Do we dare discuss the Supreme Court decision re: Healthcare

[cassiesmom]

Not really Karen. Many insurance plans have doctor co-pays that are dependent on many factors. If you have met your deductible - and you could have a variety of doctors billing toward that deductible can make a difference in what you owe. Sadly, it is not at all unusual for a doctor's office to not be able to tell what the patient's co-pay is until they have processed the claim to the carrier and learned what the carrier is going to pay. Many plans vary what the co-pay will be based on the purpose of the visit as well.

Plans that have the same doctor co-pay regardless tend to be HMO type products.

Plans with variable co-pays are probably the most common these days as the insurance companies continue to look for ways to control costs and increase profits.

Don't blame the doctor's staff! It is just often not as easy as a quick computer search. I was in Kaiser HMO for a year and knew exactly what a doctor visit would cost. Now that I am back in a PPO (high deductible) I don't have a clue until the doctor files the claim and bills me.

(And if you wonder why I went back - I am tied to what the employer offers!)

I learned something very interesting when I worked for a company that paid its own claims. The claims are generally paid in the order they arrive. So if a big bill gets to the carrier and you haven't met your deductible, they will apply it toward your deductible. Then the next one that comes in might be paid because you met the deductible with the previous huge one. It was a bugger for people who were reaching their policy maximum because the providers who got their claims in first got paid, and the ones who dragged their feet got denied because the member had met their policy maximum. I've also worked for two Fortune 500 health plans and I can say with certainty that it's a huge help if you are familiar with your plan - deductible, co-pay, out of pocket and all that stuff. Someone from the physician's office can call the 800 number but they frequently have to plow through a lengthy menu of phone prompts to get the information they need.

I had a high-deductible health plan for a little while. It was expensive but relatively easy to manage- I paid for everything and submitted claim forms. I think the Affordable Care Act is going to have more people confused and uncertain about their coverage and benefits for awhile until the payors and providers figure out what the laws require, and it all gets sorted out.

This in a nutshell, is a huge fault with the current system.

It's why people wind up in bankruptcy for medical bills, hard to plan when you have no earthly idea what your expenses are going to be beyond some very, very vague guidelines, further exacerbated by the contractor shell game. (Well, yes, all our staff are PPO for your insurance, however, Dr XYZ isn't part of our staff, he/she contracts with us through Dewy, Screwem and Howe, and therefore aren't part of our PPO group. hat do you mean you didn't realize what you were agreeing to while you were in excruciating pain? We have your signature, it's valid.)

This is how we used to coach patients to respond to the contractor shell game. Say to the provider: No no no no. That was emergency department care. Payable at in-network level under prudent layperson rule. I want Dr. XYZ's care to continue to be paid at the in-network level for continuity of care purposes. What do I have to do to make sure that's done? What else can you do to help me get that done?
Then call your insurance. If you contact the payor yourself they might send the claims back for reprocessing at the higher level. The squeaky wheel gets the oil, so squeak!.