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I had never given a second thought to the details of the bills that my health insurance (HI) company used to send me until I moved to a HSA plan.

My typical (before the HSA plan) bill claim would be like, e.g.:

  • provider charged us: $550
  • HI company says provider is not allowed to charge more than: $200 (so the HI company basically asked the provider to take a hike for the rest of the $350)
  • my co-pay: $50
  • HI company pays: $150

Now that I have the HSA, the issue has become that the provider is charging me $550, as they always used to.

I asked for a cash discount and explicitly told them I am paying out of pocket.

When I brought over the previous invoices, they told me "we were writing the $350 off as cost of doing business with your HI company. In your current situation, we will report whatever you don't pay to collections and you work that out."

The biggest challenge though has been trying to find out which provider charges what, so I can select a provider based off cost and reputation. But, anytime I ask for a price list, I get a standard "ask your HI company" go around.

It feels too wishy washy so far with the providers basically telling me "we would like to charge you $1000 for a basic office visit, even if you had the sniffles, but we will take whatever we can get in reality so we won't put a cap to what we might ask you for any service we provide. Whatever it comes down to at the end of you debating prices and lengthy negotiations and hours of your time wasted is what you will need to pay with you running a risk of us reporting you to collections if you paid anything less than what we asked for."

Similar story: http://twed.com/some-guy-posted-his-hospital-bill-online-youll-see-why-everyones-talking-about-it/

For those of you who are using HSAs successfully, how has your experience been and is this experience of mine typical? How can I deal with this price problem?

Help! I never thought an HSA plan would be like pulling teeth in practice!

  • I think their price list would not change, you just wouldn't get the "adjustments". I have only ever used my HSA with my PPO, so I can't state otherwise. – FossilizedCarlos Mar 31 '14 at 3:32
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    I don't think this has anything to do with your HSA. Instead, it sounds like you are going to a medical provider that is not affiliated with your insurance provider. Doesn't your HI company (who you have the HDHP with) have a list of providers that they work with? – Ben Miller Mar 31 '14 at 3:47
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    @BenMiller: my provider became out of network for the current HDHP plan (they were in network for the previous PPO) – sekharan Mar 31 '14 at 3:50
  • @sekharan Is the new HDHP plan with the same HI company as your old PPO plan, or is it a different company? – Ben Miller Mar 31 '14 at 3:53
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    I am on the fence for editing your question, but your issue is really with your HDHP, not the HSA. The HSA is how you are paying your medical expenses, but the HDHP is what is responsible for the negotiated costs. Would you edit your question to reflect that? – MrChrister Mar 31 '14 at 13:51
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The big difference for me under the High deductible plan has been that instead of paying the co-pay, now I am now responsible for the negotiated rate until I reach the deductible limit. The HSA is only a way to funnel medical payments through a tax free account the insurance company and the doctor don't care about the HSA.

If we go out-of-network, then I am responsible for the full rate, but they only count the negotiated rate as a credit against the out of pocket/deductible. This big difference makes it very important to pick a doctor in-network.

For your example: I would have paid $50 under the PPO, but $200 under the high deducible plan. If I go out-of-network I would have to pay whatever the doctor want me to pay, but the insurance company would only credit me $200 against my deductible. I can pull the extra $350 from the HSA.

It is hard to get good pricing information from some doctors, but the price difference for me has been so large that in-network is the only way to go.

For prescriptions the high deductible plan has been worse, because we pay the full price with no discounts for the medicine, until we reach the plan deductible. That makes the cost of the prescriptions as much as 10x's more expensive. In fact the annual cost of our prescriptions all but guarantees that we hit the deductible each year.

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    Right, OP has gone out of network. That's the source of his issue. I still take issue with a system that has such a disparity in fees they'll accept. Half of the health care issues might be resolved by legislating a maximum premium/discount for in/out of network. – JoeTaxpayer Mar 31 '14 at 15:24
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    @Joe - Legislating a maximum disparity for in and out of network is equivalent to saying that insurer networks are to be substantially devalued. That weakens their ability to negotiate down costs, since the cost of a provider being expelled from a network is reduced. It also increases insurer costs, both for claims and for administration, since they must pay more claims and must also have more administrators to handle more payees. Rather than setting somewhat arbitrary insurance rules, I think the better path is to reduce the role of insurance in paying for routine medical care. – NL7 Mar 31 '14 at 17:39
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    You are probably right on all counts. My remark was based on how I was taken aback to see that my wife's $20k appendectomy bill was written down to less than $10,000. The uninsured person gets gouged by seeing a $20k bill. The overcharging is a vicious cycle, in my opinion. – JoeTaxpayer Mar 31 '14 at 19:16
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I had an HSA for two or three years. I found very routinely that my insurance company had negotiated rates with in-network providers. So as I never hit the deductible, I always had to pay 100% of the negotiated rate, but it was still much less than the providers general rate. Sometimes dramatically so. Like I had some blood and urine tests done and the general rate was $450 but the negotiated rate was only $40. I had laser eye surgery and the general rate was something like $1500 but the negotiated rate was more like $500. Et cetera. Other times it was the same or trivially different, like routine office visits it made no difference.

I found that I could call the insurance company and ask for the negotiated rate and they would tell me. When I asked the doctor or the hospital, they either couldn't tell me or they wouldn't. It's possible that the doctor's office doesn't really know what rates they've agreed to, they might have just signed some contract with the insurance company that says, yes, we'll accept whatever you give us. But either way, I had to go to the insurance company to find out. You'd think they'd just publish the list on a web site or something. After all, it's to the insurance company's advantage if you go to the cheapest provider. With a "regular" non-HSA plan, they're share of the total is less. Even with an HSA plan if you go to a cheaper provider you are less likely to hit the deductible.

Yes, medical care in the U.S. is rather bizarre in that providers routinely expect you to commit to paying for their services before they will tell you the price. Can you imagine any other industry working this way? Can you imagine buying a car and the dealer saying, "I have no idea what this car costs. If you like it, great, take it and drive it home, and in a few weeks we'll send you a bill. And of course whatever amount we put on that bill you are legally obligated to pay, but we refuse to tell you what that amount will be." The American Medical Association used to have a policy that they considered it "unethical" for doctors to tell patients the price of treatment in advance. I don't know if they still do.

  • Second this, labs seem to be marked up about 10x over the contracted rates. Even if you're going to pay out of pocket because the deductible hasn't been met you have them bill the insurance anyway to get the markdown. – Loren Pechtel Apr 1 '14 at 3:47
  • "Can you imagine any other industry working this way?" Until 2018, engineering. Read casetext.com/case/national-soc-of-professional-engineers-v-us and below "As Revised July 2018" at nspe.org/resources/ethics/code-ethics – Ben Voigt Jul 19 at 19:55
  • Just to clarify: I'm back on an HSA. And with the HSA, I still have an insurance company -- you have to have certain types of policies to qualify for an HSA. And when I pay with the HSA card, I get the negotiated rate from the insurance company. The insco pays $0 until I hit my deductible (with some exceptions), but I still get the negotiated rate. – Jay Jul 21 at 1:06
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First, as noted in the comments, you need to pay attention to your network providers. If you are unable to pay exorbitant prices out of pocket, then find an in-network medical provider. if you are unhappy with the in-network provider list (e.g. too distant or not specialists), then discuss switching to another plan or insurer with your employer or broker.

Second, many providers will have out of pocket or uninsured price lists, often seen in outdated formats or disused binders. Since you have asked for price lists and not been provided one, I would pursue it with the practice manager (or equivalent, or else a doctor) and ask if they have one. It's possible that the clinic has an out of pocket price list but the front line staff is unaware of it and was never trained on it.

Third, if you efforts to secure a price list fail, and you are especially committed to this specific provider, then I would consider engaging in a friendly by direct negotiation with the practice manager or other responsible person. Person they will be amenable to creating a list of prices (if you are particularly proactive and aggressive, you could offer to find out of pocket price lists from other clinics nearby). You could also flat out ask them to charge you a certain fee for office visits (if you do this, try to get some sort of offer or agreed price list in writing). Most medical practices are uncomfortable asking patients for money, so that may mean flat refusal to negotiate but it may also mean surprising willingness to work with you. This route is highly unpredictable before you go down it, and it's dependent on all sorts of things like the ownership structure, business model, and the personalities of the key people there.

The easiest answer is to switch clinics. This one sounds very unfriendly to HSA patients.

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    Nothing to do with the HSA, it's a function of the health plan itself. – JoeTaxpayer Jul 7 '14 at 16:32

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