If you have health insurance, you probably know that the charges for "out of network" services are more than services provided by doctors and hospitals that are "in network." This article by Chad Terhune explains just how much the differential can be and whether the system is in need of reform. Here's an excerpt:
A Southern California surgery center charged teacher Lynne Nielsen
$87,500 for a routine, 20-minute knee operation that normally costs
about $3,000. Despite the huge markup, the Long Beach Unified School District and
its insurer, Blue Shield of California, paid virtually all of the bill
from Advanced Surgical Partners in Costa Mesa. Blue Shield mailed the
$84,800 check to the high school Spanish teacher last month and told her
to sign it over to the surgery center. Nielsen … refused to send the check. Instead,
she asked the California attorney general's office to investigate the
matter. … [Nielsen is] caught up in a growing battle nationwide over billing by
outpatient surgery centers. Industry experts say some of these surgery
centers seek out well-insured patients such as Nielsen, sometimes by
waiving their copays and deductibles, and then bill their insurers
exorbitant amounts for out-of-network care. All too often, critics say, insurers pay these large sums and then
cite high medical bills for why insurance premiums keep rising for
businesses and consumers.
Please be accurate. The charges are not higher. Medical providers bill the same price for similar services across all payer types. It is the reimbursement that differs among payer types. Yes, the differences are large. But you can’t draw valid conclusions just by looking at pricing. You have to look at reimbursements and uncompensated care, too.
I need help!! I have a daughter that has a substance addiction. She has been to a in state 30 day rehab twice. Our insureance partially pays. She recently has gotten very sick again. I called our insureance and found out where to take her for detox. They told me so we went to the site. Once getting there she was put through the intake process. she was told they could detox her, wait while we confirm it with your insureance. They came back to her and told her we can detox you as a out patient. She instantly knew this would not work. So she called a state ran detox, she was turned down because she carries health insureance. So she in turn called the rehab she has been to twice already. She was told to come in. After being there 2 days her drug dealer checked himself in. They both left the rehab in one day. she then went out and did so many mixtures of drugs she was near death. As her parents we knew we had to do something drastic. We found a well known 90 day rehab out of state and took her there. It has cost us all of our savings. My question is, our insureance refuses to help with any of the doctor charges or any of the medication because she is out of state. If we would not of put her out of state she would of been dead. The only rehab they pay partially for was the one she walked away from. She is now far enough away where dealer can not find her, and they monitor who she calls and writes. She has been there 3 weeks and she is starting to think rationally. She is very thankfull she has gotten away and is in treatment. We do not expect our insureance to pay for the recovery center, but we do feel they should help with doctors and meds. Our insureance says they will not pay any doctor out of state. Is there a way to get around this, it seems very unfair. I feel very sure if we had not removed her she would be dead. Thank you.