Financial Stuff - The Beginning.

SPOILER ALERT!!!!  The following post may very well be soporific (still trying to get some points, here).  Please do not operate heavy equipment or drive while reading.

Well, the poll is not over, but I think I get the general idea.  Overall, those of you who voted would like to see what all this stuff costs.  So, as an experiment, I am going to try to put together something that summarizes Dates of Service, Procedures, Associated Costs, whether or not it was in-network or out-of network, how much the insurance comapny paid out and then how much was written off as a result of negotiated contracts.

To begin, a real quick primer on insurance claims.  (If anyone has any corrections they would like to make or additions that might make it EASIER to understand, please feel free to comment.) 

All physicians, hospitals, medical providers, etc. have charges associated with their services.  These charges are the same no matter who gets seen or what their insurance coverage.  Person A is uninsured.  Person B is insured, but out-of -network.  Person C is insured, in-network.  The hypothetical patient has an Office Visit.  For this visit, the physician charges $250. 

Side Note:  All charges accrued by the patient are ultimately the responsibility of the patient.  Claims filing is a service offered by the physician and is not a requirement.  The patient must follow up and make sure all claims have been filed and paid out per contract.

Person C owes the co-pay required by insurance (say, $20).  The rest is billed to the insurance company.  The insurance company has a contracted rate with the physician that allows the physician to bill $85.  Of this, $20 has already been paid by you.  The insurance company pays $65 and the physician is REQUIRED to write off the rest.  $250-$85=$115.  That $115 cannot be billed back to the patient. Person C pays $20.

Person B owes all $250.  They may be required to file their own claim to recoup some of that money.  Or the physician's office may be nice and bill for them.  The insurance company will probably pay 80% of the charges after they have applied a "usual and customary" rule to it and reduced the charge.  So, of $250, the insurance company says, "usually the customary charge for this service is $165.  We will pay 80%, or $132."  $250-$132=$118.  Person B owes, not only 20% of $165, but the unpaid balance of the physician's charge.  Overall, person B pays $118 (if his deductible is met; otherwise he pays all $250).

Person A is not covered by insurance at all and owes the full amount.  Person A pays $250.

The reason I covered this is because some of my claims are going to be paid in a special out-of-network category.  My insurance company negotiated a contract with another insurance company (not the physicians, themselves) to pay at THEIR contracted rates.  So, if I go see one of these doctors, my insurance pays out at 80% of THOSE rates.  I owe the 20% but the balance of the charges cannot be billed back to me because of that contract between their insurance company and mine.

Side Note:  If you, my readers, haven't tried this, I highly recommend it.  Repression of feelings through analytical analysis ROCKS!!!!!!  I feel better already.