Cash Price Vs. Network Price

[rmorris]

Have any of you done any research or questioned your customers about their Dr's cash pricing vs. the network discount? Obviously copay customers don't care (this is one of the problems with healthcare costs IMO), but for HSA customers there is a HUGE gap sometimes that is unknown!

Example:
I've been once to a PCP in the last 2 years and once to a specialist as a follow up visit from 4 yrs ago.

PCP - Cash price is $70. Insurance price with my plan was $130. I paid cash with my HSA and had the option to manually file the claim later.

Specialist - $60 returning patient cash price. But insurance was going to be billed anywhere from $130 - $350! They couldn't tell me because their billing 'specialist' was out of the office. So even though my network discount may have been $70-$150, I opted for the cash price. They didn't have my insurance on file but knew had it and was not giving it to them. They got mad and said I MUST give it to them as they HAVE to file on it with my carrier. After refusing to give them my card, they called their billing specialist and finally conceeded to charge me the cash price.

But the problem lies that the front office staff at Dr's office has no clue about HSA's most of the time. Plus you never known when it will be beneficial to use the insurance vs. cash price. We know that most lab work is cheaper on a insurance network, same major procedures (just had a client with a $21,000 hysterectomy bill repriced to $2,300 with BCBS).

Talk about why the system is screwed up! If we as agents have a hard time finding out how the insurance is billed because the front office staff is either incompetent or taught to mislead you, then how the hell do we advise our clients to truly be 'Consumer Driven'?

 

[somarco]

PCP - Cash price is $70. Insurance price with my plan was $130.

The only way to know for sure what the "insurance" price is would be to file a claim. Par providers are not allowed by contract to offer a lower cash price than the negotiated rate. The carrier has the right to boot them off the plan if they discover they are giving discounts below the negotiated rate.

Specialist - $60 returning patient cash price. But insurance was going to be billed anywhere from $130 - $350! They couldn't tell me because their billing 'specialist' was out of the office.

See response above.

Their "billing specialist" will not know how much the carrier will allow so it doesn't matter if she is working that day or at the local bar having a margarita.

 

[IndividualHealthGuy]

I worked for the local Blue here, and saw many, many claims. There is no way that someone offering cash for a one-time service will beat a carrier's combined negotiating ability.

 

[ABC]

Great Topic

What I am see on a network discount from PCP on $110 charge is it is discounted to about $57.

Now on the specialist I am way impressed if they let you out the door for $60.

I would like to know what kind of specialist you saw and what procedure you had done?



I have never advised a client to try the cash system but it does make sense from a dr standpoint to take the cash now.

 

[moonlightandmargaritas]

Their "billing specialist" will not know how much the carrier will allow so it doesn't matter if she is working that day or at the local bar having a margarita.

I think I dated her a couple of years ago...

 

[GreenSky]

Several years ago I had a MRI of my knee. At that time, my policy had a $1,000 deductible and it had yet to be met.

Although it too awhile, the network price was $660. The cash price was $400. I paid the $400. Shortly thereafter I incurred additional bills and met the deductble. I submitted the $400 bill and it was treated as out of network, even though the imaging center was in network.

The explanation was that for in network coverage only the provider to submit a bill. So they resubmitted and everyone paid more.

Still can't figure that out.

Rick

 

[CHUMPS FROM OXFORD]

Labs and X-rays are discounted big-time! Roughly 80%.

 

[rmorris]

I would like to know what kind of specialist you saw and what procedure you had done?

I had Chron's many years ago that was surgically removed and I've been one of the lucky few to not have any issues since. So this was a gastroenterologist that I hadn't seen in 5 years, but saw yearly before that.

I can promise you that I always call ahead and act dumb asking about cash price and then ask about insurance price. With this specialist I was told since I'm a returning patient: $60 follow up with cash. When I asked about insurance price it seriously ranged from $120 - $350 billed to the insurance. Of course "we don't know what your network price will be until after we submit the claim". Maybe she's right, but I call bullsh*t! They see this exact same CPT code billed all the time and have a good idea of what my carrier rate is.

As for the PCP - again, called ahead to find out cash was $70 and they billed almost double to insurance.

I know for a fact the labs and x-rays have huge discounts. But it seems like consultations are cheaper on the cash price. IndHealthGuy - I challenge you on your statement as I do think consultations break the mold. I wish there were a way to compile a report of the cash vs. insurance network price for a BCBS or UHC plan.
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I've gotta add 2 things:

1st: For those of you with an HSA or catastrophic plan that have been to your PCP or specialist in the last year, and you used your insurance for your visit, look up how much you paid. Now pick up the phone and call that same office and act like a new patient inquiring about the cash price. Try to get apples to apples. You might ask about the specific thing you had done like stomach bug, or allergy shot, etc. Then report back

2nd: These facilities screw patients and know it, but get away all the time I'm sure! Examples:

• Client says he setup a $5,500 payment plan for wife's hysterectomy with Baylor Hospital. After calling BCBS to inquire about where they stand with HSA deductible, we find out $21,000 was billed from Baylor. BCBS network pricing was $2,330. The only OON Dr. charged $30. WTF? Where is the other $2,170 on that payment plan coming from?
• Brother just has 1st baby girl. Doctor screws up the 1st 'foot prick' where they obtain blood and do labs. They get asked to come back and let them do it again. Upon leaving the 2nd time, billing says 'that will be $xxx. Matt, a group broker, is furious and says he is not paying for their incompetence when they screwed up the first time. Get's referred to their billing dept where he is told the same thing even after arguing his side (they screwed up the first test). He's told - "sir perhaps you would be happier if we just discarded the blood sample we have and you can go elsewhere for this procedure". His response - "perhaps I show up on your doorstep with channels 4, 5, 8, & 11 with a special on why I have to pay for this test twice when your dumbass dr's don't know what they're doing". Turn's out the supervisor's boss was more than happy to take care of his bill!

All of this just boils my blood. Think about how many clients pay up front thinking they have to because that's what the billing specialist says. 2 weeks later they get an EOB showing they overpaid. If they are smart, they follow up with the facility/dr and get their refund back in 6-8 weeks.
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Several years ago I had a MRI of my knee. At that time, my policy had a $1,000 deductible and it had yet to be met.

Although it too awhile, the network price was $660. The cash price was $400. I paid the $400. Shortly thereafter I incurred additional bills and met the deductble. I submitted the $400 bill and it was treated as out of network, even though the imaging center was in network.

The explanation was that for in network coverage only the provider to submit a bill. So they resubmitted and everyone paid more.

Still can't figure that out.

Rick

EXACTLY! I've been told by carriers that to be seen as an in-network claim, it must be submitted by the Dr's office. So essentially the insurance company WANTS to pay an extra $260 for no reason??? This doesn't make sense!

 

[somarco]

how many clients pay up front thinking they have to because that's what the billing specialist says. 2 weeks later they get an EOB showing they overpaid.

I tell my clients to do what I do. Pay nothing at time of the visit or tender a typical copay.

Never had any complaints.

Try and get a refund after the fact. What a hassle.

As for getting a lower price for cash vs insurance, yeah, it happens. There are also folks who walk away from a serious accident without a scratch and they weren't wearing a seatbelt. But those situations are rare.

Providers sign contracts with MCO's and agree in writing to certain terms. Among them is not to balance bill on covered items, another is an agreement that they will not offer insured clients a lower fee.

That doesn't mean these things don't happen.

Frankly, with all the cash flow issues providers are having these days I can't imagine why any of them would be willing to accept less than they can get normally.

 

[IndividualHealthGuy]

Several years ago I had a MRI of my knee. At that time, my policy had a $1,000 deductible and it had yet to be met.

Although it too awhile, the network price was $660. The cash price was $400. I paid the $400. Shortly thereafter I incurred additional bills and met the deductble. I submitted the $400 bill and it was treated as out of network, even though the imaging center was in network.

The explanation was that for in network coverage only the provider to submit a bill. So they resubmitted and everyone paid more.

Still can't figure that out.

Rick

The same contract that requires the provider to not balance bill, also stipulates that in network providers MUST submit claims for their insured patients (this is really a service by the ins. co. Could you imagine having to submit those claims?) and that in return the carrier MUST pay the claim direct to the provider.
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I know for a fact the labs and x-rays have huge discounts. But it seems like consultations are cheaper on the cash price. IndHealthGuy - I challenge you on your statement as I do think consultations break the mold. I wish there were a way to compile a report of the cash vs. insurance network price for a BCBS or UHC plan.

I can see there being certain services where a cash price will beat the network allowable, but these providers do walk a fine line. I can only speak with specific knowledge of bsbskc provider contracting guidelines, but the provider is explicitly restricted from billing ANYONE less than the billed amount sent to the carrier.

They are also not allowed to waive the patient's responsibility for deductible or copay (although a few do). The carriers are not in the business of giving away money. If they catch wind that a provider is charging less than what the carrier is being asked to pay, it would not go well. These providers fight to get more money out of the carriers each year come contracting time, so to accept less from a singular person...