Ask An Expert Part 3: What Are You Paying and Why?

Part 3 of our Health Insurance series is about how to understand what you may ahve to pay for your doctor's visit, why it may cost different than your friend's bill, and how to try to limit out-of-pocket costs. If you don't recognize some terms (allowed amounts, in-network, etc.,) see our Part 1 and Part 2 posts from the previous weeks!

If every insurance company has different rates for services, how can I know what I’m going to have to pay for my service?!

The only way to know what you’re going to have to pay for a service is to talk to your doctor’s office prior to your service.

Only your specific provider’s office will have access to their own contracted rates and should be able to provide an estimate of your costs based on your planned service and their contracted “allowed amounts” set by their contract with your insurance company.

My friend and I have the same insurance. My friend went to the doctor’s office for routine follow up and they were charged $50. I went to a different doctor’s office for a routine follow up as well, but I was charged $100. My friend and I compared our bills and they look exactly the same except I have to pay more! What gives?!

Every insurance company sets their own “Allowed Amount” that differs from insurance company to insurance company BUT they ALSO negotiate different “Allowed Amounts” with different provider offices and medical facilities.

EACH insurance company negotiates their rates differently with EACH of their participating (in-network) providers. This means the same exact service performed by the same exact provider could not only have completely different costs for patients with different insurance companies but also have completely different costs for patients with the same exact insurance receiving the same exact service in a different medical setting (office vs hospital vs outpatient facility.)

What are my options to limit my out-of-pocket costs, if everything is varies so widely between insurance companies and doctor’s offices?

Here are a couple things I would suggest looking for:

1. Try to steer away from the larger health groups if possible. Find a doctor that you trust that practices in a smaller, independently owned practice.
2. Insurance companies usually set MUCH lower “Allowed Amounts” with small, independent practices because the insurance company doesn’t really care about whether that small practice remains in their network or not.
3. The insurance companies focus their negotiations on the large health groups with multiple providers because they’re more interested in keeping 20 providers in their network happy than 1-2 providers in a smaller practice.
4. Also, look for a provider’s office that is willing to communicate transparently about their costs for services. You never want to get a surprise bill. The more the provider’s office is willing to communicate with you, it becomes less and less likely that you will receive any surprise bills.
5. Exact costs can sometimes be hard for an office to provide, but they should always be able to provide an estimate range.

In sum, INSURANCE IS CONFUSING!!! But that’s okay because the experts at Signe Spine & Rehab are here to help you understand. We want you to know what you’re paying for and why.

Stay small, ask questions, and use the resources available to you and you should start to feel more and more comfortable when talking to medical office and facilities about your bills.

Thanks for reading, and we will see you next time!

Author

Nicohl Cave, CPC Insurance Coordinator and Certified Professional Coder. Nicohl has worked with the Signe Spine & Rehab for 3 years and is the expert about all things insurance, billing, and coding. She has 6 years experience working with health insurance and coding in various healthcare settings.