Consider the following:
When you walk into a restaurant in New York what do you see?
You see a menu of food options with an associated cost and calorie count, you see specials posted, and you know how much you will or might spend during this encounter.
Alternatively, when you walk into a doctor’s office what do you see?
There is no menu of services, there are no specials, there is no cost for services posted and you do not know what you will or might spend during this encounter. You have little knowledge of how much a service might cost and there are no guarantees related to the quality of services you will receive. Further, there are no penalties for doctor’s billing too much for a service.
Take for example the following charges for an MRI of the brain (70553) for services rendered within 10 miles of each other in the same network.
|Billed Charges||Paid Charges|
|Facility 1 Global Charges||$1,950||$672|
|Facility 2 Global Charges||$2,800||$703|
Excessive/Inflated Mark-up for Healthcare Services!
So why do hospitals and doctor’s bill insurance companies for an amount that exceeds the amount any payer is willing to pay based on a fee schedule?
- Doctor’s see patients with varying insurance companies and benefit policies; this dictates a wide range as to what services are covered
- Reimbursements vary in how doctor’s are paid for services and they want a guarantee of maximum allowable payments
So what is being billed and why is it different?
- Uniqueness/technology requirements of the service (need for contrast/dye injection; CT vs PET Scan vs MRI; body part being examined)
- Overhead considerations, contract guarantees with payers, and equipment capability/quality (cost of equipment)
- Reimbursements vary based on state and availability of equipment for required services (local competition)
- Technical fees for the cost of the procedure and professional fees for readings
What can CareCore National and the patient do about it?
- Do your homework before you select a site for your procedure. You wouldn’t just call the first plumber in the phone book.
- As a patient, ensure the recommended service has been authorized, if required.
- Understand what your doctor ordered and what the doctor is trying to rule out so you can find quality providers of that service.
- When in doubt, call your plan to determine insurance reimbursement coverage based on your benefits.
- CareCore National offers site selection and member scheduling options for payers to assist consumers in finding high quality, low cost imaging providers within your network.
Common Terminology and Understanding your Health Insurance Policy and Indirect Costs:
|Patient Health Insurance Obligations||Indirect or Out-of-Pocket Costs|
|Out-of-Pocket Maximums||Balance Billing|
Other Interesting Links…