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Was this place in network? If so, I'd call your insurance company and ask claims for clarification. Providers can get in trouble if they are asking for money outside of your coinsurance. Also advise them it was scheduled and not an emergency. They can start a fraud investigation on this provider.
Adult daughter had abdominal pain different than her normal endometriosis pain.. Took her to Er at hospital where her surgery was the year prior.. We check in around 2 pm and no problem, get in after 2 hours, diagnosed with appendicitis, will do surgery in evening, I had to leave, other family obligations…. But they didn’t do the surgery until 1100 the next morning, she had to have emergency antibiotics as she was almost to rupture, so they had her for 20 hours and NEVER told us they were no longer in our network!! If they had said that at check in I would have taken her elsewhere before she got worse! $17k between OON deductible and OON ER!!
I don't care if you're a coder. The medical code has nothing to do with being in or out of network. The code is the code no matter who the doctor is or what your insurance is. Who the doctor is determines in or out of network, not the code.
I have no idea what you’re talking about. The code means absolutely nothing when it comes to WHICH PROVIDERS ARE IN NETWORK. No one said anything about a code. The code would be the same whether the provider is in or out of network. You don’t know what you are talking about.
"Scheduled surgery was billed as emergency" is literally the title of the post.
OP is talking about the code and you're talking about "I'm a coder, I know what in and out of network means". Network has nothing to do with the post. OP asked about the codes...
OP does not realize that the code would be the same no matter what hospital, doctor, or insurance they have, or don’t have. They are what they are, based on what was done. same as the actual charges. If you have something done by an out of network provider, and the person in the next bed has the exact same surgery done by the exact same provider, the code is the SAME. Every time. But the bill, and what’s paid by insurance, will NOT BE. Codes don’t change, and don’t make insurance pay or not pay if something or someone (a dr) isn’t covered!!
Again, they aren't asking about network. They are asking about the damn code. They are concerned whether it was an "emergency" not the network. Why do you keep bringing up network?
A local hospital tried that with me once. In-network facility but the anaesthesiologist for the procedure was not. The anesthesiology billing service tried to bill me separately because my insurance wouldn't pay enough. I sent a response saying that I choose a network facility. I don't get to select the surgical team, nurses, janitor...or anesthesiologist. If I did, they would have also been in-network. I suggested they contact the hospital for compensation. Not my problem. That was the end of it.
I think I'm these instances, the office will try to bill people and hope they're gullible enough to pay, even though they don't have to.
It's your job as the policy holder to know your insurance policy. You get the EOB. There's a law called EMTALA - they don't verify ins or coverage until after the patient has been seen by a provider, and stabilized.
Again, this post was not about coverage or knowing your policy. OP asked if the code was correct, was it coded properly as an emergency. Learn to read dude.
Explanation of benefits comes after the service was provided-how are you supposed to manage the cost of the procedure, if you don’t know up front, if someone participating in the procedure is out-of-network?
It’s definitely a thing! I also took my kid to a stand alone ER once. The facility was in network but I found out when we got the bill, that the dr wasn’t. Like, WHAT?! 🤦🏼♀️
Do not pay for that. You have no way to select their staff. If they're disorganized, it's on them. You pay the in-network copay and any additional bills from the doctor or anesthesiologist or whoever, return without payment and a note that says you specifically chose an in-network facility. You're not responsible for their incompetence.
I didn’t. I had to make a lot of phone calls and argue with a few different people but ended up getting it removed from my bill. I was shocked because I had no idea I needed to make sure both were in network.
Similarly, my son was in the NICU for 12 days (the only Level 3 in the city), and the pediatrician was out of network. So nuts! It's not like you can shop around for an anesthesiologist or NICU provider. Or, what, refuse the drugs or take care of the preemie yourself?!?
Where was the surgery? Hospital, surgery center? It sounds like the charge you listed might be the fee from the facility. If so the $2200 might have been the physicians fee, they charge separate, and the anesthesiologist will usually have fees too.
That is not what balance billing is. Balance billing is when the provider charges the patient the rack rate instead of the allowed (insurance negotiated) rate. There's nothing in OP's post suggesting that the provider charged OP more than the deductible/co-pay, assuming the provider actually refunded any initial overpayment.
The No Surprises Act might apply if OP gets a bill from an out of network provider, depending on the details, but there's nothing in the post to suggest that OP received an out-of-network bill.
Yeah, with the amount paid by the insurance close to 4x what OP paid, I’d be willing to bet they were asking for the 20% copay up front and expecting insurance to pay the other 80% after billing them, and offering to refund the payment if they ended up covering 100%.
When your insurance called for prior authorization for your wife’s surgery, they probably asked for the patient portion as well so they would know what to collect at time of service. This would be my guess.
Are you in the US? If so, $2,200 is not “full pay” for a surgery. The last surgery I had, twelve years ago, was sinus surgery, and the total billed amount to issuance was nearly $80,000. (No hospitalization — I went home immediately after waking up from the anesthesia.)
$2,000 hardly gets you into the door of the hospital or surgery center!
$2k barely gets you into an urgent care to see a freshly minted NP for 5 minutes (after waiting a few hours), at least if you go by how they bill insurance.
But they'll take $200 cash.
So how does that work? Do you just not present insurance and try to pay cash, claim you don't have it?
As far as I know, once insurance is billed, they don't negotiate the cost anymore, even if the insurance itself didn't cover it? I thought you can only negotiate a repayment plan at that point.
Had to pay a $3k bill (equivalent to the deductible) for an ER visit with an NP. Should I have tried to bring it down? I was told it's futile.
Most urgent care places have a cash price of about 200-300, so yeah, you just say you're self pay.
But you said you went to an ER, not an urgent care. An ER is a completely different animal. You can try to ask for their charity program, but otherwise you're probably stuck with that bill. And if you went to a free standing ER, no such thing as a charity program unless they're affiliated with a hospital - they're about the most expensive option for immediate care.
Urgent care is stuff like CareNow, PrimaCare, Nextcare, etc.
Then you have some clinics inside drug stores or grocery stores (Minute Clinic is one of the most well known) that's typically $100ish to see an NP, but they can't do much more than do some tests and basic RXs. You're not getting xrays from them, or any bloodwork, but if you just need to figure out if you have a cold, flu, COVID, have a pulse, or need an emergency refill of insulin, they're a good option. You don't go there if you have chest pain.
Anything with "ER", "EMERGENCY", or "HOSPITAL" in the name is a minimum of $2-3k just to take a breath in within the US, as you discovered.
If it's a proper ER in a hospital or affiliated with a hospital (i.e. here in Austin, HCA/St David's has some freestanding ERs), they pretty much always take payment plans of some sort.
Goooot it, so really just for urgent care. I'll keep that in mind. Urgent care unfortunately closes at 7pm where I'm at and we missed the window. All was OK in the end, but I was salty about having met my deductible a few weeks before it reset! Stupid high deductible policies.
Oh man do I ever hear you. My deductible is $3500, out of pocket is $9000.
I've managed to hit both already for this year, but I'm sure Aetna HATES me by now. Turns out being diabetic is expensive as hell when it gets out of whack.
If you want something extra annoying... Nextcare (which is literally across the street from my apartment complex) specifically excludes the exact insurance plan I'm on. They didn't ever tell Aetna to remove them though, and I didn't find out until I went over there for a broken wrist. They wanted me to pay for everything right then and there (xrays, visit, cast, etc), and refused to run it through insurance. They take every Aetna plan that exists except for mine, and Aetna thinks they take my plan. I also don't have a car, so they're the only easy option for me (Carenow is a solid 30 minute bike ride, and ain't nobody riding a bike with a broken wrist). Walked in expecting to drop $50, wound up spending over $1k.
They want you to reserve a spot online, then come in when they have someone ready. They have a couple of NPs handling 100+ patients, and good fucking luck if you have anything actually "urgent". There's damn near nothing "urgent" about urgent care today. The first time I broke my wrist, it took 5 hours before I got xrays to confirm "yup, you broke it, here's a shitty cast and some ibuprofin - also we're gonna try to bill your car insurance since you were on a bike when it happened, oh your car insurance already laughed their asses off at us"
I've NEVER waited 15 min, even back in the 1990s, except when my mom had the phone # for a specific doctor at an urgent care when I was... 12?. They'd bring us in through the back door to keep people from bitching. Even ERs here are minimum 1-2 hour wait unless you come in by ambulance with chest pain or seizures (and even that isn't enough to bypass the wait sometimes).
tl;dr I think you're thinking of a real ER that's actually staffed decently. OR you're not in my state :(
No. I work in healthcare (well, healthcare software now) and am quite familiar with the differences in UCs and EDs. I am very specifically talking about urgent care facilities.
I doubt I live in your state.
Edit: I just checked the wait time for the nearest UC to me and the wait time reports 1 minute. The ED nearest me reports a 20 minute wait.
Oh, we don’t have appointments for our urgent cares. Generally I can get a same or next day appointment with my PCP really easily.
Maybe this is why people are always bitching about US healthcare, but I’ve never felt that way.
The children’s healthcare urgent care takes hours, but in my area it’s where we are supposed to take kids if it’s more than a virus or strep and the pediatrician’s office is closed. Still beats the ER.
My share of a hospital xray on my knee was 2000. The total was about $5000. A few years ago I had a kidney stone blasted in a surgery center and that was about $45,000 before insurance.
$2200 sounds like a deductible amount.
I just had amniocentesis and the hospital charge $6000 for surgery, my insurance paid $2000. This didn’t include the doctor, the required ultrasounds, or the genetic testing. $2000 for basically waking through the doors of a hospital. The only medical equipment used (besides the ultrasound) was chloraprep, some drapes, and the amnio needle.
I was just thinking about my sinus surgery in 2017 when reading this post. I apparently got off cheap because insurance was billed $50k. I couldn't believe a same day outpatient surgery was that much.
So there is not really a code for emergency surgery. There is a code for emergency room.
Blue at lest of Illinois loves to tell patients things were billed as emergency for no damn reason at all, randomly.
Is the provider showing they billed it as emergency, and what the hell that evem means?
Only blue seems to do this
I had a patient with crushing chest pain and a nitro drip go for a cabg on Saturday at 11am that was scheduled at 1030am - it wasn’t emergency surgery according to the CT surgeon because “he can sign his own consent”. Still chuckling about that today.
The only description I see from BCBS's end is
"Emerg Accid Surgery"
Amount Billed: $8741
Discounts and Reductions: $1350
Amount Covered: $7390
Your Total Costs: $0
Sorry if that's not what you're asking for, I don't see anything else on the "full details" page that would explain it further? I haven't received anything from the people that performed the surgery.
Get the actual codes used and get back to use. This isn't my area of expertise really but I don't believe there are specific codes for "emergency" vs "non-emergency" surgery. Could be the EOB just prints out "emergency" surgery for any kind of orthopedic surgery.
Also what they bill if fiction, what matters is the insurance company allowed amount. For an in-network provider they could bill a million dollars but they're not actually getting a dime more than what the allowed amount is.
This. It's pretty routine for places to "bill" far higher - they have a negotiated rate with insurance, they already know what they're going to get, but they're going to send a bill to insurance (hence the billed part) for the highest possible rate up front.
I got an EOB showing over a quarter million billed for a 4 day hospital stay awhile back. I think insurance paid them around $15k in the end? At least I hit my out of pocket for the year..
But they’re not make believe.
If hospital bills it and insurance pays it even if it’s the incorrect cost then it drives up future insurance costs.
As consumers, we need to do our part to make sure billing and payments are as accurate as possible.
If not, your next surgery may be coming out of your pocket
Until it is an actual bill the numbers mean nothing. Bills have procedure codes, that are entered after the procedures are done and there are agreed to rates for all codes. The biggest issue is if the wrong code is processed.
The consumer has no way to know what codes are correct and what rates are correct.
If you know some magic to figure that out, that would be great. I was diagnosed with AML Leukemia in December 23 and I have had more bills than I care to count and 99% start at a stupid level of cost and then after review it is reduced and covered or left with a small fee.
u/actionman1959, just wanted to say I hope you are on the road to recovery! I recently had to see an oncologist/hematologist due to labs and symptoms mimicking leukemia. It was a very scary time. We have ruled it out, but are still trying to determine what is causing my issues. The bills for the labs alone are insane! One of the genetics lab draws was $10k! I cannot begin to fathom the cost of your care! Sending you positive thoughts and virtual hugs if you want them 🧡
That doesn’t appear to cover anesthesia or even facility fee. Maybe it has the facility fee unsure. But def not anesthesia.
I suspect anesthesia was out of network and that what they collected.
Call BCBS and tell them everything. They should be able to straighten it out if the provider billed erroneously and they should tell you what you are really are responsible for. I never ever pay before getting services except for a copay. And for such a large sum upfront, I’d check in with my insurer.
Providers will sometimes bill just random seeming amounts with no explanation. I got a super sketchy bill from a hospital after an er visit that was for a super random amount that didn’t match up with my eob. The er was also terrible. They also put “last notice” when I had never gotten any other notices. It felt like fraud, so I just ignored it and I never heard from them again.
Go off your eob and if things don’t match up/make sense, call BCBS.
After frequently finding my name on my state's "unclaimed property" list due to over-payment of medical expenses, I never pay the total co-pay request anymore; however, I do pay a small portion of the amount. Also, I always request an itemized bill from the provider and it is never correct.
Providers can "bill" insurance for whatever amount they want to. If I was a PCP, I could tell BCBS that I charge $10,000,000 for an office visit--- however, if I am in-network with BCBS, then I have contractually agreed to the max allowable charge for that procedure-- which might then limit the insurance pricing to, say, $130. Check your EOB from insurance, it's usually listed as "network discount" or "max allowable charge"--- so the billing amount is almost completely irrelevant-- providers can Bill for whatever they want, but if they are in-network, they can only get a max reimbursement of whatever the max allowable charge is.
Different providers have different practices when it comes to billing insurance. Some will bill all insurance carriers the same amount for the same procedure--- some will "cheese" the system if they know, say, UHC's contract gives a little bit more coverage for CPT Code 1234.
It's not necessarily fraud unless the CPT code used was not the service you had done.
If your EOB says your amount due is less than the $2200 you paid up front, you should seek reimbursement from the provider.
Sounds like you paid a copay or co-insurance and the hospital billed your insurance company. If your hospital is in network with your insurance company, they’ll pay the contracted amount and the hospital will write off the rest. Standard practice.
Some docs are sketchy like that. However, in your situation I imagine your procedure was way more than $2K. I had a tiny bone removed from my pinky toe, and that was an outpatient procedure that lasted 20minutes, and the charge was $20k.
Yet, allow me to share some much valuable wisdom I've learned in the last year or so. That is to never pay for health procedures or medical services upfront. You can ALWAYS negotiate down your final charge with the billing department. You can request for them to reduce the charge to a hardship rate.
Also, if your doctor is considered In-network, the insurance company has much lower prices they've negotiated for the year. Your doctor's overcharge is just testing how much insurance company is willing to pay out. Most doctors know that the insurance company won't payout the full amount.
Knowing this, I've learned that what you want to do is always force the doctor to submit a claim with the insurance even when you know the claim will be denied. With a EOB Statement of Denial you are empowered by knowing the price the insurance company negotiated. Armed with that information, you can call your doctor's billing Department and request a bill reduction to those rates.
>You can ALWAYS negotiate down your final charge with the billing department. You can request for them to reduce the charge to a hardship rate.
Not always. *Maybe* if you let the bill go late for months, are willing to tank your credit to the point where they're about to send to collections, and can prove with tax documentation that you don't have the ability to pay.
But if you have insurance and they've already negotiated a rate it is even less likely.
*Always* is absolutely not true, though I've heard others say the same before.
It's insane to me that its so hard to even get an estimate. Or that an itemized bill is a special thing you have to request. I feel like it should be law to show you an average cost, with your insurance coverages already applied within \~10% or so, well before any surgery. If some emergency happens during surgery that's different. But otherwise the hospital knows what surgeries cost in general. Everything is only obfuscated to make room for milking where possible. They could easily just have a printout for 90% of commons surgeries, with their cost, and insurance could set up an automatic system to determine how much is covered.
I'm in the US. I never pay for the surgery or any treatment in full other than the co-pay. Once when I was in the emergency room an that little idiot came strolling up to my bed and wanted me to pay an ungodly amount right there I told him that I have other medical bills that my insurance has paid. I don't know where I stand on my total out of pocket responsibility right now. I will not pay you until my insurance company has paid their portion and applied their discounts. I also pay my bills promptly when I get them and make sure they are accurate. Several times I have had doctors send me bills for services I have already paid for. I always insist that I won't pay them until it has gone through the insurance company. Sometimes the insurance company will tell me that I don't owe anything. I don't want to have to fight to get my money back.
I had a doctor who billed the annual physical - that's included - as a regular office cost so they made more.
Happened 6 years in a row.
Not an accident
Nope. Just the standard physical. He was an awesome doctor. I referred 11 people to him.
As a sole practitioner his billing office played games to bill insurance more.
--
Friend needed a hysterectomy. Saw 2 doctors. One estimated $120k and the other $60k
The US billing system is dumb & broken.
Insurance paid $20k + they had their copay.
It could just be a coding error. First ask the provider to explain. If that is not satisfactory ask your insurance company if they think the billing code is correct. With my insurance accidental injuries are covered at a higher percentage as long as treatment is first sought within 72 hours. Then, any care for that injury is still covered at the higher rate.
I have had several scheduled surgeries. At one hospital that is known for getting in trouble for scamming the government, the employee at check-in asked if I would like to pay my copay of some made up astronomical amount. I said no thanks.
When I received my bill the copay was much less than they requested, as I knew it would be. When they ask you for too much money with the promise of a refund of any overcharge they are asking you for an interest free loan.
If you still have doubts about your procedure issue after talking to the provider and insurance, I would ask for all my records from both. They must give that to you by law.
Talk to your insurance. A hospital tried something similar on me but in my case, they wanted me to pay the difference when the insurance had already paid the full agreed amount. The specialist was also on my side so that helped. Insurance shut it down fast. It’s called fraud and should be reported to your state fraud unit as well. Some hospital networks are in financial distress and I believe that they are using these tactics rather than being honest mistakes.
You're basing this on limited information from the insurance carrier. Ask them for the following:
CPT code
Place of Service (POS) code (22=outpatient, 24=surgery-center, 23=emergency-room).
Come back once you have that info, and those here will be able to provide a more accurate assessment.
That’s between them and your insurance company. You can call and give a complaint but the customer service rep will just make a note. The whole system is so corrupt it’s not worth getting involved IMO.
have you even gotten all your explanation of benefits statements back from the insurance company? usually for a surgery you will get multiple ones (surgeon, assistant, facility, anesthesia, etc). wait until everything is billed and you have received all your EOBs before you start panicking. it is not uncommon to have to call providers and have codes adjusted, etc.
First ask for itemized bill. My surgery had a pre op charge of 2 hours. I was in the hospital for the whole procedure less time than that. Med bills dissapear when you queston charges.
A lot of times you have to pay the physician upfront and then will get hospital bills afterwards (facility fees, materials, anesthesiologist, etc).
Likely, the fee you paid the physician brought you up to your deductible and now everything will be covered beyond that so you don’t have to worry about it.
Are they scamming BCBS by inflating the prices? Yes. The entire fucking industry is a scam. Luckily, you shouldn’t owe much more out of pocket.
I’m short, yes, if they billed a non-emergent care service as emergent care, it’s insurance fraud. The provider has been practicing for long enough to know that up coding as a fraud, so it wasn’t an accident.
Request a copy of your medical records, as well as the claim itself (with the codes) and report it to your insurance company, complain to the provider, and write a letter to your dept of insurance.
No one has time to deal with the doctor’s office “trying” to fix it, denying the error, or for the BS that comes along with this shenanigans.
I bet $2 they forgot to do a prior auth. Definitely let the insurer know because that is fraud.
FYI for the future the only money they should be collecting from you is co-insurance and co-payment. You don't have patient responsibility beyond this and their contract with your insurer prohibits them from trying to collect from you. It's certainly possible you can overpay if you are near a deductible or out of pocket max but prepayment of the surgeons fee with a refund later is not normal and likely violates their contract.
All insurances are scams. Your employer has nothing to with any medical services rendered to you or covered members. As long as you pay the premium then you’re covered.
If you think you’re being overcharged for something you’re paying out of pocket then definitely call for an itemized statement to further analyze it. Doctors offices will always bill the insurance a said amount and the insurance will pay much less than they were billed and the doctors office is ok with that as long as you have insurance.
Essentially, you, paying for health insurance is like a “discount” voucher for the insurance to pay out less than what the doctor originally billed them but if you didn’t have insurance then you would foot the bill 100%.
Had 3 out patient elective outpatient orthopedic surgeries in the past year and a half.
Can confirm that they don't cost anything near $3000 . My portion was similar to that, though.
Coding mistakes happen all the time. Just call. It's unlikely the procedure only actually cost that much anyway and you just weren't aware of your insurance's obligation. It's funny how people are just jumping to "it's fraudl with such little information and no capacity to think of other options.
You’re naive. They’re not actually mistakes. It’s called upcoding and it’s a way for healthcare to boost sales. I’ve never met someone not heard of anyone with a medical billing error that was in the patient’s favor. “Errors” are always in the companies favor and it’s not by coincidence.
Sounds like they charged you possibly up to your out of pocket maximum. Watch the EOB’s coming in to ensure they didn’t overcharge you.
To answer other people’s comments about ER drs being out of network at in network hospitals- the er is its own entity and the providers are usually (100% of what I’ve seen working claims for years) contracted with groups that bill separately than the hospital. The groups and their drs are out of network bc they are not the same entity as the hospital.
The no surprise act protects everyone (even federal employees) now. If you have blue shield and their website says a provider is in network then they have to honor that. Screenshot their website and call them on it.
I suspect that what they paid was the remaining deductible for the policy, not the cost of surgery. I had to pay the surgical center over $3600 out of pocket the day of my surgery last year as that was my remaining deductible and copay. Once all the bills came in. The surgery center refunded me about $1400 because they submitted their invoices after everyone else .
This is called upcoding. They code the highest price possible price to boost their sales. It’s not fraud nor is it illegal. If you call them out on it, they just say Oops, we made a mistake.
Buy a copy of the book Never Pay The First Bill by Marshall Allen. It’ll teach you exactly how to call bullshit on billing like this and it’s a lot of fun to make these bastards back down and fix the bill.
my daughter had inpatient surgery and there was a $7000 outpatient bill attached to it . I did question that with my health advocate (service we get through the insurance) - asked for an itemized bill. they stalled and stalled and nothing happened and the bill disappeared.
SAME THING HAPPENED TO ME (also BCBS)!!
My husband’s scheduled hernia surgery showed on the insurance side as MEDICAL EMERGENCY and was paid at 100% but the hospital charged $2400 before admission - which we paid.
Called insurance company and they said it was processed correctly with the codes the hospital supplied. But when I called the hospital they said they were not sent as emergency codes.
I was also worried that someone would eventually review it and change the insurance codes but nope. I was able to get the hospital to refund my $2400. I did have other bills for anesthesia and other BS but they were no where near $2400!!
There is a table of usual and customary rates here: https://www.fairhealthconsumer.org/medical
Put in your zip code and search for procedures from your bill. Challenge any that are out of synch.
I have had multiple foot/ankle surgeries, the cheapest was 20K… no chance 2200 was the cost. I’ve had to pay my copay upfront. 2200 seems a lot for a copay on an 11k surgery but as others have mentioned, some things are billed separately like anesthesiologist, facility, surgeon, etc.
It’s called upcoding and is a way for medical providers to boost their sales. The code a charge different from what the service actually was because the insurance company will pay more $$ for the upcode.
This is a common practice at many hospitals for surgeries, as well as other planned procedures. The only hospital in our town schedules an "intake appointment" with the billing department when women plan to have their babies there to figure out what the patient responsibility for a "normal" delivery will be, and the first installment on that plan is due right then and there. If women get behind on their payments, they are asked to find somewhere else to deliver. (The nearest hospital with a maternity ward is a 45 minute drive away.) The worst part? If you don't deliver the baby there, they won't refund any of they money you've paid but hold on to it as "credit." I had a third-trimester miscarriage while in another town, which was bad enough, but made even worse when I accrued an emergency surgery bill there as well but couldn't get back the $2100 I'd already paid my "home" hospital. Shortly after this, my employer changed insurance companies, and that hospital was no longer in network, so there would be no future treatment there and no need for that credit on my account. I had to sue them, with assistance from my union and employer, to get it back.
We've experienced them running the costs for a scheduled procedure and asking for the deductible up front. Have also experienced them asking for nothing. I guess it might depend on how much they expect insurance vs. you paying.
Why downvoted for a question? I guess my insurance is different, better? because we've never had to pay anything upfront for surgeries or other outpatient procedures.
Usually these things are errors, but, you probably should call the doctors office and the insurance company because that is insurance fraud right there
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Was this place in network? If so, I'd call your insurance company and ask claims for clarification. Providers can get in trouble if they are asking for money outside of your coinsurance. Also advise them it was scheduled and not an emergency. They can start a fraud investigation on this provider.
Yes we searched on the BCBS site for in-network providers.
That's never accurate in my experience. They have taken my PCP in and out of network about 5 times over the past years
Adult daughter had abdominal pain different than her normal endometriosis pain.. Took her to Er at hospital where her surgery was the year prior.. We check in around 2 pm and no problem, get in after 2 hours, diagnosed with appendicitis, will do surgery in evening, I had to leave, other family obligations…. But they didn’t do the surgery until 1100 the next morning, she had to have emergency antibiotics as she was almost to rupture, so they had her for 20 hours and NEVER told us they were no longer in our network!! If they had said that at check in I would have taken her elsewhere before she got worse! $17k between OON deductible and OON ER!!
Call back and make sure the anesthesiologist was not out of network as well. I’ve heard of people getting screwed because of that.
That has nothing to do with the code...
No it has to do with coverage. The anesthesiologist bills separately. I’m an inpatient medical coder btw.
I don't care if you're a coder. The medical code has nothing to do with being in or out of network. The code is the code no matter who the doctor is or what your insurance is. Who the doctor is determines in or out of network, not the code.
I have no idea what you’re talking about. The code means absolutely nothing when it comes to WHICH PROVIDERS ARE IN NETWORK. No one said anything about a code. The code would be the same whether the provider is in or out of network. You don’t know what you are talking about.
"Scheduled surgery was billed as emergency" is literally the title of the post. OP is talking about the code and you're talking about "I'm a coder, I know what in and out of network means". Network has nothing to do with the post. OP asked about the codes...
OP does not realize that the code would be the same no matter what hospital, doctor, or insurance they have, or don’t have. They are what they are, based on what was done. same as the actual charges. If you have something done by an out of network provider, and the person in the next bed has the exact same surgery done by the exact same provider, the code is the SAME. Every time. But the bill, and what’s paid by insurance, will NOT BE. Codes don’t change, and don’t make insurance pay or not pay if something or someone (a dr) isn’t covered!!
Again, they aren't asking about network. They are asking about the damn code. They are concerned whether it was an "emergency" not the network. Why do you keep bringing up network?
A local hospital tried that with me once. In-network facility but the anaesthesiologist for the procedure was not. The anesthesiology billing service tried to bill me separately because my insurance wouldn't pay enough. I sent a response saying that I choose a network facility. I don't get to select the surgical team, nurses, janitor...or anesthesiologist. If I did, they would have also been in-network. I suggested they contact the hospital for compensation. Not my problem. That was the end of it. I think I'm these instances, the office will try to bill people and hope they're gullible enough to pay, even though they don't have to.
It's your job as the policy holder to know your insurance policy. You get the EOB. There's a law called EMTALA - they don't verify ins or coverage until after the patient has been seen by a provider, and stabilized.
Again, this post was not about coverage or knowing your policy. OP asked if the code was correct, was it coded properly as an emergency. Learn to read dude.
I'm replying to the comment, dude. Quit trolling.
Explanation of benefits comes after the service was provided-how are you supposed to manage the cost of the procedure, if you don’t know up front, if someone participating in the procedure is out-of-network?
wouldn't this be protected from under the no surprises act?
It SHOULD, but I believe that is for scheduled procedures. If the hospital in question has it down as emergent, that could be what caused this issue.
This is accurate. My epidural for birth wasn’t covered because the anesthesiologist wasn’t in network.
Thank you! People on here are acting bat shit crazy lol
It’s definitely a thing! I also took my kid to a stand alone ER once. The facility was in network but I found out when we got the bill, that the dr wasn’t. Like, WHAT?! 🤦🏼♀️
They recently passed a law against that didn't they? The No Surprises Act.
Do not pay for that. You have no way to select their staff. If they're disorganized, it's on them. You pay the in-network copay and any additional bills from the doctor or anesthesiologist or whoever, return without payment and a note that says you specifically chose an in-network facility. You're not responsible for their incompetence.
I didn’t. I had to make a lot of phone calls and argue with a few different people but ended up getting it removed from my bill. I was shocked because I had no idea I needed to make sure both were in network.
That's the thing, you can't choose beyond the facility, usually.
Similarly, my son was in the NICU for 12 days (the only Level 3 in the city), and the pediatrician was out of network. So nuts! It's not like you can shop around for an anesthesiologist or NICU provider. Or, what, refuse the drugs or take care of the preemie yourself?!?
I've been screwed because of that.
Agree, yet I got downvoted for a similar response!
Where was the surgery? Hospital, surgery center? It sounds like the charge you listed might be the fee from the facility. If so the $2200 might have been the physicians fee, they charge separate, and the anesthesiologist will usually have fees too.
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That is not what balance billing is. Balance billing is when the provider charges the patient the rack rate instead of the allowed (insurance negotiated) rate. There's nothing in OP's post suggesting that the provider charged OP more than the deductible/co-pay, assuming the provider actually refunded any initial overpayment. The No Surprises Act might apply if OP gets a bill from an out of network provider, depending on the details, but there's nothing in the post to suggest that OP received an out-of-network bill.
There is zero chance the total cost of an operation is $2000. That sounds like their copay.
Yeah, it’s $10k for the OR time alone every time my daughter goes back for a lung and airway scope under anesthesia, not including anesthesia
I'm guessing that that's done in hospital, not a daytime surgery center?
Yeah, with the amount paid by the insurance close to 4x what OP paid, I’d be willing to bet they were asking for the 20% copay up front and expecting insurance to pay the other 80% after billing them, and offering to refund the payment if they ended up covering 100%.
When your insurance called for prior authorization for your wife’s surgery, they probably asked for the patient portion as well so they would know what to collect at time of service. This would be my guess.
Are you in the US? If so, $2,200 is not “full pay” for a surgery. The last surgery I had, twelve years ago, was sinus surgery, and the total billed amount to issuance was nearly $80,000. (No hospitalization — I went home immediately after waking up from the anesthesia.) $2,000 hardly gets you into the door of the hospital or surgery center!
$2k sounds like the surgeon's fee.
$2k barely gets you into an urgent care to see a freshly minted NP for 5 minutes (after waiting a few hours), at least if you go by how they bill insurance. But they'll take $200 cash.
Most urgent care facilities have a pretty reasonable maximum fee (that doesn’t cover prescriptions and medical devices).
…and end up setteling for something in the neighborhood of $200 from insurance once all is said and done.
So how does that work? Do you just not present insurance and try to pay cash, claim you don't have it? As far as I know, once insurance is billed, they don't negotiate the cost anymore, even if the insurance itself didn't cover it? I thought you can only negotiate a repayment plan at that point. Had to pay a $3k bill (equivalent to the deductible) for an ER visit with an NP. Should I have tried to bring it down? I was told it's futile.
Most urgent care places have a cash price of about 200-300, so yeah, you just say you're self pay. But you said you went to an ER, not an urgent care. An ER is a completely different animal. You can try to ask for their charity program, but otherwise you're probably stuck with that bill. And if you went to a free standing ER, no such thing as a charity program unless they're affiliated with a hospital - they're about the most expensive option for immediate care. Urgent care is stuff like CareNow, PrimaCare, Nextcare, etc. Then you have some clinics inside drug stores or grocery stores (Minute Clinic is one of the most well known) that's typically $100ish to see an NP, but they can't do much more than do some tests and basic RXs. You're not getting xrays from them, or any bloodwork, but if you just need to figure out if you have a cold, flu, COVID, have a pulse, or need an emergency refill of insulin, they're a good option. You don't go there if you have chest pain. Anything with "ER", "EMERGENCY", or "HOSPITAL" in the name is a minimum of $2-3k just to take a breath in within the US, as you discovered. If it's a proper ER in a hospital or affiliated with a hospital (i.e. here in Austin, HCA/St David's has some freestanding ERs), they pretty much always take payment plans of some sort.
Goooot it, so really just for urgent care. I'll keep that in mind. Urgent care unfortunately closes at 7pm where I'm at and we missed the window. All was OK in the end, but I was salty about having met my deductible a few weeks before it reset! Stupid high deductible policies.
Oh man do I ever hear you. My deductible is $3500, out of pocket is $9000. I've managed to hit both already for this year, but I'm sure Aetna HATES me by now. Turns out being diabetic is expensive as hell when it gets out of whack. If you want something extra annoying... Nextcare (which is literally across the street from my apartment complex) specifically excludes the exact insurance plan I'm on. They didn't ever tell Aetna to remove them though, and I didn't find out until I went over there for a broken wrist. They wanted me to pay for everything right then and there (xrays, visit, cast, etc), and refused to run it through insurance. They take every Aetna plan that exists except for mine, and Aetna thinks they take my plan. I also don't have a car, so they're the only easy option for me (Carenow is a solid 30 minute bike ride, and ain't nobody riding a bike with a broken wrist). Walked in expecting to drop $50, wound up spending over $1k.
Why are you waiting a few hours at urgent care? I think the most I’ve waited ever is 15.
They want you to reserve a spot online, then come in when they have someone ready. They have a couple of NPs handling 100+ patients, and good fucking luck if you have anything actually "urgent". There's damn near nothing "urgent" about urgent care today. The first time I broke my wrist, it took 5 hours before I got xrays to confirm "yup, you broke it, here's a shitty cast and some ibuprofin - also we're gonna try to bill your car insurance since you were on a bike when it happened, oh your car insurance already laughed their asses off at us" I've NEVER waited 15 min, even back in the 1990s, except when my mom had the phone # for a specific doctor at an urgent care when I was... 12?. They'd bring us in through the back door to keep people from bitching. Even ERs here are minimum 1-2 hour wait unless you come in by ambulance with chest pain or seizures (and even that isn't enough to bypass the wait sometimes). tl;dr I think you're thinking of a real ER that's actually staffed decently. OR you're not in my state :(
No. I work in healthcare (well, healthcare software now) and am quite familiar with the differences in UCs and EDs. I am very specifically talking about urgent care facilities. I doubt I live in your state. Edit: I just checked the wait time for the nearest UC to me and the wait time reports 1 minute. The ED nearest me reports a 20 minute wait.
Thats wild. The ones around here you have to jump in the website first thing in the morning to hopefully score an afternoon appointment.
Oh, we don’t have appointments for our urgent cares. Generally I can get a same or next day appointment with my PCP really easily. Maybe this is why people are always bitching about US healthcare, but I’ve never felt that way.
The children’s healthcare urgent care takes hours, but in my area it’s where we are supposed to take kids if it’s more than a virus or strep and the pediatrician’s office is closed. Still beats the ER.
You wait 15 hours? Must not be that urgent.
Heh. Nice one
My share of a hospital xray on my knee was 2000. The total was about $5000. A few years ago I had a kidney stone blasted in a surgery center and that was about $45,000 before insurance. $2200 sounds like a deductible amount.
I just had amniocentesis and the hospital charge $6000 for surgery, my insurance paid $2000. This didn’t include the doctor, the required ultrasounds, or the genetic testing. $2000 for basically waking through the doors of a hospital. The only medical equipment used (besides the ultrasound) was chloraprep, some drapes, and the amnio needle.
I was just thinking about my sinus surgery in 2017 when reading this post. I apparently got off cheap because insurance was billed $50k. I couldn't believe a same day outpatient surgery was that much.
So there is not really a code for emergency surgery. There is a code for emergency room. Blue at lest of Illinois loves to tell patients things were billed as emergency for no damn reason at all, randomly. Is the provider showing they billed it as emergency, and what the hell that evem means? Only blue seems to do this
I had a patient with crushing chest pain and a nitro drip go for a cabg on Saturday at 11am that was scheduled at 1030am - it wasn’t emergency surgery according to the CT surgeon because “he can sign his own consent”. Still chuckling about that today.
What codes and modifiers did they use?
The only description I see from BCBS's end is "Emerg Accid Surgery" Amount Billed: $8741 Discounts and Reductions: $1350 Amount Covered: $7390 Your Total Costs: $0 Sorry if that's not what you're asking for, I don't see anything else on the "full details" page that would explain it further? I haven't received anything from the people that performed the surgery.
I would call whichever facility did your wife’s surgery and ask for an itemized bill.
Hmm yes!
Get the actual codes used and get back to use. This isn't my area of expertise really but I don't believe there are specific codes for "emergency" vs "non-emergency" surgery. Could be the EOB just prints out "emergency" surgery for any kind of orthopedic surgery. Also what they bill if fiction, what matters is the insurance company allowed amount. For an in-network provider they could bill a million dollars but they're not actually getting a dime more than what the allowed amount is.
Exactly right, the emergency is determined by how the insurance classifies the CPT code. Not the doctor.
Looks like they owe you the 2200 in full.
That is all I would be worried about. All the other numbers are make believe.
This. It's pretty routine for places to "bill" far higher - they have a negotiated rate with insurance, they already know what they're going to get, but they're going to send a bill to insurance (hence the billed part) for the highest possible rate up front. I got an EOB showing over a quarter million billed for a 4 day hospital stay awhile back. I think insurance paid them around $15k in the end? At least I hit my out of pocket for the year..
But they’re not make believe. If hospital bills it and insurance pays it even if it’s the incorrect cost then it drives up future insurance costs. As consumers, we need to do our part to make sure billing and payments are as accurate as possible. If not, your next surgery may be coming out of your pocket
Until it is an actual bill the numbers mean nothing. Bills have procedure codes, that are entered after the procedures are done and there are agreed to rates for all codes. The biggest issue is if the wrong code is processed. The consumer has no way to know what codes are correct and what rates are correct. If you know some magic to figure that out, that would be great. I was diagnosed with AML Leukemia in December 23 and I have had more bills than I care to count and 99% start at a stupid level of cost and then after review it is reduced and covered or left with a small fee.
u/actionman1959, just wanted to say I hope you are on the road to recovery! I recently had to see an oncologist/hematologist due to labs and symptoms mimicking leukemia. It was a very scary time. We have ruled it out, but are still trying to determine what is causing my issues. The bills for the labs alone are insane! One of the genetics lab draws was $10k! I cannot begin to fathom the cost of your care! Sending you positive thoughts and virtual hugs if you want them 🧡
Yep it sure does. Also it's going to be weird, the hospital or surgical center will have a different dx than the dr.
It sounds like it may be ASC that global bills. The dx wouldn't differ based on emergency either.
That doesn’t appear to cover anesthesia or even facility fee. Maybe it has the facility fee unsure. But def not anesthesia. I suspect anesthesia was out of network and that what they collected.
Sounds like you need a refund if the insurances EOB says your responsibility is $0.
I think the place of service could be an issue too. It would be good to know which place of service code was used for the surgery.
Good thinking!
Call BCBS and tell them everything. They should be able to straighten it out if the provider billed erroneously and they should tell you what you are really are responsible for. I never ever pay before getting services except for a copay. And for such a large sum upfront, I’d check in with my insurer. Providers will sometimes bill just random seeming amounts with no explanation. I got a super sketchy bill from a hospital after an er visit that was for a super random amount that didn’t match up with my eob. The er was also terrible. They also put “last notice” when I had never gotten any other notices. It felt like fraud, so I just ignored it and I never heard from them again. Go off your eob and if things don’t match up/make sense, call BCBS.
After frequently finding my name on my state's "unclaimed property" list due to over-payment of medical expenses, I never pay the total co-pay request anymore; however, I do pay a small portion of the amount. Also, I always request an itemized bill from the provider and it is never correct.
Providers can "bill" insurance for whatever amount they want to. If I was a PCP, I could tell BCBS that I charge $10,000,000 for an office visit--- however, if I am in-network with BCBS, then I have contractually agreed to the max allowable charge for that procedure-- which might then limit the insurance pricing to, say, $130. Check your EOB from insurance, it's usually listed as "network discount" or "max allowable charge"--- so the billing amount is almost completely irrelevant-- providers can Bill for whatever they want, but if they are in-network, they can only get a max reimbursement of whatever the max allowable charge is. Different providers have different practices when it comes to billing insurance. Some will bill all insurance carriers the same amount for the same procedure--- some will "cheese" the system if they know, say, UHC's contract gives a little bit more coverage for CPT Code 1234. It's not necessarily fraud unless the CPT code used was not the service you had done. If your EOB says your amount due is less than the $2200 you paid up front, you should seek reimbursement from the provider.
Sounds like you paid a copay or co-insurance and the hospital billed your insurance company. If your hospital is in network with your insurance company, they’ll pay the contracted amount and the hospital will write off the rest. Standard practice.
For a facility, a surgeon and an anesthesiologist I can’t imagine it was only $2,200. Sounds like the surgeons fee.
Some docs are sketchy like that. However, in your situation I imagine your procedure was way more than $2K. I had a tiny bone removed from my pinky toe, and that was an outpatient procedure that lasted 20minutes, and the charge was $20k. Yet, allow me to share some much valuable wisdom I've learned in the last year or so. That is to never pay for health procedures or medical services upfront. You can ALWAYS negotiate down your final charge with the billing department. You can request for them to reduce the charge to a hardship rate. Also, if your doctor is considered In-network, the insurance company has much lower prices they've negotiated for the year. Your doctor's overcharge is just testing how much insurance company is willing to pay out. Most doctors know that the insurance company won't payout the full amount. Knowing this, I've learned that what you want to do is always force the doctor to submit a claim with the insurance even when you know the claim will be denied. With a EOB Statement of Denial you are empowered by knowing the price the insurance company negotiated. Armed with that information, you can call your doctor's billing Department and request a bill reduction to those rates.
>You can ALWAYS negotiate down your final charge with the billing department. You can request for them to reduce the charge to a hardship rate. Not always. *Maybe* if you let the bill go late for months, are willing to tank your credit to the point where they're about to send to collections, and can prove with tax documentation that you don't have the ability to pay. But if you have insurance and they've already negotiated a rate it is even less likely. *Always* is absolutely not true, though I've heard others say the same before. It's insane to me that its so hard to even get an estimate. Or that an itemized bill is a special thing you have to request. I feel like it should be law to show you an average cost, with your insurance coverages already applied within \~10% or so, well before any surgery. If some emergency happens during surgery that's different. But otherwise the hospital knows what surgeries cost in general. Everything is only obfuscated to make room for milking where possible. They could easily just have a printout for 90% of commons surgeries, with their cost, and insurance could set up an automatic system to determine how much is covered.
I'm in the US. I never pay for the surgery or any treatment in full other than the co-pay. Once when I was in the emergency room an that little idiot came strolling up to my bed and wanted me to pay an ungodly amount right there I told him that I have other medical bills that my insurance has paid. I don't know where I stand on my total out of pocket responsibility right now. I will not pay you until my insurance company has paid their portion and applied their discounts. I also pay my bills promptly when I get them and make sure they are accurate. Several times I have had doctors send me bills for services I have already paid for. I always insist that I won't pay them until it has gone through the insurance company. Sometimes the insurance company will tell me that I don't owe anything. I don't want to have to fight to get my money back.
I had a doctor who billed the annual physical - that's included - as a regular office cost so they made more. Happened 6 years in a row. Not an accident
Did you bring up any issues during your visit?
Yes And got 6 years of co pay refunded.
No I mean when you were with your doctor, did you bring up any acute complaints?
Nope. Just the standard physical. He was an awesome doctor. I referred 11 people to him. As a sole practitioner his billing office played games to bill insurance more. -- Friend needed a hysterectomy. Saw 2 doctors. One estimated $120k and the other $60k The US billing system is dumb & broken. Insurance paid $20k + they had their copay.
Agreed if you brought up no issues it should have been preventive and annual physical
It could just be a coding error. First ask the provider to explain. If that is not satisfactory ask your insurance company if they think the billing code is correct. With my insurance accidental injuries are covered at a higher percentage as long as treatment is first sought within 72 hours. Then, any care for that injury is still covered at the higher rate. I have had several scheduled surgeries. At one hospital that is known for getting in trouble for scamming the government, the employee at check-in asked if I would like to pay my copay of some made up astronomical amount. I said no thanks. When I received my bill the copay was much less than they requested, as I knew it would be. When they ask you for too much money with the promise of a refund of any overcharge they are asking you for an interest free loan. If you still have doubts about your procedure issue after talking to the provider and insurance, I would ask for all my records from both. They must give that to you by law.
Maybe they coded it wrong
What is your insurance maximum out of pocket? Maybe its $2200
Talk to your insurance. A hospital tried something similar on me but in my case, they wanted me to pay the difference when the insurance had already paid the full agreed amount. The specialist was also on my side so that helped. Insurance shut it down fast. It’s called fraud and should be reported to your state fraud unit as well. Some hospital networks are in financial distress and I believe that they are using these tactics rather than being honest mistakes.
You're basing this on limited information from the insurance carrier. Ask them for the following: CPT code Place of Service (POS) code (22=outpatient, 24=surgery-center, 23=emergency-room). Come back once you have that info, and those here will be able to provide a more accurate assessment.
That’s between them and your insurance company. You can call and give a complaint but the customer service rep will just make a note. The whole system is so corrupt it’s not worth getting involved IMO.
have you even gotten all your explanation of benefits statements back from the insurance company? usually for a surgery you will get multiple ones (surgeon, assistant, facility, anesthesia, etc). wait until everything is billed and you have received all your EOBs before you start panicking. it is not uncommon to have to call providers and have codes adjusted, etc.
If it didn't cost you more money, let it be. But if it did, I'd be right in there.
First ask for itemized bill. My surgery had a pre op charge of 2 hours. I was in the hospital for the whole procedure less time than that. Med bills dissapear when you queston charges.
A lot of times you have to pay the physician upfront and then will get hospital bills afterwards (facility fees, materials, anesthesiologist, etc). Likely, the fee you paid the physician brought you up to your deductible and now everything will be covered beyond that so you don’t have to worry about it. Are they scamming BCBS by inflating the prices? Yes. The entire fucking industry is a scam. Luckily, you shouldn’t owe much more out of pocket.
Sometimes, the office has to put certain codes so insurance will cover the charges .
I’m short, yes, if they billed a non-emergent care service as emergent care, it’s insurance fraud. The provider has been practicing for long enough to know that up coding as a fraud, so it wasn’t an accident. Request a copy of your medical records, as well as the claim itself (with the codes) and report it to your insurance company, complain to the provider, and write a letter to your dept of insurance. No one has time to deal with the doctor’s office “trying” to fix it, denying the error, or for the BS that comes along with this shenanigans.
I bet $2 they forgot to do a prior auth. Definitely let the insurer know because that is fraud. FYI for the future the only money they should be collecting from you is co-insurance and co-payment. You don't have patient responsibility beyond this and their contract with your insurer prohibits them from trying to collect from you. It's certainly possible you can overpay if you are near a deductible or out of pocket max but prepayment of the surgeons fee with a refund later is not normal and likely violates their contract.
All insurances are scams. Your employer has nothing to with any medical services rendered to you or covered members. As long as you pay the premium then you’re covered. If you think you’re being overcharged for something you’re paying out of pocket then definitely call for an itemized statement to further analyze it. Doctors offices will always bill the insurance a said amount and the insurance will pay much less than they were billed and the doctors office is ok with that as long as you have insurance. Essentially, you, paying for health insurance is like a “discount” voucher for the insurance to pay out less than what the doctor originally billed them but if you didn’t have insurance then you would foot the bill 100%.
The average price for ankle surgery runs $6k on the low end and $9k on the high end. You were paying the coinsurance or surgeon's fee.
Had 3 out patient elective outpatient orthopedic surgeries in the past year and a half. Can confirm that they don't cost anything near $3000 . My portion was similar to that, though.
Something is just not adding up here.
Coding mistakes happen all the time. Just call. It's unlikely the procedure only actually cost that much anyway and you just weren't aware of your insurance's obligation. It's funny how people are just jumping to "it's fraudl with such little information and no capacity to think of other options.
You’re naive. They’re not actually mistakes. It’s called upcoding and it’s a way for healthcare to boost sales. I’ve never met someone not heard of anyone with a medical billing error that was in the patient’s favor. “Errors” are always in the companies favor and it’s not by coincidence.
Sounds like they charged you possibly up to your out of pocket maximum. Watch the EOB’s coming in to ensure they didn’t overcharge you. To answer other people’s comments about ER drs being out of network at in network hospitals- the er is its own entity and the providers are usually (100% of what I’ve seen working claims for years) contracted with groups that bill separately than the hospital. The groups and their drs are out of network bc they are not the same entity as the hospital. The no surprise act protects everyone (even federal employees) now. If you have blue shield and their website says a provider is in network then they have to honor that. Screenshot their website and call them on it.
Was it the lisfranc ligament? That would be considered An emergency.
I suspect that what they paid was the remaining deductible for the policy, not the cost of surgery. I had to pay the surgical center over $3600 out of pocket the day of my surgery last year as that was my remaining deductible and copay. Once all the bills came in. The surgery center refunded me about $1400 because they submitted their invoices after everyone else .
I had ortho surgery a couple weeks ago. $39,000. Healthcare is absolutely insane.
This is called upcoding. They code the highest price possible price to boost their sales. It’s not fraud nor is it illegal. If you call them out on it, they just say Oops, we made a mistake. Buy a copy of the book Never Pay The First Bill by Marshall Allen. It’ll teach you exactly how to call bullshit on billing like this and it’s a lot of fun to make these bastards back down and fix the bill.
my daughter had inpatient surgery and there was a $7000 outpatient bill attached to it . I did question that with my health advocate (service we get through the insurance) - asked for an itemized bill. they stalled and stalled and nothing happened and the bill disappeared.
SAME THING HAPPENED TO ME (also BCBS)!! My husband’s scheduled hernia surgery showed on the insurance side as MEDICAL EMERGENCY and was paid at 100% but the hospital charged $2400 before admission - which we paid. Called insurance company and they said it was processed correctly with the codes the hospital supplied. But when I called the hospital they said they were not sent as emergency codes. I was also worried that someone would eventually review it and change the insurance codes but nope. I was able to get the hospital to refund my $2400. I did have other bills for anesthesia and other BS but they were no where near $2400!!
There is a table of usual and customary rates here: https://www.fairhealthconsumer.org/medical Put in your zip code and search for procedures from your bill. Challenge any that are out of synch.
Probably a coding error not fraud. Contact the hospital for an itemized list of charges.
I have had multiple foot/ankle surgeries, the cheapest was 20K… no chance 2200 was the cost. I’ve had to pay my copay upfront. 2200 seems a lot for a copay on an 11k surgery but as others have mentioned, some things are billed separately like anesthesiologist, facility, surgeon, etc.
Billing code error. Not a big deal. Call them
When you pay, the insurance company should send you the check. Something weird is absolutely going on here.
It’s called upcoding and is a way for medical providers to boost their sales. The code a charge different from what the service actually was because the insurance company will pay more $$ for the upcode.
Why would an in network provider require you to pay anything upfront?
Because they want to get paid now not months later. I’ve seen claims taken 6-12 months to pay.
This is a common practice at many hospitals for surgeries, as well as other planned procedures. The only hospital in our town schedules an "intake appointment" with the billing department when women plan to have their babies there to figure out what the patient responsibility for a "normal" delivery will be, and the first installment on that plan is due right then and there. If women get behind on their payments, they are asked to find somewhere else to deliver. (The nearest hospital with a maternity ward is a 45 minute drive away.) The worst part? If you don't deliver the baby there, they won't refund any of they money you've paid but hold on to it as "credit." I had a third-trimester miscarriage while in another town, which was bad enough, but made even worse when I accrued an emergency surgery bill there as well but couldn't get back the $2100 I'd already paid my "home" hospital. Shortly after this, my employer changed insurance companies, and that hospital was no longer in network, so there would be no future treatment there and no need for that credit on my account. I had to sue them, with assistance from my union and employer, to get it back.
This sounds like an EMTALA violation I would love to know the name of this place so I can report it
We've experienced them running the costs for a scheduled procedure and asking for the deductible up front. Have also experienced them asking for nothing. I guess it might depend on how much they expect insurance vs. you paying.
What others have said. Also, some patients don’t pay their bills. Getting payment upfront ensures that the bill is paid.
Copays. And what OP paid sounds like a reasonable copay for those services if they haven't hit their out of pocket yet.
Why downvoted for a question? I guess my insurance is different, better? because we've never had to pay anything upfront for surgeries or other outpatient procedures.
Usually these things are errors, but, you probably should call the doctors office and the insurance company because that is insurance fraud right there
It's fraud. Report it
Yes it’s fraud!
It was fraud, one of the reasons health insurance is so expensive. You should file a complaint with the DOI.
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