Husband got a pre-approved colonoscopy a few weeks ago and this was the bill from the anesthesiologist? Thank god the insurance is covering/paying but wtf? Did they add an extra zero on accident? This makes me so angry.
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Yup, the procedure cost was $350. This is the shit that pisses me off so much with healthcare. If they billed someone who is uninsured $400, they might actually get it. Billing $21,000 might as well be infinity-jillion dollars. They’re never gonna get it. Everyone knows this, yet the system goes on.
There’s a separate charge master for self pay patients. It would drop the bill down to $400. Sometimes it can get hinky when it looks like a patient has insurance (or says they do) but then they really don’t and that’s usually when a bill at the full price gets sent to the patient. For most places, if you just call and tell them you need the self pay rate, they drop it way down. Hospitals are also too busy to go hunting through every eligibility pull they can without an ID number for every patient that has terminated insurance so they just send you the bill and hope youll call them to ask what’s going on so they can get your correct insurance or manually drop it to the self pay rate.
Source: medical biller for a primary care doctor but some of my coworkers bill for hospital doctors. The facilities might actually be scammy but Tyne doctors usually have their own billing department and that’s what we do.
Im not sure how its dirty when the provider contracts list the allowable amounts in them. This is why we see hospital systems advertise that they may go out of network with a particular insurance, they are arguing over allowable amounts.
The big numbers are usually just that- a big number that the provider knows will be over the allowable amount for every network they're in network for. Hence the billed amounts being irrelevant. Providers can bill a billion dollars for a bandaid or $10 for a bandaid, but their contracts already have the predetermined allowable amounts for every cpt code.
Doesn’t work out very well for the uninsured. That makes it kind of dirty making up numbers to bill. Billed amounts become much more relevant to people if there is no insurance to pay them.
I don’t understand why more people don’t grasp this and get outraged by it. Providers, by creating these fantasy billed amounts, wind up making the people least able to afford the cost (the uninsured), pay the highest prices. And yes I know you can negotiate a cash discount, but it’s a discount off of an obscenely high starting point. It’s criminal.
Labs do this they charge ridiculous amounts and then say it's their policy not to reduce (Quest) if denied. Which is why I am stuck with $700 bill even though insurance amount would have only been $35.00 had it been covered.
Its a symptom of the providers being beholden to the insurance companies, but people will do the mental gymnastics to tell you it's perfectly reasonable.
I just don’t think this can be blamed on insurance companies. I’m not a fan of them at all, but the idea that the provider needs to jack up the price 10x so that the insurance company thinks they are getting a 90% off deal just doesn’t hold water. The insurance company knows what a procedure costs and they negotiate by playing providers off each other to see who will give them the best net price. It’s the providers doing this to either milk the uninsured who can and do pay or to demonstrate the level of free care they provide (which in the case of certain facilities then gets reimbursed to some degree by the govt)
It isn’t so that the insurance thinks they’re getting a discount, it’s because the insurance will negotiate it down to 90% of the total cost anyway so they have to inflate the total cost to get paid at all.
For example, say you have a procedure and it cost the doctors office $10 to do that procedure, and they want to charge $100 for it so that they make $90 in profit (they have to pay providers, overhead, and insurance.) The problem is these insurance companies come in and demand lower and lower payments or they’re not going to cover the services at all (that’s in network vs. Out of network.) In order to still make profit after these silly negotiations, the doctors office inflates the total cost because they already know that insurances are going to demand 90% off the top already. If they still want to make their $100 for that procedure they now have to charge $1000 for it.
This is the same reason many providers no longer accept Medicaid or Medicare. They have pre-negotiated rates that don’t always allow providers to make a profit.
It truly is the insurance companies here that are driving up the cost for uninsured people. Insurance companies are the only reason that the doctors office is now charging $1000 for a procedure that only cost them $10.
Now, it is possible that greed on the part of the medical institution is also at play, but it is nothing in comparison to the greed of the insurance companies. You have to consider as well, these insurance companies want to make being insured the ONLY option. Driving up costs for people without insurance only benefits them in the long run.
Do you believe that if provider A bills $4000 for a procedure but agrees to a 95% discount with insurer (so net cost to insurer of $200) that then the insurer will pick them over provider B that bills $1000 for the same procedure but only provides a 90% discount (so net cost to insurer of $100)?
I believe that insurers are generally evil but that they are also pretty darn smart. They pick the lowest cost provider. Provider A wants $200, Provider B wants $100. Thus Provider B will be in network and Provider A will not be. Insurers don’t care about discount off rack rate, they care about net cost.
So I dont buy the argument that insurers drive rack rate.
Providers agree to charge the insane rate to anyone not insured or out of network. They do not agree to not being able to negotiate prices.
If you get a high bill when uninsured just call and try to negotiate, any decent provider will immediately give you the insurance discounted rate(or near it)
The uninsured would most likely have a completely different rate, or, they could negotiate a rate. Generally uninsured can bargain down to the Medicare rate or double the Medicare rate (because Medicare is actually quite low.) Often in financial systems, they have these large amounts so in certain cases they can claim the difference as a loss on their tax bill. (Doesn't work for contracted rates, it's more for indigent/no-pay patients.)
The made up numbers matter because they compile that data to create the allowable amounts. If providers billed "reasonable prices" the insurance companies would not play ball with allowable amounts on contracts.
I was taught this when I learned how to run a PT/OT/SLP practice. We are encouraged to bill at least 3x known allowable amounts to "show what services are worth". Otherwise, insurance companies will devalue our serviced and continue to reduce allowable amounts. When providers don't bill outrageous amounts, insurance WILL decrease what their contractual payments. It's why those contractual fights exist.
This is completely made up. I believe someone told you this but it is pure BS. The rate is set by what providers in the market demand, irrespective of how much they bill
Insurance companies make deals with providers, we send you patients through our portal and you give us a massive discount.
The problem is providers can't give a massive discount, so they say ok what if we raise prices 10x and then give insurance a 90% discount is that ok? Insurance is fine with that so that's what happens
No one cares about "proving your worth".
Also you can always call and negotiate prices if you don't have insurance, the provider's contract with insurance says they have to bill that insane price but it doesn't say they can't negotiate. Most Providers will just immediately drop to the discounted price if you try to negotiate.
This is just not true. Hospital bill rates are the opposite of competitive pressure. They set their billed rates at the maximum allowable for the most generous plan, obviously most insurers negotiate these rates but providers are incentivized to bill at high rates for the one insurer out of ten who will pay it otherwise they are technically leaving money on the table.
The insurance companies compile that data gathered to set the allowable amounts contractually. The way I was taught is that businesses and hospitals are encouraged to bill at least 3x the known allowable amounts to ensure the data compiled demonstrates the need for higher contractual rates.
But it's as you Said, to avoid leaving money on the table.
But the biller doesn't know what my individual insurance agreement is? We are on a high deductible plan and oftentimes, we get the 'difference' applied to our deductible. So having fabricated amounts just for giggles potentially means I could potentially get hit with the difference. Yes, they adjusted it and paid it 100%, for which I am thankful for. But for approx 45 minutes of Propofol for a routine procedure, $21,000 is ridiculous. He didn't have open heart surgery. We are so gaslit in the US now that we excuse this as it's OK cause it's a made up number anyway so don't worry about it? Why is that OK?
Well the provider and your insurance company have an agreed upon price for everything you could get billed for. So if hypothetically the contracted price for anesthesia was $1,000, they can bill $7,000,000,000 and you will see a discount for $6,999,999,000. Then from there, that $1,000 is applied based on your plan benefits. So you’re not any more screwed being on a high deductible plan and being billed $7 billion. Using an in network provider and receiving care that is covered under your plan will bring the billed amount down to the contracted amount for the service no matter what.
You wouldn't get hit for anything. Patient responsibility would have been zero no matter what. Yeah, the system sucks, but you should learn how it works since we're stuck with it.
If you didn’t have insurance, you probably would’ve paid like 250 or 300 or something.
It’s all a giant game, they use these charge masters for leverage in negotiations and also to do some funny accounting for tax purposes
When people get those bills for hundreds of thousands of dollars, very rarely, are they even close to accurate. If you’re not covered usually the bills are very small fraction of what you actually end up paying
That definitely seems excessive for a colonoscopy, but the entire thing is arbitrary. They know how much the insurance is going to pay so they can put whatever number they want there. Now, if you had to pay 20% of that, then you have a very good point, but it should be covered 100%/
Typically, a medical practice uses the same gross charge for a CPT code across all insurance companies. The amounts allowed by each insurance company are likely different, so the "plan discount" (contractual adjustments) are used to reduce the charges to the allowed amount.
Yes, that's the whole point. They have agreed to charge that amount to everyone, then they give "discounts" to insurance companies they partner with.
If you're uninsured they have contractually agreed to charge you that crazy amount, they however have not agreed that they can't negotiate prices. Just call and negotiate and you should get the "discounted" insurance rate or near it.
They don't know what insurance is going to pay - they submit an arbitrary excessive amount to ensure that they get the maximum payout from insurance - this saves them from having to keep track of what they have negotiated with every insurance they accept.
Of course they know what insurance is going to pay. They have a contract that spells it out.
The real crime is that they are willing to accept $350 from insurance but will bill you the full 21k without it. And they aren’t losing money at $350.
Providers and insurance have contracts. It says exactly what the payment for everything is. It also says that the providers must give insurance a "discount" aka providers gotta charge everyone this insanely high rate and then "lower" it for insurance.
Nothing is arbitrary, not the billed amount, not the amount payed to the provider. It's all predetermined in the contract.
I honestly don’t understand how hospitals and providers can manage with Medicare. I grateful to be on it, and it’s not ‘free’ by any means. But I look at the payments and don’t get it.
That’s health care in the USA for you. Is this provider INN or OON. With the No Surprises Act, it doesn’t matter for you—but out of network providers are going to make sure to charge the most they can so they don’t undershoot the allowable amount, because insurance is not going to pay more than what was billed. INN providers do this too.
They likely would have applied a hefty discount if it was denied or the patient was uninsured. Federal law says prices charged to the patient have to be reasonable. One provider I know charges in the 50ks for intraoperative monitoring, try to get as much as they can from insurance, but the self-pay rate is $200. That sort of thing is pretty common. It doesn’t always happen, so yes, there is a chance you may have been on the hook for that much (unless you wanted to lawyer up and fight it but lots of people don’t have the means).
It makes people crazy and not that I don’t get it, but also realize there is tension between providers and insurers regarding what’s a “reasonable” rate. This tension is a good thing (at least, in the absence of real federal standards) for patients because it ensures that both the standard of care and affordability of care are considered. But without standards, patients can get caught in the middle. That’s why so many insurance companies lobby for bills like the No Surprises Act, which mandate mediation or negotiation, to prevent that.
My coworker was billed by the anesthesiologist after her colonoscopy last year and I tried to find out from her whether it was just copays allowed by insurance, or they were balance billing because they were out of network (even though procedure was through in-network practice). I tried to explain to her that if she was being balance billed she could dispute it but she didn't know about the no surprises act. The bill wasn't $21,000 though, it was more like $1000.
I feel like a lot of the medical billing world is very arbitrary. Previously I had a HDHP through Blue Cross and my primary care would bill a random number like $459 for an office visit and I would pay $99 as the negotiated rate. Urgent care visits would be similar random numbers. It was so weird.
Angry about what? A contracted amount between hospital and insurance? That would be like being angry about what McDonald's pays for their Coke when you have a coupon to get it for free.
Why are the prices so high in the first place? Charge a reasonable and real amount and then cash paying patients wouldn’t get screwed. Why does insurance get preferred pricing?
This is all a scam to force people to have insurance or f them over otherwise.
Just how it works is shorthand for a corrupt scamming system.
There are so many middle men and players (insurance, PBM etc) that grift at each step to make money off of you. Universal healthcare is the only path forward (like every other developed country in the world)
And working in healthcare I can tell you the cash price isn’t as low as you’d think…
I really didn’t want your input at all. They were more rhetorical questions to get anyone reading to wake up and realize that healthcare in America is a scam.
Even the fact that someone has to “manage a revenue cycle” for healthcare is unthinkable in most first world countries and is quite sickening to be honest. Healthcare isn’t about revenue- it’s about providing health..and care..to those who are sick period.
And I also work in healthcare. But more with meds. And I can very confidently tell you that for newer meds, if you don’t have insurance and don’t qualify for PAPs you are 100% screwed.
Insurance and PBMs exist to make a buck off of you. Healthcare should be public and affordably priced - you know, the “extremely complicated” system that every other first world country (and the VA) have somehow figured out…?
Uhh no, if you don't have insurance to negotiate for you then you can just call and negotiate yourself.
Providers aren't trying to scam you, they get screwed and forced to do this bs pricing by insurance. Just call and they will give you the "discounted" insurance price(or near it).
To go back to the Hamburger example would you buy a Hamburger when it could cost somewhere between 5 and 500 depending on a discount you may or may not get
In some states there are "prompt pay laws" that require insurance companies to settle claims within a given time frame. If they don't pay within a given time frame, there are fees and penalties that the company has to pay in addition to the claim amount. Sometimes these fees and penalties are based on the billed rate. So setting the billed rate so high, making potential payout $10,000 instead of $10, adds pressure to insurance companies. It is a necessary check and balance to the powers insurance companies have over physicians.
There's also the idea of tax write-offs. Whatever portion isn't paid can be deducted from yearly tax bills. How much is dictated by area.
The other people that say that the number is arbitrary and made up are not wrong. Consider that a heart surgery prolongs someone life for another 20 years. How much is it worth to them to see the children and grandchildren grow up instead of just waiting for the inevitable; how much would the patient be willing to pay? How much is the physician willing to accept? There's no real hard, black and white way to set that. Maybe be a healthcare provider in a dictatorship, but even that is just a person or group of people making up numbers and forcing it on a population enmasse.
The medical field is high demand with necessarily very high barriers to entry. This can skew that economic law into making things very expensive for patients. Write-offs, fees, penalties, etc are ways that developed to help control that.
If ANY other business gave you a bill like this, you'd tell them to stick it where the sun don't shine. Not to mention any correspondence you get from your insurance company has about 5 sheets of paper with one paragraph of useful information.
There should be a law regarding what percentage 125 percent as example etc providers/labs can bill over their highest payors contractual amounts. This is why healthcare gets a bad reputation. If you have insurance and it's paid, that's fine. However, if they decline than yeah you call and ask for a negotiated rate, but it's a negotiated rate of a crap billed amount. However the labs per their policy are not reducing. They keep the patients with the amount they bill which was exuberant to start with. It's flawed charging 3 x will not make the insurances pay you more there are set fee schedules per payor for contracted rates for every CPT/HCPC codes. If you feel you are being paid too low by your payors then you need to call and try to get new contactual rates showing your worth as a provider to justify higher payment in your area. (Maybe you are the only specialist in a rural area offering a specific type of service within 50 miles etc) If a provider is out of network there should also be a set amount but higher than in network percentage rate.
Probably because the number appears to be pulled out of someone's ass, making it impossible to get any kind of real comparison between hospitals. Also, would an uninsured person be paying $21000. This nonsense would not be tolerated in any other industry I know of.
It's comparison between hospitals. You should be able to compare an actual price in one hospital versus the price for the same procedure in another hospital.
This is just simple common sense. As far as I know there is no other industry where a refusal to quote an actual price is tolerated.
Insurance is the reason why. I work at an out of network dental office. We can tell people our fees because we have no contracts with insurance. We take the insurance. We have no idea what insurance will pay but we can tell the patient how much the service is. This is the best way to run healthcare here. But being out of network “ fee for service”. Is so hard to be successful in because most people actually don’t really care what the actual price of the service is… they want to know what their insurance covers and what costs will be. So most health offices are not run by how much a service is that they decide. Each individual insurance company they go into contract decides. The fact they had to inflate their price to 21,000 just so they can get the $350 should show you the issue. Example from my office … a regular cleaning is $110. That’s what are fee for service is. Some insurance pays it’s all some don’t and patient pays the remaining. If our office was in network with insurance a lot of offices will say a cleaning is $150-$180… but they will only get $50-$60 back from insurance and can’t bill remaining… so that’s why they inflate the price.
What other services are you referring to? All other businesses can give a quote because they are the ones charging you and taking the fee. Hospitals are dealing with insurance it’s complicated and completely different. If you go to a hair salon and they say a haircut and color is $300 . Then you would pay that. But if you went to that hair salon and showed them a coupon that they didn’t print but have to accept but doesn’t say really how much the coupon is worth, what it covers and also it decides what the total cost would be…. No other business would ever accept this.
You can compare pricing. But you have to talk to someone, give them the procedure codes and they can pull the contract to see what their allowed amount will be.
You’re angry you paid nothing and your insurance paid 349?!
The top number doesn’t matter. No one pays that. Even people without insurance paying cash would not pay 20K. All the matters is what you are on the hook for which is 0$. Congrats.
I'm angry that we are apparently supposed to be cool with the fact that the top number is totally made up and is not rooted in reality, doesn't reflect actual services rendered or true costs. And then I'm supposed to celebrate that I didn't pay $21,000 when in reality, the bill never should have even remotely been $21,000. The justifications of some in this comment section being well, you didn't have to pay it is not the point and y'all are justifying it as it's all good cause it's fake anyway??
I understand that, but why would they bill $21k in the first place? We all know that's not what 45 minutes of sedation cost, so why are we all making excuses for fake amounts being used? If the provider knows they will only get $350 for the procedure, then why not bill $350? It's a joke.
I won’t lie to you, I’m not even close to qualified to give you an answer to that. I’m not completely stupid when it comes to medical billing, but I’m also not the most knowledgeable either & it would be a disservice to you if I was to answer that question. My work is a patient facing one & I don’t handle billing. There’s a whole separate department at my agency for that. I do however know that the “amount billed” number is damn near pulled out of thin air. If I was to take an educated guess, it’d be one of a few reasons.
to bleed insurance dry for as much as they can
put pressure on insurance through regulation and get them to pay claims sooner (some states have laws that dictate they HAVE to pay promptly or get fined a % of the billed amount)
prevent insurance from devaluing their services (which is why contract fights “we won’t be in network with x insurance company because of an unfavorable contract” happen)
because they feel like it.
I’m an EMT so whatever services I render gets billed to the patient for me & without me having to care. Do I agree with it? No. I don’t agree with our healthcare system in the SLIGHTEST. It needs reform. Do I know everything? No. Take what I say with a spoon of salt cause I could be 0 for 4 and nothing I said was right. That’s simply my best guess and I can’t give you a definitive answer.
Did you know that pre-approval only means the procedure is covered by your insurance, not YOUR procedure? This sub pointed that out to me and said I owed 13k. The insurance administration refused to pick up the phone for me and my doctor. They wrote it off, but I worried for a year and a half. Our system is beyond stupid.
The “amount billed” is the list price (or for the hospital what’s listed in the chargemaster), then “discount” is the reduction to contracted price for that specific billing code.
I insisted on staying awake during my last colonoscopy in 2020, which the Dr. said had only happened several times prior because some patients can't handle the anestesia. I also played "Dark Side of the Moon" on my phone's speaker during the colonoscopy, which the Dr. said no one had ever played music during a colonoscopy. "Matter of fact, it's all dark."
My husband's doctor wants him to get one, but warned that he could pay an out of pocket facility fee. i hope that's not true, we can't afford ANYTHING right now.
This happened to me I found out the anesthesiologist was out of network. When I called the GI doc asked why was I being billed for something never told about prior they said just ignore the bill. The bill was $350 wasn't much. I suspect many would just pay it and not look into it if you call and complain just tell you to ignore it.
This is the way. There isn’t evidence supporting the practice of using MAC for colonoscopies. Patients should start refusing anesthesia and requesting moderate sedation that can be administered by the GI physician and nurse. Then no separate bill to worry about.
I have a theory that anesthesia must be a major revenue generator for hospital networks. Is this accurate?
This recent opinion is based on a recent experience of mine involving a wrist surgery with pins, which I later learned could be done without me having to be under general anesthesia.
Furthermore, my local hospital network did not include on its Good Faith Estimate to me prior to surgery (as a self-pay patient) ANY anesthesia services. They then billed me after the fact.
I have a NSA appeal against the network in process.
I may be mistaken, but can't you get a colonscopy with just a mild sedative? It seems like popping a few bars of Xanax would do the trick for most people. Maybe some nitrous oxide and xanax?
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