How Did My Health Insurer Save Me THIS Much?

[kyphysics]

I went to my endocrinologist. Saw her for about 30 minutes + blood draw.

My bill: $5.00!

Insurance wouldn't allow them to charge me for the visit.

Bought a drug (don't want to name it) that was supposed to cost $178. My insurer saved me all the way down to $15.

In my insurance portal, it doesn't say the insurer made up the difference. It just says they didn't allow it by the provider/pharmacy. ...How is this possible? Do they pay them "behind the scenes" somehow? Like how the heck can my endocrinologist make money if I'm paying them just $5.00. That is not a typo.

 

[berkeman]

Preventative care (like annual checkups) can sometimes be covered at close to 100% by some health insurance providers. I don't know if these fall under that category, though.

 

[kyphysics]

Do the preventative docs get paid by the insurer? I'm just shocked. This would normally run me $400-$500 for that much time/physical exam/blood draw.

 

[berkeman]

Yeah they do, at their negotiated rates. I don't think I've paid much or at all for my last few annual checkups.

 

[russ_watters]

I went to my endocrinologist. Saw her for about 30 minutes + blood draw.

My bill: $5.00!

Insurance wouldn't allow them to charge me for the visit.

This seems really unlikely. Did you get this from the Explanation of Benefits form from your insurance company or is that just what your co-pay was at the time of the visit?

 

[Office_Shredder]

The insurance is clearly paying them a lot of money and just not telling you about it in whatever notification they're sending you. The usual bill looks like
- you get billed for 800 dollars
- the insurance company says they will cover 200 dollars, but they can only charge you 15 dollars.
- the bill is for two Advil, so the provider says sure that sounds good
- insurance company tries to convince you they did an amazing job.

 

[kyphysics]

This seems really unlikely. Did you get this from the Explanation of Benefits form from your insurance company or is that just what your co-pay was at the time of the visit?

Yeah, it was my bill in the EOB seen in online portal.

They didn't charge me a co-pay at visit. I think it's coinusrance instead and they waited to bill my insurance...I owe $5!...The visit was $0...that was $5 for blood tst.

 

[russ_watters]

They didn't charge me a co-pay at visit. I think it's coinusrance instead and they waited to bill my insurance...I owe $5!...The visit was $0...that was $5 for blood tst.

Wanted to bill your insurance what?

I don't have co-pays either, but that doesn't mean the visits are free.

 

[kyphysics]

Wanted to bill your insurance what?

I don't have co-pays either, but that doesn't mean the visits are free.

Not sure. I'm guessing from reading ppl's comments here that they're getting something on the back end that I'm not aware of.

My insurance portal still reads $5.00. I'm calling them Monday to ask what the deal is. I am not complaining...just curious why it's so low.

 

[kyphysics]

On the other hand, my endo doc. "lied" to me. Said my libre patches would be covered by insurance. Nope.

Got to pharmacy and had to pay $75 out of pocket (insurance covered only like $40). Dumbest purchase ever. These things aren't worth it!

 

[kyphysics]

Wanted to bill your insurance what?

I don't have co-pays either, but that doesn't mean the visits are free.

Here's how my portal looks:
Bill by Provider: $345 (office visit)
Plan Discount: $345
Allowed by Plan: $0
Plan Paid: $0
What You Pay $0

...same headings above for the blood draw ends up with me owing $5 (it cost $10, but my discount was $5). ...

What I'm unsure of is what the difference is between a "plan discount" vs. "plan paid" header? It just seems like a plan discount MEANS that my insurer paid that amount to the provider (why else would the fee be reduced?)...

Anyhow, I've been reviewing my Explanation of Benefits this year and it's been interesting. I'm sure there is an internal logic to how insurers choose to pay vs not pay (and how much) on our medical visits. But, I'm not seeing any intuitive logic to things.

There have been times when I've gone in for an seemingly serious issue (urgent care) and got billed $200 only to owe $50 (after the plan discount). Another time, I went to primary care to get a COVID test + consultation (sore throat & cough/ear-nose-throat infection) and was billed $160 and my insurer paid it all (i.e., I owed $0).

Then, I've gone to a specialist (not my endo, but another one I don't wish to name out of embarrassment) and been billed $469 and owed $279.

I think the ONLY possible pattern I see is that my insurer tends to discount more at primary/urgent (walk-in) care and discounts less at specialists. Except, that's not largely true. As stated, my endo was free essentially. And, for another specialist, I owe $75 (which is cheap, given the large bill).

To me, it looks like there is no rhyme or reason for which ones get the bigger discounts. *shrug*

Anyone else feel this way?

 

[kyphysics]

On the positive, my insurer saves me huge bucks on diabetes meds.

Farxiga costs (for 30 pills - 1 a day): $635.99 (higher than my monthly premium)
My cost is $60 after insurance discounts the drug.

I give them credit for knocking down my drug prices.

 

[BillTre]

This is my understanding of medical pricing through insurance companies.

You as an uninsured individual would have to pay some amount to the doctors/hospital/whatever.
A big insurance company carries a lot more weight in price negotiations. For one, a contract with them will guarantee minimal amounts of business for the to the medical people. Among other things, this gives them a level of certainty in what their income might be, and thus how they might invest their money.
They can also easily negotiate for minimal prices among different suppliers.

The bigger you, are the better the deals; and insurance companies are really big.

The government is also really big.
But its not allowed to take the most logical price saving measures.

 

[kyphysics]

This is my understanding of medical pricing through insurance companies.

You as an uninsured individual would have to pay some amount to the doctors/hospital/whatever.
A big insurance company carries a lot more weight in price negotiations. For one, a contract with them will guarantee minimal amounts of business for the to the medical people. Among other things, this gives them a level of certainty in what their income might be, and thus how they might invest their money.
They can also easily negotiate for minimal prices among different suppliers.

The bigger you, are the better the deals; and insurance companies are really big.

The government is also really big.
But its not allowed to take the most logical price saving measures.

Yeah...Although, in some cases, you can get a cheaper non-insurance rate with some providers.

For example, my physical therapy sessions would run $105 if billed to insurance and $75 self-pay.

Not sure why that is, b/c it was also true with a different physical therapy company I went to back in 2014 after an auto accident (although, the guy who hit me's insurance essentially had to pay, so it was a non-issue...but the provider offered a similar non-insured discount).

The only benefit really of doing the $105 is to run up my deductible in case I have some massive medical bill later. But, if I don't expect to bust my deductible, I'm better off self-paying at $75 (and not billing insurance).

The biggest question I have is why some doctor's visits end up with larger discounts? I can't seem to figure out any pattern of logic for which ones end up getting discounted more.

 

[BillTre]

The biggest question I have is why some doctor's visits end up with larger discounts? I can't seem to figure out any pattern of logic for which ones end up getting discounted more.

It may be the difference between being inside and outside of your medical/insurance network.

I have good insurance and use a medical provider group or something like that.
I got a lot of physical therapy for a $10 copay.
The insurance company and the medical provider group have things set-up and the medical providers had some physical therapists constantly busy on site. This is all in network.
Bigger groups can get things done more efficiently.

When I ran a large zebrafish facility, we provided lots of really sophisticated services (mutangenized fish, fish eggs, haploid fish, quarantining of fish, good fish health) to lots of graduate students and post docs. Many of them did not know how to maintain or breed fish. Without a big fish facility, the experiments they could do severely would be limited.

 

[phinds]

@kyphysics, my wife and I, between us, have had at least 7 VERY expensive surgical procedures and although I don't have an exact figure, I'm confident that the total cost of it all, including hospital stays and so forth, plus the surgery itself, if we had been billed for it directly by the hospitals and doctors would have been at least $400,000 and probably considerably more.

Our actual total out of pocket cost for it all? Zero. Zip. Zilch.

Pays to have good medical insurance.

We used to pay a modest co-pay for every doctors appointment and every medication. Now that we're both retired and have medicare as our primary and our commercial insurance as the secondary, all of our doctor's visit co-pays have gone to zero (but we do still co-pay for medications).

 

[Frabjous]

On the positive, my insurer saves me huge bucks on diabetes meds.

Farxiga costs (for 30 pills - 1 a day): $635.99 (higher than my monthly premium)
My cost is $60 after insurance discounts the drug.

I give them credit for knocking down my drug prices.

If you have an expensive drug, check with the drug company to see if they have any support programs. They can end up paying for the deductable.
There is also Canada. Some drugs are cheaper even if one is only paying the deductable.

 

[kyphysics]

It may be the difference between being inside and outside of your medical/insurance network.

If you're talking about HMO in-network providers, I am very careful to always choose providers within my network. I am aware of the higher costs of going outside of it.

Thus, that wouldn't be the explanation in this case.

I sometimes wonder it is just the whim of the insurance claims processor? My doctors are the same people, but perhaps the claims handler is different each time and his/her mood or desire to push back affects the outcome when negotiating with my doctors?

 

[BillTre]

I sometimes wonder it is just the whim of the insurance claims processor? My doctors are the same people, but perhaps the claims handler is different each time and his/her mood or desire to push back affects the outcome when negotiating with my doctors?

Have you asked anyone in the companies about it?

 

[russ_watters]

Here's how my portal looks:
Bill by Provider: $345 (office visit)
Plan Discount: $345
Allowed by Plan: $0
Plan Paid: $0
What You Pay $0

Dunno. Maybe they made certain types of visits (preventive care) free for the purpose of lowering overall costs. It still wouldn't exactly be free as they mark-up other services to cover it, but it looks free. Rest assured, the doctor didn't clock out before seeing you that day.

 

[kyphysics]

Have you asked anyone in the companies about it?

Do you mean the providers/doctors?

I asked about that $345 bill that turned into $0, but they didn't give me a reason. They just said that's how the insurance-company dealings worked out.

I DID NOT want to complain. So, let's just say I wasn't eager to press them (lest they change their mind and charge me). I'd probably be more inclined to question a higher bill in the future. . .

Dunno. Maybe they made certain types of visits (preventive care) free for the purpose of lowering overall costs. It still wouldn't exactly be free as they mark-up other services to cover it, but it looks free. Rest assured, the doctor didn't clock out before seeing you that day.

Possibly.

I guess it makes some sense in that they want to encourage you or reward you for doing stuff that could save the insurer money down the line. E.g., If I'm lowering my blood sugar levels, insurance is probably thrilled. They know diabetes can lead to heart attacks, kidney failure, blindness, loss of hands and feet, etc. Those are probably nightmare medical bill situations.

It could make logical sense that they make preventative-like stuff free and let providers charge higher for later stage problems to incentivize you to never let things get that far. . .

 

[kyphysics]

@kyphysics, my wife and I, between us, have had at least 7 VERY expensive surgical procedures and although I don't have an exact figure, I'm confident that the total cost of it all, including hospital stays and so forth, plus the surgery itself, if we had been billed for it directly by the hospitals and doctors would have been at least $400,000 and probably considerably more.

Our actual total out of pocket cost for it all? Zero. Zip. Zilch.

That's good to hear.

I'm surprised you pay $0 literally. Usually I'll hear people get big savings at times, but still having to pay a small amount. Zero is actually amazing!

 

[Tom.G]

For example, my physical therapy sessions would run $105 if billed to insurance and $75 self-pay.

Not sure why that is

I did ask once (several years ago).

The response came down to:
a) at least two calls to the insurance company
b) creating and sending the paperwork claim to them
c) waiting 3 months to get paid
d) if someone at the insurance company had a hair across their behind that day, double or triple the above

d1) add a few phone calls to/from you​

As opposed to: You are there with a wallet and cash, bank card, or credit card.

In their position, which would YOU prefer?

Cheers,
Tom