I you carry you’re own insurance congratulations! You’re already saving thousands a year….if you choose in-network/participating medical providers.

Before I get to in-network/participating let me start by describing the various types of physician practices: individual, partner, small group, large group. The definitions are pretty obvious, but one thing that isn’t is the charges and treatment. Individual providers stand alone and usually have a lot of overhead (assistant, nurse, rent, utilities, ins.) that’s why it’s rare to find this type today. They are acutely aware of the cost of treatment. A partner might have one or two other physicians in the same office but seperate who’s patients are who’s and split the cost of an assistant, biller, nurse, rent, etc… Small and Large groups are pretty obvious but one thing that isn’t is their contractual agreements.

From what I’ve seen, most group practices are owned by one physician or the group as a whole. They have a contracted agreement to make $x amount for the year to see patients on x days from say 9 - 5. They never see a bill or a charge amount. They may get a bonus or profit share if their patients pay the bills.

I always look for group practices for this reason and also if I can’t get in with my preferred physician I can see someone else in the practice. This is my first step.

The next step is to make sure not only is the group in network/participating with your insurance, but the individual doctors are as well at the address you will be seeing them! The might be in two seperate offices but only enrolled with the insurance company at one address. In-network/participating means that they signed a contract with the insurance company to only take $x amount on a procedure regardless of what they billed. (I recently received a bill from an x-ray tech for my daughter that was billed at $332….my cost $3.99)

Say you went for a strep throat culture at an in-network group practice. You can expect a bill from the group on behalf of the dr sticking a Q-tip down your throat and the lab that processed the culture. Say the group bill was $150. They would bill your insurance co with a procedure code (it’s called an ICD-9 code and they are standard in medical billing…this code will be your key to further savings explained later) which the insurance company would say “you signed a contract for $20 for this procedure”. Your explanation of benefits (EOB) would show the $150 charge, the $130 as the provider’s responsibilty and the $20 remainder as patients responsibility (with traditional insurance, assuming you haven’t meet your yearly deductibleand paid a $20 co-pay at the office visit and that co-pay went for the office visit charge…completely seperate ICD-9) Assuming your deductible was met and your insuranc policy had a 80/20% co-insurance, then the $20 would be reduced by 80% showing as “plan paid $16″ and you would need to pay the remaining $4.

That takes care of the dr, but what about the lab. You must always, always make sure the group practice utilizes an in-network/participating lab. If not you can request a prescription to go to an in-network/participating lab seperate from your doctors office. Do NOT let the doctor state they are unable to do so. If the doctor says they can’t do it, let them know that the lab they use (and are most likely contracted with) is out of your insurance network. Most physicians are aware of the cost for out-of-network procedures. The same procedure will apply to the lab bill as above for the doctor/group.

You just saved yourself roughly $300 for a strep throat culture!!

Also, if you’re facing an upcoming surgery make sure the surgeon, physician, and hospital are in-network. Generally, the in-network hospital is required to obtain a pre-authorization from your insurance company for the surgery. If the hospital fails to do so, get this…the HOSPITAL is responsible for their bill, not you!! This would be the same for your physician and surgeon.

If the original bill to your insurance company gets denied, do NOT call your insurance company unless you get a bill from the hospital/physician. Most likely they are having problems with the pre-authorization. It is NOT your responsibility to get the insurance company to pay the hospital/physician if they are in-network/participating. Use this time to save more money to pay the bill when it finally comes.

If you want to find out a rough estimate for the surgery, get the ICD-9 code from the doctor’s billing office. Most likely the doctor won’t know the code and don’t waste their time asking, they need to worry about patients. Call your insurance company and tell them the doctor/surgeon/hospital name and the ICD-9 code. The insurance company should be able to give you a rough estimate of what you’re charges will be. Please keep in mind it could be off by a couple hundred dollars depending on what other bills are pending with insurance and which bill is processed by the insurance company first.

Also, you have a right to a list of your charges after you leave the hospital. Keep a notebook of what they gave you. When I had my first child they nurses opened a breathing thingie since I had a C-Section (sorry don’t know the techincal name) after I specifically requested not to receive it. Guess what, since they opened it they billed me $152!!!(I had crappy insurance) I saw the same thing at a medical supply store for $5!! I saved it and when I had my second child I brought it with me. The nurses looked at me like I was mad until I told them that they already charged me $152 for this one 2 years ago and I’m absolutely not paying for another!! I requested a charge list from the hospital to make sure they didn’t charge me again.

Also, the $4 prescriptions are not always cheaper than insurance if you have a high deductible plan. Mine will run under $4. If you want more info on this post a reply.

Hope this helps people!!!

Oh, please. I’m from the UK, and that’s hogwash.

The NHS is not without its problems — for example, waiting time for non-critical procedures — but quality of care is not one of them.

I can’t speak for the physician you worked for and his methodology. However, take for example the UK, where they have socialized medicine, and no adequate conditions. Patients get jammed into a cattle call room, asked to remove their clothes, and use sometimes soiled gowns. I find that unacceptable, but that seems to be what some people want. Less expensive services.

As for your comment about prescription companies, I never once mentioned the drug manufacturers. You make uneducated statement. Keep in mind that everyone is either a sales person or a buyer in some capacity. Drug Reps are out there to push their product, like anyone else. Sales is sales, and if they don’t like it they should get out of it. Drug Reps also get paid on the higher of the income scale in sales related positions, and there is very little competition among them.

At the end of the day, why do people like yourself try and justify that a physician overcharges, when they don’t mind spend hundreds of dollars on clothes or shoes. Physicians are entitled to make money too. They are not in it for charity, and your health should always be the first priority.

And I do go for second opinions, when I am unsure of something. There is nothing out there that states you cannot do so, or shouldn’t.

My husband went to the doctor for an earache. During the examination, the physician removed some wax from his ear. He never mentioned that this was a separate “procedure” or “surgery,” or that it would be billed under another code in addition to the office visit. I freaked when I got the bill. He coded it as “surgery” and charged $150. My insurance has a $100 co-pay (that doesn’t count toward deductible) for “surgeon’s fees,” so now that ear cleaning will cost us a pretty penny.

Do I have any recourse with the physician who didn’t tell us that what he was doing wasn’t covered as part of the exam (it always is for my daughter at the pediatrician’s), or that it was a separate bill/code, and certainly not that it was a “surgical code.” (We would have denied the service b/c if he had told us it was a surgical code we knew at the time about the surgical co-pay). I’m so frustrated b/c I do know my insurance policy, but I’ve never had a physician bill me for something without telling me in advance.

Any advice from someone who has dealt with this before, or is a physician or lawyer in the know? Thanks.

Recently I had a regular checkup and the doctor took a blood sample. A few weeks later I received a bill of $300 from Summa Healthcare at Akron for telling me that I am OK with cholesterols. Is it ridiculous? If I was told of the cost, I would have to decide on it.

I guess you will be going for your prostate exam at the local Walmart Automotive Service Center? You are wrong on many levels about physicians as pricing they set. Did you ever hear about medicare insurance and the ongoing costs that physicians pay? It only goes up. Why do you think that there are fewer and fewer physicians staying in the field of medicine, it’s because of insurance companies driving the pricing, and squeezing the physicians, and no I am not a physician. I just understand the reality of the econmics. So go ahead have your proceedure done at home with your craftsman tool set next time. You are very foolish, and ignorant of what is really going on about the field of medicine.

Every medical procedure has a code. That code for that particular procedure is the same nationwide. If a doctor suggests you have a specific medical procedure done, you have the right to request and be given that cost of that procedure. If the doctor refuses to give you the cost, go to another doctor.

Also once you get the code, call your insurance, give them the code of the procedure and your zip code, (what insurance pays for different procedures varies by area) and ask the insurance what is their reasonable and customary payment amount for this procedure.

If the rate quoted by the doctor is higher that the rate quoted by the insurance, then you would be stuck paying the difference, plus your deductible amount.

But if you tell the doctor what the insurance will pay and ask he if he will accept that amount as the total cost of the procedure, he will usually agree to that amount.

Both the doctor’s office and the insurance will try to give you the run around when you ask for these figures, but if you are persistent, you can save yourself thousands of dollars on a procedure.

Also do not hesitate to get prices from more than one doctor if the procedure is a costly one, and what medical procedure isn’t these days. Doctors get very cooperate if they understand that they are competing for your business.

If you take the time to make these agreements before hand, you save a lot of money. If you try to get the situation taken care of after the fact, the doctors, hospitals, and insurance companies are much harder to work with, although in my experience it is still worth the effort.

Even before you go to the doctors office for a routine checkup or a shot, call ahead and ask what it will cost. If it seems to high, call other doctors. Shop for medical care like you would shop for a vehicle. If you are going to pay cash, then tell the medical provider you are willing to pay what the insurance or ppo is paying and request that cost up front.

I believe a major reason our health care costs are so high in this country is that me have been brainwashing into accepting what ever the medical establishment charges. We need to treat medical care costs just as we treat every out cost in our lives, aggressively challenge the costs and negotiate cost just as we would for other costs.

Drug companies don’t charge me anything. Except for the few supplies I keep on hand(vaccines and Demerol and one antibiotic for emergencies). Drug companies charge the patient at the pharmacy. I don’t charge insurance companies high prices, they set the fees I can charge.

I fully agree that costs should be more clear to the public. But I disagree that we can keep insurance costs down by being good consumers - after all, you don’t choose to get sick, and you should get the treatment that is right for you, not the cheapest treatment. Medicine is not the same as shopping. You don’t place an order and your doctor fills it. We can keep insurance costs down by being a healthy populace - using prevention instead of treatment to battle disease. Another way is by using good generic medications when possible, but that should be for doctors to worry about, not patients.

The cost for paying in cash is usually far higher than the cost if you have insurance, for the reasons noted above. Insurance companies bargain a cost based on their market power. If you are just an individual, you have no bargaining power. The other problem with this approach is that doctors cannot necessarily charge what they think a procedure or service is worth - it doesn’t matter what price is officially put on something, what makes the difference is what insurance is willing to pay.

Doctors can be on dozens of these networks, and they really don’t tend to know what the agreements specify.

So even assuming the doctor knows their own charges for procedures, they have no way of knowing (a) what the PPO agreement for your insurance specifies, (b) what portion of that you are required to pay in terms of your coverage, and (c) what’s going on with your deductible.

They could just tell you what their charge is, assuming they know it (and I’m sure they always know about what it is), but you’d probably freak out for no reason.