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Knowledge is Power

You know that insurance companies have contracts with doctors and hospitals.  If you have ever tried to analyze the Explanation of benefits statement that they sent to you you will see that what the charges are and what the insurance ends up paying are very far apart typically.That’s because of the contracts that the insurance companies have with the provider’s.

 So why do the hospitals and doctors charge more than the contracted price? That is a pretty complicated answer. All the insurance companies have different rules on how they calculate what the payments to the providers and hospitals and clinics will be. Some of these formulas or guidelines are based on the percentage of charges that the institutions charge. For example, if Tri care says it’s only going to pay 60% of whatever the institution charges come up the institution will tend to increase their overall charges so that they can get more from Tri care.It doesn’t really matter to  Most of the commercial insurers like blue cross or United Because they’re going to get whatever their contracted amount is anyway.    So who really gets Screwed by this system? ….Mostly people with no insurance who pay cash. Sometimes people with very high deductibles also end up paying a lot more.  However, there is something that cash paying patients can do to keep from Being price gouged by our crazy system.  They can ask for a discount. While the contracts for most to the commercial insurers may say that we are required to charge everyone the same amount for comparable service, There Are no rules stating that patients can’t negotiate their own discounts just like the insurance companies can. This is a legal right.


 Patients are allowed to negotiate the same discount pricing that the insurance companies get.


Patients are allowed to negotiate the sand discounts that the insurance companies negotiate. So how-do-you-do this? It helps if you asked the question before you go to whatever appointment you are going to. Many offices have standing policies for when people ask for discounts.It also helps if you have some idea as to what medicare will pay. Medicare has something called a most favored nations clause. That means that insurance providers who take me to care are not allowed to Charge anyone less than what medicare pays or medicare can turn around and ask for the same payment for every one they’ve ever seen. It’s kind of crazy.So if you go to an office visit the cost is $100 but medicare only pays $68, usually The office will be willing to accept somewhere near $68 instead of the 100.  So why Can the insurance companies just automatically Charge cash paying patients less? Again a has to do with the insurance company contracts. Most contracts were read something like, it will be against the contract to charge any one person or any 1 person with insurance or without insurance or people with different types of insurances different charges…. Even though we get paid something different by every person and every plan anyway.  So the insurance companies have really put a lot of rules in place that increased cost for people other than their own clients. But again if you know some things to ask, you can lower your own costs. 


This is also very helpful for people who have high deductible plans.  Check out The next article On how to get Similar discounts if you have a high deductible






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Post Author: Admin Doc

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