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JLeslie's avatar

Doctors: when you tell a patient their insurance covers a procedure, do you mean 100%?

Asked by JLeslie (55532points) September 29th, 2010

I can’t tell you how many times I have received a surprise bill from my doctors. So, I started asking if my insurance covers something before allowing a procedure, and I still get surprise bills. I feel like I must be miscommunicating, probably partly my fault, with my doctors.

Like, when I had an MRI I had to pay around $200 at the time of the scan, they told me that was my total responsibility, and then I get a bill for the doctor who reads the scan. In my mind I am thinking how much do I owe for my MRI and obviously reading it, what is the point if it is not read?

A few months ago I went to an ENT, and paid $330 out of pocket, at the time of the appointment I asked how much would be my responsibility and charged it to my credit card, and still got a bill for another $100+ a month later. When I called they said it should be just $26 something. Their explanation is it is because of my insurance, but doesn’t the doctor have a responsibility to quote me the correct amount?

If I ask a doctor, “does my insurance cover it?” I mean I will not have to pay anything out of my pocket, do doctors mean the same thing when they answer me, “yes, your insurance covers it.”

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18 Answers

wundayatta's avatar

Nope. It’s not your doctor’s job to tell you what the insurance company will do. The insurance company is the only one who can, and they can’t tell you until they know what all the bills will be.

If you are self-insured, you have a lot of work. You probably need to negotiate ahead of time what you will pay for all the procedures.

Of course, doctors are used to “unbundling” procedures. They get paid a lot more for several different items that make up a whole thing then they do if they charge once for the whole thing. You’re pretty much SOL if you aren’t insured. That’s why health care reform is so important.

sleepdoc's avatar

You are much better off asking your insurance. They actually have the final say in what gets paid for and how much they pay on it. As a side note, things like the radiologist reading your film are billed separately from what your doctor has asked for. This is because that physician is a consultant based specialty. Unfortunately, most of the time there is not anyone detailing these types of things for you. The same holds true for things like anesthesia for a surgery.

JLeslie's avatar

My last example about the ENT, the doctors office called my insurance while I waited to check my costs. In the last 2 years I have been to three ENT before this one, all did the same procedure, and I have been charged nothing to $30 to $240. This ENT did something totally different so I am not including him regarding these other charges. Those other three were all in network. I don’t see how we can say it is only dependent on my insurance.

john65pennington's avatar

Most health insurance companies pay on an 80/20 percentage. your doctor was correct when he stated “your insurance covers it”. in reality, he meant your insurance only covered 80% of the costs incurred. he told the truth, but not the whole truth.

Everyone’s health insurance plan is different. read yours from top to bottom and maybe this will eliminate any future surprises for you.

JLeslie's avatar

@john65pennington Yeah, but my other examples I specifically asked how much I owe. The MRI example they told me the amount based on the 70/30 split I have, and I still owed more. Sometimes procedures are covered 100% sometimes not. It’s very annoying. I just wondered what docs are thinking when they say it is covered, and if they really feel it is ok that they call the insurance company before a procedure, and then come up with a bill different than what they originally stated to me? Believe me I blame the insurance industry more than anyone, but I think the docs hold some responsibility too. If I agree to a price for a procedure, how is it ok to charge me differently after the fact?

Rarebear's avatar

Right. Doctors generally don’t know anything about what the patient’s co-pay is. There are a lot of different insurance companies, each with their own rules. It’s the doctor’s job to order what you need. It’s the insurance companies job to pay for it. It’s your job to be informed as to what your co-pays are.

Seaofclouds's avatar

Each different thing has a different billing number. When you asked how much for the MRI, they gave you the cost of the MRI alone. If you needed medications during the MRI, they would have been an additional cost and the reading of the MRI is an additional cost.

The best thing to do is ask your doctors office or the lab/facility doing the testing for all of the billing codes associated with whatever is being done. Then call your insurance company with the different billing codes and ask them what’s covered.

For example, imserting an IUD. There is a billing code for the actual IUD and then another billing code for the actual insertion by the doctor. If you called and only asked your insurance company if they covered the IUD, they would most likely just tell you about what they cover for the IUD itself and not even mention that there is a separte cost for the actual insertion. Most medical issues are billed this way. It sucks sometimes and is why I spend many hours a day on the phone with insurance companies when I am at work.

JLeslie's avatar

This is why I want single payer. It’s ridiculous. Ridiculous for the doctors and the patients. Your answers were very helpful by the way. Thank you.

YARNLADY's avatar

When I had a private practice doctor, he totally refused to answer any questions about insurance or even discuss it. He could tell me what the charges would be, but paying them was entirely between me and the insurance company.

Now I have Kaiser, and they explain exactly what everything is going to cost and who is going to pay it.

sinscriven's avatar

Medical billing is a total nightmare for patients, They get frustrated (understandably) that nobody is capable or willing of telling them the “total” cost, but that’s because nobody really knows. For example I work in teleradiology, and I’m likely not supposed to give patients any sort of idea of cost because we don’t bill patients directly, and those facilities get a sort of volume price per exam. So even if we’re charging $Y for X exam, that’s not going to be the final price, the hospital/facility will mark it up from the cost of materials used, the technician’s salary to do their job, any medication or contrast materials used for imaging, and whatever voodoo they work to give the final price (which is probably in the hundreds).

Anyone who doesn’t see the benefit of single-payer either has either been lucky enough to never be in a health situation that requires that kind of care, or has been in an HMO all their lives where everything is done for them.

perspicacious's avatar

Your doctor is not the person to depend on to tell you this. You should be in touch with your own insurance company to be sure what is covered.

sleepdoc's avatar

@JLeslie ... One thing to consider in all this. Most of the time the doctors bill the same thing for the same procedure for every patient. They kind of have to. There is a giant billing and coding system that has to be used to do this. When you call an insurance company, you are getting someone who looks in the system and tries to infere what the procedure is. In other words they are making a guess on what is going to be billed. It is not until the bill with all the coding gets to the insurance company that they actually and see how things break down and determine what they will pay.

JLeslie's avatar

@sleepdoc ok, but if the doctors insurance person is the one calling to find out how much to charge me for my part of the responsibility what is the excuse for not knowing the billing codes that are going to be used? If something unexpected is discovered or done during a procedure I understand why there might be more costs, but if not, it just looks like incompetence all around.

When I was having my worst health difficulties of my life I turned to my husband at one point and I said, “you will have to be the one to deal with the insurance companies, I am going to start just giving doctors anything they bill me whether a mistake has been made or not, because I can’t stand it, the stress is unbearable dealing with insurance, and I am already mentally strained from being ill.” Basically they had won, beaten me down. I have no problem paying for services, or paying a bill I owe. But, I don’t like when I pay for insurance, something should be covered, and I am still billed. I feel sucker punched all of the time. They won because I do care about paying my bills, if I was a deadbeat I could have just ignored it all and dismissed it in my mind. I think doctors and insurance need to realize someone who calls about a bill, is trying to do the right thing, even if they are saying verbally they don’t think they owe the money. People I know who don’t pay their bills never make that call, they ignore and avoid bills and collection agencies.

Basically what you are saying is as patients we need to know as much as an insurance expert, and we still will probably get quoted the wrong amount, and it is totally acceptable.

Seaofclouds's avatar

@JLeslie I’ve called insurance companies and asked them about things being covered for patients before and then they end up denying the claim last minute for some other reason. It all depends on the insurance company.

For example, I once called and asked about an insurance company covering gastric bypass for one of our patients, at first they said no, but then after going through an authorization process, I got it approved because the patient also had sleep apnea. Once the patient had the procedure done, they denied it. The patient called us and I had to get back on the phone with the insurace company. For whatever reason, the insurance company lost the authorization for it. After talking with the insurance company and several different people, we ended up working it out and getting it approved again.

A lot of insurance companies have many different rules and regulations about what they cover and what other things need to be met in order for them to cover it. I’ve seen insurance companies that won’t cover birth control pills just for contraception. Instead, the patient has to have a problem with heavy bleeding, acne, or PCOS in order to get their birth control pills covered by their insurance company.

The best thing I can suggest is if your doctor’s office ever calls the insurance company and is told something will be covered and then you get a bill afterwards is to ask the person who originally called the insurance company to call again.

Cupcake's avatar

@JLeslie That’s awful. I’m so sorry you have to deal with that.

I have never had such a problem, but my health insurance company operates differently than most in the country.

I think in this situation that your insurance company is completely to blame. I would try to switch to someone else, if at all possible, if I were you.

JLeslie's avatar

@cupcake that story is a long time ago, and a different insurance company from what I have now. I actually think the insurance I have now is awful also. But, I have dealt with insurers that have been much better also, and relatively little headache. Although, what I have noticed is if you get sick, that is when the headaches start. When I hear HMO’s talk about well and preventive care it almost gets me angry, because I have found that it is almost secret code for but if you are sick you are shit out of luck. My current insurance covers me fully for a routine mammogram, but if I find a lump and need a diagnostic mammogram I have to pay a portion. So, if I am more likely to have a cancer I have less coverage. I find that unethical.

@seaofclouds I appreciate your advice. Indeed many doctor’s office are helpful, some not at all. I understand that doctors must be frustrated also, and for the most part want to help their patients :) and I would guess want to get paid themselves, so of an insurance company says they will pay the doc wants them to pay up.

sleepdoc's avatar

@JLeslie .. if you want the simple answer, most offices don’t actually do the billing. It is done by someone who is paid to do just that the coding and billing.

dgwilson50's avatar

My opinion is that the person who has the insurance make themselves familiar with their policy. There is a lot of information on the web-site. You would be surprised to know that doctor’s offices don’t know everything about a patient’s coverage. There are far too many patients that see a doc in a practice to keep up. Take it from me, I work in this field.

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