patrick.net

Objectivity and representativeness can be difficult to find in this sector, because the data are often manipulated by insurance companies. Litigation has brought some progress in New York, but most other states have not followed suit (so to speak). Practices should disclose their average cost per procedure and diagnosis, and practices accepting public $ should be require to do so, but they don't and they aren't required.

My cost for an onlay was within the wide range on costhelper.com, but to find out what something should cost check Mexican prices. Everything above that is mostly American markup.

You could also see if you could access what the Medi-Cal pay rates are for all the procedure codes.

Insurance companies seem to be getting fairly close to the same pay rates (at least it seemed that way when I had access to that kind of info).

However, private pay is seriously higher. If you're paying cash, though, you should at least try to negotiate the charges down.

Make friends with someone at EDS - if they're still the one's handling Medi-Cal. If you can't get a copy - take someone to lunch and see if they'll help you figure things out.

I think it should actually be public knowledge because our taxes pay for Medi-Cal - so by rights we should have the right to know what we're paying for.

Although, it's probably a big secret.

With regards to meds - you could try the Pharmacy Red Book - if that's what it's still called. You'd be surprised how often they'll list 1 - without saying if it's one bottle, one case or whatever and the price they charge on the bill is more like the cost of the case - not one little bottle.

Pharmacists don't oversee the payments on meds (at least they didn't use to - so I don't know how the insurance companies handle it). I know that each line on a pharmacy bill that goes to EDS is read by a different person (at least that's how it used to be) and Medi-Cal overall said they had about a 30% error rate. So I question how it is with insurance companies.

And it always used to be that if the inpatient bills didn't get paid in a timely manner - it seemed like they (hospitals)added more meds to the bill when they rebilled. Not sure if they make up the extra drugs or if it's legit.

I would say that most bills get cut by about 2/3 if not more if it's paid by an insurance co. However, I did see a major cardiac surgery once that was billed at $100,000 and paid at $7,000.

It's never a straight shot when trying to figure out costs. You could have complications.

Anymore they really really stress being paid ASAP and there isn't much time before they send things off to collections. At least that's the case with the bigger institutions.

It always helps if you can at least get a ball park estimate before you go in - and maybe ask the Dr. if they'll accept Medi-Cal rates plus 10% or so (to make it fair) paid in 30 days or less.

It's not the low rates that Medi-Cal pays that drives Doctors crazy. It might be one factor - but it's the billing that drives them nuts. Some smart guy at EDS figured that they would kick the bill out at the first error. Therefore the provider fixes that error and resubmits the bill and low and behold the 2nd error now kicks out the bill. They couldn't figure out how to flag all the errors on the first round. Maybe they did that on purpose cause they probably get paid for each and every bill they have to read.

You should check into this. Because it's a waste of tax payers money if it's true - and there's too many unemployed programmers and analysts for something like that to keep on happening.

Also Medi-Cal and Medicare are famous for paying and then coming along later and deciding to take a huge chunk of money (thousands of dollars) back.

So do not feel like you are cheating the Dr. if you negotiate a payment closer to what the insurance companies pay and you pay it in 30 days and promise not to take any of it back.

Also - with Medi-Cal if you have multiple procedures done at the same time they'll pay their full rate on the first one and maybe 70% of their rate on the 2nd procedure and maybe 30% on the 3rd procedure. You need to find out how the insurance companies calculate their payments.

Each state may have their own version of Medi-Cal /Medicaid but they generally set their rates about once a year (or maybe it's more often now) - but they would probably be the lowest accepted rates in our country.

Oh - forgot to add this

The doctors and the labs and xray charges were/are slashed the most.

The pharmacy and durable medical goods were/are paid at pretty close to the billed prices. Unfortunately - this may play into why doctors might invest in pharmaceuticals and then prescribe too many of them.

Zlxr says

our taxes pay for Medi-Cal - so by rights we should have the right to know what we're paying for.

Medi-Cal Rates are online.

One more issue - regarding Blue Cross.

When they decide to take some money back - say they want to take $200 back for John Jones - they don't take the money back from his account directly and take the $200 out of the amount paid.

Instead they will do something like pay $9 less for each and every patient on the remittance. The only way the provider can correct this is to go in and manually adjust each and every account.

I do hope this isn't causing anyone a problem as far as having to pay a balance that technically isn't theirs to pay.

They know better than to do this - so I don't know why they can't figure out how to correct this issue.

And every once in awhile they totally screw up everything and their customer service is the pits.

I am not a programmer/analyst - but it seems to me that a group of you guys should get together and call the insurance providers on some of their crap. They make sure they get paid but they screw everyone else.

Zlxr says

When they decide to take some money back - say they want to take $200 back for John Jones - they don't take the money back from his account directly and take the $200 out of the amount paid.

What do you mean "take back"? Please explain. And thanks for multiple helpful posts.

PS: The 2x high rate I have referred to earlier IS the negotiated rate. I have made an addendum to the thread post about that. I am well aware that the "list price" for uninsured patients is often 3x the negotiated rate.

curious2 says

Medi-Cal Rates are online.

Awesome. There are text files and xls files available, packed into zip files. I will use grep (text search) and see what I can find.

One problem is that my statments from the provider does not include ANY billing codes, only procedure names. I wonder if MediCal uses the same procedure terminology.

All providers bill using the same procedure codes as far as I know and there are thousands of codes. But there's all kinds of conditions and modifiers that could change how a certain procedure code is paid.

How it comes back is another story.

I'm not a biller either so I can only sort of point you in certain directions.

I also believe that certain surgery codes are tied to time increments. In other words your surgery could be 20 mins. or 2 hours so it could be billed using a procedure code that bills by 15 min. increments. It's been a long time so don't quote me.

The reason I picked Medi=Cal/Medicaid is because the provider has to accept those payments as "payments in full" and cannot bill the patient for any outstanding amounts. If you can figure out how your visit or surgery was billed (if the Dr. or Hospital will give you a copy with procedure codes) - you can figure out how much you paid compared to other insurances.

You could probably get a copy of a bill if you tell the provider you just got insurance and you want to bill the insurance yourself. Then they might provide you with a bill with procedure codes. Actually they should provide that info if you just ask - but they also might charge you extra. I don't know - this is something you guys will have to figure out.

As far as I know procedure codes didn't come into existance until computers arrived. It saves computer space to make everything into a number. Unfortunately it's also a pain in the ass. A number is only part of the story and it puts you in a class that may not be entirely true if one were using words. Doctors need to get paid and they only get paid if they use procedure codes to bill so they use the procedure codes that are "either the only one they know to use, or the one that best fits the situation" - and sometimes they make mistakes.

Sometimes it's a combination of your diagnosis code and the procedure code that determines how providers get paid. For instance it could make a difference if your diagnosis is HIV and you get pneumonia as opposed to being a healthy individual and getting pneumonia.

I'm not sure entirely about insurance companies taking money back - but here's my best explanation. All insurance companies take money back. It's just that Medi-Cal and Medicare do it more often and in much larger amounts.

One is that the first priority is to pay quickly and check later. So if they decide to deny coverage to a patient that could be one reason. The other reason is that they decide they were overpaying a certain procedure code and decide to take all their overpayments back. Unfortunately they usually take a year or more to figure this out so they'll decide to take money back from 5,000 or more accounts or something like that and it can add up to big bucks. It wouldn't change anything for a Medi-Cal patient - but it could maybe for a Medicare patient if for some reason they have to pay what the insurance does not.

I did see one case of a Dr. who billed and instead of getting a payment he got a bill for $10,000 so they withheld that check. How can a Dr. or small provider hope to stay in business if they spend the money they receive and then find out later that they owe some of it back?

If I had connecions - some of the things I would love to know is what criteria EDS (the Medi-Cal Intermediary) has for getting paid themselves. Same for Blue Cross and Blue Shield as they handle or used to handle Medicare.

And then I'd like to know what criteria all other insurers use for paying private insurance - as well as how they pay themselves. If you knew all this - you'd know how much we are actually getting screwed when we pay them as well as when they pay our bills.

I kind of don't think most Doctors would be willing to accept Medi-Cal rates exactly - but they also hate the billing process (I think it takes around $20 or so to generate a bill when you consider all the steps and office help involved). And they hate getting jerked around by the insurances and then maybe having to give money back.

This is one reason why you should always (if you have insurance) make sure that your procedure is pre authorized. Because this is one of the reasons they use alot to deny payment. And you should always cross check the payment advice from your insurance with what the provider is billing you or has billed you. There seem to be incidences where a provider can actually keep more money than they originally billed. But you also need to keep them honest.

When bargaining with a provider I think your biggest bargaining tool is going to be how quickly you are going to pay. Therefore paying cash in less than 30 days would be ideal. The other possibility would be getting some kind of a Medical credit card with a low interest rate and paying the provider up front and spreading out your payments to the credit card.

There's much to learn. The best way to find out is to find a professional biller, as well as someone on the inside in the insurance industry and then find out how our tax money is paid to the Gov't funded insurers. And also consult with several Drs. to see how they would feel if uninsured patients want to negotiate payments that are more in line with what insurance companies pay. It really isn't fair if you have to pay 3 times or more than what an insurance company pays.

Zxlr, lots of good stuff there. One thing I would like to point out:

Zlxr says

This is one reason why you should always (if you have insurance) make sure that your procedure is pre authorized.

The above is definitely true if you have an "HMO" plan, but I have a "PPO" plan, and a high-deductible at that. I think with PPO the insurance company does not care about authorization until after you hit the deductible limit. I could be wrong. They should care, but they do not seem to.

Zlxr says

If you have a PPO - maybe you should try to find out what they would have paid if you had already met your deductible -

I repeat: The insurance company confirmed that the bill was at the negotiated rate. The issue is not the rate, but the code itself. As I said in the thread post, I may have been coded with the "surgery center" rate rather than the "doctor's office" rate.

justme says

I looked up one procedure and found that I got billed almost 2x the going rate, but the rate can depend on multiple factors, such as whether the procedure was performed "in the doctor's office" or "in an ambulatory surgery center".

Sorry for the misunderstanding.

Then go to the provider and ask for a copy of your bill with all the procedure codes. You are entitled to a copy of your records (I believe) but they may charge you a small fee for copying them.

I know when Lawyers come to the office - they usually bring their own copy machine - but they may still pay a fee. They usually copy the patient's entire file, though, when it's a legal issue.

Then speak with the provider's billing person and ask them exactly what they were billing. You might have to speak with a Supervisor but if you are polite and explain yourself well - I would say you stand a pretty good chance of getting an explanation.

If it was me - I might pretend that I was sort of ignorant when I asked for the explanation because if you accuse them right off the bat they'll get defensive.

Then go to your insurance (with your bill in hand with the procedure codes on it) - it should not be a big deal for them to look up their pay schedule for those codes.

Then I would go online and look up Medi-Cal rates - or find a biller with Medi-Cal knowledge and find out if your insurance pays those same rates - or at least compare the differences. It could turn out that you would be better off uninsured except for catastrophies.

If you pay over $500 per month for premiums and then you have to pay $5,000 or more before the insurance kicks in - it would seem like you'd be better off with just being covered for catastrophies and using the money to keep yourself healthy.

My gripe with health plans is having to pay money and then they refuse to treat certain things so I'm on my own. So it's still out of my pocket.

Health coverage is not about being healthy at all - it's about giving your money away to someone who then tells you what you can or cannot spend it on - and they'd rather not spend the money once it's in their pocket.

Actually there's a chance that when you go to the provider and ask them to explain how they billed you - they might say "OOOPS" we made a mistake.

You have to remember that everything is about speeeeeeed. Mistakes do get made and they clean them up either when they discover it - or you discover it.