clarification on medical billing

[winterbadger]

I got a response from Aetna the day after I emailed them, which I have to give them credit for.

Their argument is this:

Office surgical procedures are paid at 80% subject to the $600 calendar year deductible. The office visit copay applies to non-surgical services performed in the doctor's office. The billed amount on this claim is $290 and the contract rate is $141.01 which was applied to your deductible. The provider writes off the $148.99 contractual adjustment. Therefore, since $141.01 went to the deductible you are responsible to pay this amount. You paid $25 already and the provider has credited your account. Their billing of $116 is therefore correct.

I'm not sure that I really understand this; maybe one of my more medically savvy friends can help me out? What do they mean by "contract rate"? I guess what I think I'm hearing is that they have an agreement with the provider that the going rate for this is $141, of which they will pay 80% *once* my deductible (I hadn't realized there was a deductible) is exhausted. The $149 they "pay" only in the sense that the $141 is a discounted rate that the practice offers them; no money actually changes hands. Thus, if I had already used up my deductible, I'd be paying 20% of $141 instead of all of it.

Mant, that's as clear as mud.

Comments

[flyingwolf.livejournal.com]

remember my example? in it the $100 is the contract rate.. the amount the insurance company deems is the reasonable charge and an in-network provider has to accept. (of a $200 charge) If they covered 80%, then you would only owe $20 if in network. (vs. $120 out.

Sounds like your deductable is a lot higher than you had thought.

Actually it is pretty clear. I've been in much more complicated situations. Been told by BC/BS that In-network and participating provider are NOT the same thing. Boy was that a head spinner.

[jodimelancholy]

Your journal is interesting. I've added you as a friend. I hope that you won't mind.
Jodi

[winterbadger]

Certainly not; fine by me. Welcome!

[liatha.livejournal.com]

What he said!

Basically, yes. The doctor's office normally charges $290 for the proceedure. That's what they charge someone who has no insurance. Each insurance company they sign on with assigns a specific "fair price" amount to every proceedure they allow. The doctor is forced to accept that amount in payment for those proceedures performed on that particular company's clients.

Now we get to you. YOUR contract with the insurance company has specific restrictions. Your "deductible" is the amount you have to pay each year before the insurance company takes over for a contracted percentage of the costs of everything else. The most common percentage split is 80/20... which it seems you have. What that means is... for example... if you had to have major surgery that cost $10,000... you would pay $600, bringing the total down to $9,400... then the insurance would pay 80% of that, or $7,520 and you would be responsible for the balance of $1,880.

That's just a very basic example... it can get alot more complex than that. There are plans that are 80/20 up to a certain amount and then the percentage split changes... and then they STOP paying at a cieling amount... I'd have to see your bennie's package to really explain it all to you.

god... can you tell I grew up in an insurance family?

[winterbadger]

god... can you tell I grew up in an insurance family?

LOL, yes, perhaps so... :-)

[ga-sunshine.livejournal.com]

Right. If you had already paid your $600 deductible, then your insurance would have paid the doctor 80% of $141, but since you didn't pay the $600 yet, you pay the $141 and it counts toward your deductible. You already paid $25 so now you owe $141-$25 = $116.

[balzacq.livejournal.com]

I've never been able to figure out medical insurance bills/reports.

I'm very strongly against single-payer national health care, but I would certainly support legislation requiring paperwork reduction and transparency in billing.