I had to call recently an ambulance because of a food allergy. By the time I reached hospital, I was okay. Last month, I recieved a bill of 3500 USD. I am just wondering, is it a fair charge? Since my deductible is $5000, I have to pay all this amount. I talked to my insurance and they say that the approved rate is only $1100 for this type of service. What can I do in this situation, I am ready to pay but this amount seems to be unreasonable. Any help appreciated.
Here's one source that says "negotiated rate."
An HDHP is not allowed to pay for anything except preventive care until you have paid the deductible out of pocket. If the plan has negotiated prices with providers (such as an HMO or PPO), you pay only the negotiated price. However, many employer-provided HDHPs make a contribution to your health savings account, so you do not need to come up with the whole deductible out of pocket. (You can also contribute more to the HSA on your own, up to the IRS limit.)
And here's a Reuter's article about how it can be difficult to get through the repricing system to get the negotiated rate even though you are supposed to get the negotiated rate. I particularly like "Consider any bill from a provider as the beginning of a negotiation rather than like a bill from a plumber or Visa."
Insurance companies put every claim through a repricing engine, where they figure out the difference between what the provider charges and the negotiated discount rate - and that is supposed to happen even if you have not met your deductible.
Yet sometimes people get bills from doctors and pay them without thinking about it.
"Consider any bill from a provider as the beginning of a negotiation rather than like a bill from a plumber or Visa," advises Dudik.
And sometimes the repricing never happens. Pat Palmer, founder of Medical Billing Advocates of America, says she has seen cases where insurance companies did not bother to put bills through repricing, since they were not paying them anyway.
"They take whole amount and apply it to deductible, and they neglect to put on the explanation of benefits that there is a different amount that you should be paying," Palmer says. "We have had some insurance companies tell us that 'it costs us money to put a claim through repricing, so we just process the claim.'"
That simply goes against Humana's policy, Smithson says. His advice to customers for avoiding all billing problems: Stay in-network whenever possible, because the insurer has a closer relationship with those providers and can exert more control over billing practices.
And another example of how someone has to take extra steps to get the negotiated rate.
People often roll their eyes at the mention of a high-deductible health plan. “You pay $5,000 before insurance covers anything?” They don’t see the benefit of such a plan – especially since I’m not likely to use anywhere near $5,000 in medical services in a typical year. Then I explain the benefits of insurance negotiated pricing. I can walk into my doctor, present my card, and arrange for my insurance to be billed. Yeah, I understand that eventually the bill will come back to me (without my insurance paying a dime), but the wonderful thing is that it is usually 40-60% cheaper than when I first walked in. My insurance company can use their pre-contracted rates to get me savings I might not have had on my own. (Note: It is possible to ask your doctor to bill you at a negotiated rate, but they don’t have to. By sending it through your insurance, you are guaranteed their contracted rates, plus you get an additional 30-60 days to get your finances in order until the bill comes.)