r/HealthInsurance • u/Calment20 • 1d ago
Claims/Providers Do providers offer a "discount" for private pay?
My husband and I are very blessed to be FIRE (financially independent retired early). We have our health insurance through a small insurer we found through the healthcare dot gov portal. We've had them for about 3 years now and it has worked very well for us. A month ago I got a terrible stomachache. After about 10 hours and increasing pain we went to the local urgent care (it's large and calls itself a 'hospital'). I got great care and they did a CT scan right away. I got some pain killers and went home. (More tests are ensuing with a variety of doctors.) On my insurer's portal, I see that the Total charge for that visit was a whopping $32,800. My insurance paid $8.19 - yes, the decimal is in the right place. I only owe about $1,430.
My first question is, is the reason I only owe $1,430 because I had insurance and a giant chunk was "discount/disallowed" because of that insurance? One fee from that night was $18.8k and close to $18k was disallowed.
Second question. My same insurer did not approve an initial request for a PET scan for me (prior to an MRI). We decided to pay out of pocket and were told it would be about $3600. We said okay. But when we let the provider know we were doing it private pay, it suddenly cost us only $1800. Why?
I have some family members (young adults) that are uninsured and simply don't place a big value on health insurance so they don't spend what little they have on any of it. If they needed the same urgent care I did. What would they be looking at in terms of cost? Thanks for any info.
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u/pdxtech 1d ago
Billed amounts do not matter. Only your responsibility listed on your EOB.
Most places do offer a discount for cash patients but most facilities won't let you pick and choose which services you want to self pay for.
Nobody can answer the question about your family members. If they have a non-urgent and easily treatable injury or illness it might only be a couple hundred dollars. If they have a catastrophic injury or illness it could be hundreds of thousands of dollars.
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u/MuddieMaeSuggins 1d ago
My first question is, is the reason I only owe $1,430 because I had insurance and a giant chunk was "discount/disallowed" because of that insurance? One fee from that night was $18.8k and close to $18k was disallowed.
Generally speaking, yes. The hospital sets their “official” bill rate for everything really high for kind of convoluted regulatory reasons. Then they negotiate contracts with various insurance companies and agree on the rate that company’s clients will actually pay. So one benefit to having insurance, even a high-deductible plan, is that you pay the insurance company’s contract rate, which is a lot lower than the rack rate. That is probably the same thing that happened with your PET scan.
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u/Jezza-T 23h ago
Where I work, everyone gets charged our U&C (usual & customary), if what you are getting is excluded from your insurance coverage or you don't have insurance then we offer 30% off if you pay in full or 15% off if you set up automatic monthly payments (length of payments is based upon the discounted total, longer terms for higher amounts). That discount pretty much brings it down to what most insurances allow. The thing about having insurance is that most of the time there is a maximum out of pocket which means that eventually if you end up needing a lot of medical care you will meet that out of pocket and should not owe more than that. A single hospital stay can cost over $100K if you have something major happen. That can bankrupt someone who doesn't have insurance, not to mention things like cancer, heart attack, stroke, aneurysm etc which csn happen to even young people.
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u/Calment20 23h ago
Indeed! Thank you for this “behind the scenes.” I’ve told both my adult children (they have insurance but husbands don’t) that one of the single hardest things about adulthood is figuring out health insurance.
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u/MuddieMaeSuggins 21h ago
For the husbands, a high deductible plan could be a good fit - the premiums are much cheaper, but they still get the insurance contract rate and they have an out-of-pocket max is something serious happens.
The real risk of being uninsured isn’t an emergency - in a car accident or something, a hospital will save their life regardless of ability to pay. The risk is something fatal and slowish, like cancer. Generally speaking, if they don’t have insurance, they’ll have to pay a lot upfront to get any treatment at all.
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u/Turbulent-Pay1150 13h ago
Well, now, if they were diagnosed with cancer and the first bill for 100k plus comes in even a big discount will wipe them out especially as that would be the first of many bills. Heck, even open hear surgery can easily be billed at 250k plus. Your insurance has a negotiated rate with the hospital/doctors already and in some cases your private non-insurance rate will be less but those who choose no insurance are in for a very rude awakening or bankruptcy even if they had FIRED beforehand. That plus the fact that you can’t get coverage mid year, only guaranteed during open enrollment period, for anything but Medicaid where you might be eligible for it so if you chose not buy coverage and in January had a diagnosis of cancer you can be stuck with what could be hundreds of thousands of dollars in bills - or even over a million - with no recourse other than pay at a somewhat discounted rate out of pocket. Insurance isn’t really for the minor bills - it’s value is in ensuring you don’t go bankrupt for medical procedures.
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u/PrestigiousDrag7674 13h ago
Which insurance company is that. And how much is your premium? I am interested
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u/Calment20 8h ago edited 8h ago
First, I’ll tell you I made a mistake in my post. My urgent care initial charge (before discount) was $32k. My cost is more than $1.4k.
Moda Insurance is my insurer and covers a super small area in Central Texas. Found on healthcare dot gov 3 years ago. We have a relatively high deductible. Premium is about $450 month for 2 with some subsidies. Next year (and previous years) will be much pricier. This doesn’t include dental.
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u/PrestigiousDrag7674 8h ago
is this coverage for 2 people?
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u/Calment20 8h ago
Yes. I said $450 for 2. We do get subsidies this year. Price will be significantly more in 2026. Bronze coverage.
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u/PrestigiousDrag7674 8h ago
We have the Bronze plan as well, deductible is $3k, but out of pocket max is $9,100, what is yours?
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u/Calment20 8h ago
Individual deductible is $7500. Total out of pocket for both is $15k I think.
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u/PrestigiousDrag7674 7h ago
will you consider a gold or silver plan next year?
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u/Calment20 7h ago
Probably not. So far my medical tests have come back "in my favor." I have 2 more appointments this week. But as costs are capped at $15 per year, we're okay. Insurance would have paid for the PET scan, but ONLY after an MRI had shown a need. I decided to do it sooner than that. I'm not in any dire circumstanced medically nor financially. Thank you, Lord.
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u/PrestigiousDrag7674 7h ago
with all these testing you are doing, it will add up... also I don't think they can offer you cash pricing if you have insurance. I could be wrong?
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u/Calment20 3h ago
Let me explain a little better. When my healthcare providers reached out to my insurance and asked if they would cover an MRI, they didn't say no. They indicated it would go toward our deductible. We have yet to get the bill for the MRI, but it will likely be large. However, because of our insurance we will pay a 'contract price.' My health insurance would NOT approve a PET scan because the MRI had not been done yet. They mentioned on the letter they sent me, that if the MRI had indicated that a PET scan needed to be done afterwards, it might be something they could apply towards our deductible. It would never be covered 100%. Not sure how the provider gave us such a good rate for private pay on the PET but we were standing in their finance office and the 50% reduction on the rack rate was not something we were going to argue on. We realize we may be facing a total of $11k for my healthcare in 2025, but that doesn't compare with the $50k+ that would have been the "rack rate" for the treatment without insurance.
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