The Specific Question

During medical emergency or urgent situations all we really want is proper medical and timely care. We assume that the hospital and doctors will do the right thing. That is to take our insurance and don’t overcharge us. Fortunately, it does happen that way most of the times. Then there are some times when we assume taking our insurance means they are participating in our insurance network. Unfortunately, that is often not the case. Taking our insurance simply means that the hospital or doctor will bill our insurance. If they get any payment it will be deducted from their total bill and send us the balance due.

If you are unsure the specific question to ask is exactly this: Are you a participating provider in my insurance network? To your surprise the answer to this question may be this “ I don’t participate in any insurance network.” So the next reasonable question will be: how much do you charge for this service? I am willing to bet that most doctors, and even hospitals will not give you an answer. They simply don’t know.

You want to ask: how can that be?
The answer is rather simple. In the case of a hospital the clinicians simply use an internal billing code, that is often not a code for the actual procedure; it is simply a computer system code that transfers into insurance procedure code a few days later in the computer software.
In the case of doctors, the billing company or office does the billing. The doctor may even know the actual codes and charges, but in most cases they will not disclose that information to the patient.
At this point the best one can do is getting a promise from the doctor that his or her changes are reasonable to our services.

Of course planned visits, such as office consultation, radiology services, or surgery can be financially pre arranged. It does take some work, and often putting a pressure on each party. A person need to get a CPT (procedure code), and diagnosis code from the doctor’s office. Then provide that to the insurance company and request the allowed payment amount from the insurance. Some will give it just for asking, while others have to be pressured to do so.

One thought on “The Specific Question

  1. It is seldom possible to discuss procedure codes with the practitioner providing a service, especially in an emergency room. In large clinical practices, the individual physician probably doesn’t know what his/her services cost. You can query your health plan in advance with a procedure code and a diagnosis code, and still get a denial because the “place of service” is not covered for the procedure as reported.

    Also, a healthplan may employ different networks for various products that it sells. A doctor can “participate” with the insurer but not be “in network” for some of its PPOs or POS plans.

Leave a Reply

Your email address will not be published. Required fields are marked *

The authentication requires knowledge of second grade arithmetic; please resolve the equation below, prior to logging in with your account: * Time limit is exhausted. Please reload CAPTCHA.