received the settlement which I have paid the subrogation. I have sent an appeal which was denied and am sending a second appeal but before I do would like to find out if this is a common occurrence for an insurance company to pay 100% of just one bill out of 20.I had a similar surgery at the same hospital in 2014 and 2015 had BCBC FL at the time and they paid at rate of approximately 25% but was not due to an auto accident. Also am I entitled to see their contractual negotiated rates? I did have an attorney but they were no help in the negotiation phase since they already took their fee there was no incentive for them to fight.

  32. mindy says:

    this may not be the right site for my question..but here goes..i recently opened a home health company..my first client was a mother and son involved in a car accident 29 yrs ago…the son needed medical attention from my home health..but the mother did not..it was understood that I would be doing light housekeeping at her house and I would spend the rest of the time with her son who was paralyzed..when I got there it was said that I would be spending 6 of my 8 hrs at the mothers house deep cleaning walking the dogs and outside work..along with a pantry that was covered in bugs..I was told it was my job to get rid of these bugs..i tried to explain to my client that home health doesn’t do dog walking deep cleaning and or extermination..i was let go for this converstation..her dogs were to be walked a mile a day..she wanted deep cleaning done and I worked on this pantry for hrs and hrs..her son needed the care not her..she needed a maid and a dog walker..all this was turned into insurance for medical needs..is this fraud ?

  33. Brittany says:

    I was just wondering something, I was billed up front for a wisdom tooth extraction as was my insurance company. My insurance paid out 80% which was covered and the surgeon had me pay roughly $650 for the remainder of the cost. Now, my EOB say I would be responsible for $1853 for 4 $276 uncoded “services”, $100 for anesthesia (I had know already they did not cover anethesia) and $117 for an exam that I did not even have as I had gone just the week before for a full exam with xrays which was billed separately. I had this proceedure in may and the dentist has not tried to contact me in any way regarding the rest of this sum claimed on the EOB. In addition, the previous exam I had gotten a varnish which was not covered and I paid out of pocket for. This also shows up as an owed amount even though I already paid. My question is, am I going to receive a bill for these additional amounts months from now even though I already paid upfront the amount the office said I needed to pay? Also, why are these payments not shown through my insurance account? Thank you.

    • says:

      Hi, Brittany. We would like to take a look at these charges so that we can get more information and try to assist. Can you give us a call? We can be reached at 855-203-7058. Thanks!

  34. davidnrobyn says:

    I’m reading this as part of helping my wife with a paper she’s writing for her Masters in Midwifery course. She needed some documentation for my assertion that insurance providers typically only pay 15% of the hospital’s upfront bill. I’m finding a veritable gold mine of info on the web to back up my assertion. My, my.
    This is personal–several years back I went to the hospital for tests re a reoccurrence of TB I was suffering. The total bills came to $45,000 for two days in the hospital–no treatment, just testing. I was knowledgeable enough to ask for a reduction in the bill, since I was uninsured. They gave me a 70% reduction down to about $14,000. On the invoice they called the reduction “Charity”. I’ll bet that when they bill the major insurers, they don’t call it “Charity”!
    In looking over the bill, I noticed that a major portion of the bill was called “inpatient services”! No itemization. Try getting away with that in some other industry!