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Current PPO. Go to Dr. Rich for colonoscopy. On my explanation of benefits Dr. Rich charged 1k for colonoscopy, 1k for analysis, 1k for biopsy. My insurance says colonoscopy is contracted at $800, and the analysis and biopsy have footnotes. These footnotes state that these procedures are considered part of a colonoscopy. My responsibility is my $50 specialist copay. I have never had a doctor attempt to bill me directly for a procedure that insurance company denies payment to.

HDHP. Same scenario above. How is this three way contract between myself, my insurance, my doctor and my doctor's contract handled? Would the doctor's contract with the insurance company ensure that insurance decision on procedures are "binding"? Or, could the doctor send me a bill for the two procedures that the insurance company states is not payable? If I pay a procedure that my insurance company does not consider 'reasonable/customary' does this apply to my deductible?

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If your doctor is in network or accepts Medicare, he is obligated to accept the payment schedule. Your responsibility is the co-pay terms of your contract. If the contract denies payment for the ancillary services, the MD receives no payment for them and there is no charge to you for them. The MD has the right to demand co-pay fees at the time of visit.

In the case of a high deductible plan, you pay all schedule fees until you meet the deductible. In your Dr. Rich example, you would pay $850 for the colonoscopy, assuming that your remaining deductible was $850 or more.

  • $800 though, it's not scheduled price plus co-pay. – Hart CO Nov 11 '18 at 16:28
  • I assumed from his description that the $800 was payment to doctor. If the $800 is total approved fee then of course, you are correct. – Bob Baerker Nov 11 '18 at 18:03
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    If you are seeing a non network practitioner, expect to be billed $1k for the colonoscopy. You can negotiate for his acceptance of $800 as full payment. Even though the schedule is $800, some network docs will attempt to bill you for $1k when you haven't met your deductible. I assume that this isn't allowed since when it has happened to me and I brought it to the billing department's attention, the price magically dropped to $800 (finite sample). – Bob Baerker Nov 12 '18 at 0:59
  • Under the PPO, there may be coinsurance rates to deal with as well (depends on the plan and its deductible structure). And I'm almost positive that providers are bound by negotiated rates if you're going through an insurer, even if you have to pay for everything under an HDHP the deductible for which you have not met. That requires that the provider have some sort of contract with your insurer, of course. – Upper_Case Nov 12 '18 at 17:02
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It's important to note that generally an "HDHP" is not simply a a PPO with a "high deductible." In order for an HDHP to qualify you to take advantage of the tax benefits of an HSA the plan must not cover anything until the deductible is satisfied. You still take advantage of whatever provider network your insurer maintains, the preferred pricing that is arranged and the direct billing in place.

For 2019 the minimum deductible for an HDHP is $1,350. This does not mean that any plan with a deductible of at least $1,350 qualifies as an "HDHP." PPOs generally have office visit copays and the like, an HDHP will not have such a benefit.

Other than this benefit nuance your relationship with your providers is no different than it is now. Given your facts, if the contracted amount for your procedure was $800, you would pay $800. After you satisfy your plan's deductible you'd pay some percentage but no matter your benefit structure your provider gets paid the contracted $800; all from you, all from the insurer or some combination.

Contracted in-network providers are barred from balance billing as a provision of their contract. Should you go out of network, it's likely that the doctor would send you a bill for the remaining $2,200. This is not different than your PPO now. If this provider were out of network, your insurer would have paid the what ever its responsibility was related to your out-of-network benefit and you would have received a bill for the remainder of the $800 and an additional bill for the remaining $2,200. Unlike the contractual $800, the $2,200 balance bill can be negotiated with the provider.

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Basically, in a HDHP, everything should go the same way as with the PPO, except that at the end, you pay the exact amount the insurance would have paid (and not any other amount).

In practice, most doctor's offices like to collect right when you are there, because it saves them from running after you for their money. Therefore, they try to predict what your deductible payment would be after insurance processing, and request that amount from you directly. Then they file the normal insurance request, learn after some days or weeks the real amount they can bill you, and then you potentially own some more or should get a refund. From my experience over ten years, most offices are pretty good at the prediction.

Some doctor's office like to forget to refund you, and some make it really hard, and you need to be insistent (if you go there often, it gets applied to the next visit, but if not, you have to nag them).

Some doctor's office like to save the effort of filing with your insurance, and offer you a reduced rate if you pay directly. That can be a deal, but be careful; if you accept that, the amount will not count against your deductible (so good deal if you know you will not use up your deductible in that year, potentially a loss if you do).

  • That's what I was wondering. My doctors, at least according to my EOB, are not very good at predicting. – paulj Nov 12 '18 at 14:33

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