Recently my friend had a family member go for a follow-up cardiologist visit and they sent him a bill for thousands of dollars. They couldn't believe the charges, the total charges fell within their deductible, and they reached out for guidance.
They asked some good questions and below were my responses.
1. How is the price for these services determined?
"Price for these services is whatever they want to bill you 😀 .
But if they are an in-network provider and these services are covered under your plan they are bound to the negotiated contractual price.
First step will be to send the CPT codes to your insurance company and confirm they are billing you for the contracted rate. If not and it's adjusted those prices may come down significantly.
The only other way to determine a price is 1) if the provider has a cash price and will provide that 2) is to see what Medicare reimbursements are for these services. Those reimbursements are typically far less than the insurance companies negotiated rates.
Second request the medical records and then review and compare the bill with the medical records. If anything does not look accurate or the billing seems outrageous you do have the right to challenge charges or make them an offer. That’s when you can research these codes further to determine Medicare pricing or cash pricing.
2. Do I have any way to push back on some of these costs?
Yes you do! Use the research you've gathered to challenge inaccurate or unreasonable charges and make them a reasonable offer.
"It’s not guaranteed to work but you do have the right to negotiate and often when your self pay or are paying out-of-pocket (because you haven’t met your deductible) they are more likely to work with you. Fair providers understand you paying out of pocket is different than insurance carriers paying and ultimately they want to be paid 😀."
Sound like a lot of work? We'll that's our messed up US healthcare reimbursement system!
This isn't guaranteed to work and it's TBD whether they are successful in having the charges corrected and/ or reduced, but hopefully they walked away with a better understanding of the power they have as a consumer (even with insurance) and how to better navigate the system.
If you have any comments or similar experiences would love to learn about them.