4

I had a doctor visit with a specialist recently, and my insurance company gave the following explanation of the claim:

  • Service charges: $522
  • Health Plan Allowed Amount: $157.64
  • Deductible: $157.64
  • Your Share: $157.64

The bill from the doctor said this:

  • Charges: $522
  • Adjustments: -$364.36
  • Your Responsibility: $157.64

Does this mean that the insurance company paid the doctor nothing?

If that is the case, then why does the doctor reduce the bill and not make me pay the full amount?

9

Because of some of the terms you used in your question I am assuming a US focused question.

When you go to an in-network doctor, all the rates have been negotiated. That $157.64 reflects that. They also agree as part of the rules that they can't balance bill you. Which means they can't go after the $364.36 adjustment by charging you more.

Now if you go out-of-network the insurance company will never pay more then the amount they would have covered in-network. Also the doctor can bill you the full amount unless you make a deal with the provider. Many plans also have two different deductible buckets (in-network and out-of-network), and many will only credit you with having paid the negotiated amount, even if the out-of-network doctor charged more.

In your case because you haven't met the deductible they didn't have to pay the doctor, but they did save you hundreds of dollars because of the negotiated rate.

| improve this answer | |
  • Interesting. Do you know if the insurance company has already paid the doctor to obtain the negotiated rate? E.g., the insurance company pays $1000,000/year to the doctor to get the reduced rates. – gaefan Sep 22 at 14:04
  • 3
    If the doctor wants to be in-network with a network they have to agree to the rates, but they get a steady stream of customers. Some doctors don't work with insurance companies, others are almost 100% insurance customers. I have no idea if there is a minimum amount they get each year. – mhoran_psprep Sep 22 at 14:09

Your Answer

By clicking “Post Your Answer”, you agree to our terms of service, privacy policy and cookie policy

Not the answer you're looking for? Browse other questions tagged or ask your own question.