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I visited the emergency room, out of state, for lower back pain. My bill was $1,013.08. The providers bill showed Florida Blue Cross/Blue Shield paid $129.91 but also INCREASED my bill in the amount of $227.48. Both the service provider and insurance company stated the INCREASE is in accordance with their mutual contract. Is this legal or even ethical? Why should I have to pay more than what the service provider billed me when I pay an annual insurance premium of over $20,000!!!

I stated to the provider that I don’t want to use my insurance company, BCBS of Florida, and if I don’t, my total cost would be $97.57 less (I wouldn’t benefit from the $129.91 discount but by avoiding insurance and the $227.48 increase, I save $97.57)

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    There doesn't seem to be a question here. What do you think we can help you to do about it, other than suggesting you vonsidet other insurers and health providers? I'd suggest you go to your local newspaper's ombudsman department and ask if they can help you sanity check this and/or convince the hospital or insurance to cut you some slack.
    – keshlam
    Jan 28, 2023 at 18:37
  • Thank you for your reply. My question is: Is it legal or ethical for the insurance company to increase the original cost of the service from the service provider to the patient
    – Bill
    Jan 28, 2023 at 19:43
  • Sucks for you, but it doesn't make it unethical or illegal.
    – JohnFx
    Jan 29, 2023 at 2:42
  • because you went to the emergency room did you have a mandatory co-pay of up to several hundred dollars? I can't understand the numbers in your question. Normally the EOB breaks down the billed rate, the negotiated rate, your portion and the insurance companies portion. Jan 29, 2023 at 13:09

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Whether it's ethical or not doesn't matter. It's business, they're in it to make a profit, and whatever gives them the most money that's what they'll do.

Legal - yes. Insurance companies have negotiated rates with providers, and the clients pay whatever the insurance companies have negotiated. Hospitals and doctors have a lot of leeway in negotiating with uninsured customers, but they do not negotiate with those presenting insurance - they negotiate with the insurance companies instead. Whatever the insurance company negotiated for you, even if it is more than what you'd pay had you not been insured at all, is what the hospital is going to charge you.

Generally, in the US, if you know that the insurance is not going to cover your costs - just don't claim insurance, and pay out of the pocket. That way you can negotiate directly with the provider and cut the middlemen who doesn't have your best interests in mind.

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  • Thank you littleadv! I appreciate your feed back. The hospital billed me $1,013. The insurance company made an adjustment - +$227 (added to the bill). The insurance company can actually increase the rates transparently billed to me from the hospital?
    – Bill
    Jan 28, 2023 at 22:39
  • @Bill that's the rate your insurance negotiated with the hospital. You can try and have the hospital remove the insurance, but I don't see why they'd want to.
    – littleadv
    Jan 29, 2023 at 3:10
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    Thank you again for your reply. And actually, your suggestion is the path I went on a few days ago. I spoke with a billing representative at the hospital (she was awesome and explained everything very well unlike my insurance company representative) and told her I’m going to elect not to use my insurance and pay the entire bill out of my pocket. She said she’s not sure she can adjust the current billing. In any event, it’s an interesting dynamic and view into our dysfunctional world of healthcare in the USA. I’ll let you know how it turns out. Thanks again for your feedback.
    – Bill
    Jan 29, 2023 at 19:14
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    @Bill Just be aware that paying out-of-pocket means that spending doesn't count towards any deductible and the annual out-of-pocket max with your insurer. If you anticipate any significant amount of medical expenses for the rest of the year, it may be a bad idea.
    – ceejayoz
    Jan 30, 2023 at 17:30

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