Can doctors charge whatever they want for a procedure?

[Ike0069]

My daughter had her tonsils removed. The doctor that performed the procedure was in network, but the hospital he did this at is not (at the time I was not aware of this fact).

So the hospital bill is $3400, but my insurance only allows $3100. The hospital was nice enough to drop the bill to $3100.

Now we get the bill from the anesthesiologist. It's $592, but my insurance only allows $354. That's 60% less than I was billed. I called the anesthesiologist billing up and was told that they do not discount for out of network procedures.
I was told the average bill for this is ~$650, and I'm lucky the $592 wasn't more. If this is true, why would the usual and customary bill only be $354. I find it hard to believe that anesthesiologist's would agree to a 60%+ discount for in network procedures. It would make more sense if it was closer to a 10% discount that the hospital billing shows.

My question is do I have any legal rights here, or am I obligated to pay whatever they decide to bill me for? It seems to me that since I have insurance and a job, they figure I will pay so they are milking me for whatever they can get.

Thoughts?

 

[mercanucaribe]

Welcome to the medical industrial age.

 

[Heisenberg]

Of course they can charge whatever they want for a procedure. Free market economy and all that. You got screwed because the insurance and doctor have an agreement for discounted services, but not the hospital and the insurance.

 

[Amplifier]

Your daughter should have taken a couple advils, a shot of whiskey and sucked it up.

 

[Homerboy]

hospitals and insurance groups have negotiated CONTRACT rates for EVERYTHING. If you go out of network, then its no different than you not having insurance and getting medical assistance at that facility.
Hospitals/doctors have set rates for their services. If you dont have insurance, and therefore don't get the contracted rate(s), you pay the set rate.

 

[akubi]

you could've done it for a buck fitty @ chinatown

 

[ebaycj]

60% is actually a pretty normal-ish in-network discount (over standard rates) for expensive procedures. I'd say that in my experience it ranges from 40% to 70% discount (I worked as a DBA for a healthcare billing company for 3 years up to last september, so this statement is based on that).

Also, usual and customary charges are really only about 50% of the true cost. They are almost never accurate, as they are set by the insurance companies. This is the same in just about any industry. (There is a similar rate table for auto mechanics, to say how long a given procedure takes, i.e. how many hours to bill for. Go ask any mechanic, they will tell you it really takes about half the time for most procedures).

 

[Ike0069]

Originally posted by: ebaycj
60% is actually a pretty normal-ish in-network discount (over standard rates) for expensive procedures. I'd say that in my experience it ranges from 40% to 70% discount (I worked as a DBA for a healthcare billing company for 3 years up to last september, so this statement is based on that).

Also, usual and customary charges are really only about 50% of the true cost. They are almost never accurate, as they are set by the insurance companies. This is the same in just about any industry. (There is a similar rate table for auto mechanics, to say how long a given procedure takes, i.e. how many hours to bill for. Go ask any mechanic, they will tell you it really takes about half the time for most procedures).

That's some good information, thanks.

Looks like I 'm screwed I guess.

 

[Aharami]

i dont think you're taking that big of a hit here. you arent paying anything for hospital, and for anestheologist, ins company is picking up $354. So all you're obligated to pay is $238.

as for your question, you probably do have legal rights here, but it will cost you a hell of a lot more to fight it than to pay the $238 out of your pocket

 

[vi edit]

Many ancillary services (lab testing, anesthesia, ect) are billed out seperately and do not have the same coverages (if any).

In fact, in many smaller clinics and hospitals, the anesthesia is a private practice that operates within the hospital and bills as completely seperate entity.

 

[Phlargo]

Originally posted by: Heisenberg
Of course they can charge whatever they want for a procedure. Free market economy and all that. You got screwed because the insurance and doctor have an agreement for discounted services, but not the hospital and the insurance.

Markey Economy, FTW! You chose to go to that doctor and not shop around or price match. It's not easy, but you still have the option to do it.

 

[Garet Jax]

Originally posted by: Ike0069
My daughter had her tonsils removed. The doctor that performed the procedure was in network, but the hospital he did this at is not (at the time I was not aware of this fact).

So the hospital bill is $3400, but my insurance only allows $3100. The hospital was nice enough to drop the bill to $3100.

Now we get the bill from the anesthesiologist. It's $592, but my insurance only allows $354. That's 60% less than I was billed. I called the anesthesiologist billing up and was told that they do not discount for out of network procedures.
I was told the average bill for this is ~$650, and I'm lucky the $592 wasn't more. If this is true, why would the usual and customary bill only be $354. I find it hard to believe that anesthesiologist's would agree to a 60%+ discount for in network procedures. It would make more sense if it was closer to a 10% discount that the hospital billing shows.

My question is do I have any legal rights here, or am I obligated to pay whatever they decide to bill me for? It seems to me that since I have insurance and a job, they figure I will pay so they are milking me for whatever they can get.

Thoughts?

Yes they can.

Insurance companies negotiate rates with providers and will always pay less than you would as an individual. This is why some doctors choose not to participate in certain networks. This is one of the benefits of insurance and in-network providers.

This is a sticky subject. When my wife and I had our first baby, we called the hospital to see if they were participating - they said they were.

The birth required a c-section which requires special neonatal doctors to be present. Turns out these doctors were not in network so we end up getting a bill for hundreds of dollars for their work.

We refused to pay it since we were told the hospital participated. It tooks months to work out, but we ended up not paying a thing over our co-pay.

 

[FallenHero]

Do you have a flex account you could charge it to?

 

[DaShen]

Originally posted by: mercanucaribe
Welcome to the medical industrial age.

QFT

OP, why do you think Medical Care and Insurance is such a heated issue in the States? :roll:

 

[Amplifier]

Originally posted by: DaShen

Originally posted by: mercanucaribe
Welcome to the medical industrial age.

QFT

OP, why do you think Medical Care and Insurance is such a heated issue in the States? :roll:

At least you aren't in Canada, your daughter would still be on a waiting list!

 

[Ike0069]

Originally posted by: Aharami
i dont think you're taking that big of a hit here. you arent paying anything for hospital, and for anestheologist, ins company is picking up $354. So all you're obligated to pay is $238.

as for your question, you probably do have legal rights here, but it will cost you a hell of a lot more to fight it than to pay the $238 out of your pocket

That's not exactly true. Insurance obviously doesn't pay it all, only 80% after deductibles. And you tend to get bills from everyone.
All in all, it's costing me over $1700 out of pocket for this 45 minute outpatient procedure.

My problem was that I was not aware that where my in network doctor performs his out of office work, is in fact non-network. My only choice would have been to find another physician that uses an in-network hospital/sugery center. But since I live in a very rural area, my choices are definitely limited.