MemberJanuary 25, 2017 at 2:23 pm
Recommendation for Doctors: Total Package Pricing
Dr. Tomas of FL does this fixed price stuff for no insurance patients. You can see more here
Once you have insurance in place all kinds of variables kick in and no doctor in USA can guarantee a fixed price because the ins company plays its own games. The proof is no father than your regular claims that come in mail. The doctor submits a price of $26 for blood work and ins pays $2.80. How does that work? It is pittance to doctor since doctor’s office has to pay the technicians, electricity for machine, rent blah blah. When you get a cleared claim you will be happy to see that since doctor is in network you owe nothing more but when doctor sees this payment (s)he frowns but cannot do anything because if doctor does anything ins will (threaten to) throw the doctor out of network.
So this loop makes doctor to submit various codes for one visit you go. At least this is my personal opinion, after seeing how ins companies operate for over 20 years. The reasonable amount ins pays is for office visit. If Dr. submits $180, they pay like $140. Rest of the codes get the cut, sometimes at 95% cut. Even for MRI they do not pay full. For that reason the MRI is billed at 3x initially since they know they only get paid “x” 🙂 Usually MRI costs over $3000 in USA but if you go to another country it can be done at $100 to $150. Even with return airfare included ($1200), this will go cheaper than what USA centers bill. But then the insurance may not cover that for you!
See another example. Eye insurance for which you pay about $15 premium every pay period covers eye exam, frames and glasses. They have a limit like $150 for frame and glasses are given whatever the cost. For one pair this total will be like $220 all inclusive. So you call the insurance and tell them that you will get two pairs of glasses for $99 at some local shop since some shops (lens crafters?) give free eye exam for that deal. And then you will submit $99 to insurance to claim the money. Your argument is, if you spend $99 you can save money for Insurance as well and you will get two pairs. Win-Win situation, huh? Call the insurance and see what they will say. “NO, that is NOT allowed,” they say because they are happy to pay $150 to network providers since they are “allowed to bill” that way. WTF, you think. Yes pal, that’s how things work here. Either take it or leave it. It is a slap in the face (not wrist). To make matters complicated, some joints like Sam’s club even bill this $220 to insurance and THEN ask you to pay the tax on it from your own pocket. Insurance will not pay taxes!! Some joints like 20/20 eye centers include taxes and insurance will pay them. So why is the difference from one joint to another? The answer you get is “That’s how things work in and out of network and national retailers and local joints.” So what we do? We have to “unlearn” things we thought we already know.
Comparatively hospitals who bill exorbitant prices are well paid. Example – Two Tylenol tablets given to you in the hospital when you went there for regular colonoscopy or such are billed at $26 (you will get at least three bottles of 100 pills each at Sams or Walmart for that price) are paid without uttering a word by the insurance at least at $20. Hospitals also bill utter nonsense in their claims to insurance such as needles, gloves, trash collection and you name it. All you need to do is to ask them to give you an itemized bill to see what they did.
That’s the main reason any Dr office will not give you exact price once you mention insurance. Otherwise any dr will be happy to accommodate you for a fixed price and even agree for a payment plan. It is all business now. Beats the logic and common sense.