7 ms·

I am sad to say this, but the insurance probably did not pay for the last $10K, that probably magically disappeared after the insurance paid for what they paid

I am sad to say this, but the insurance probably did not pay for the last $10K, that probably magically disappeared after the insurance paid for what they paid for. Again the explanation in the form of an example: My wife's dentist always puts in big bills to our insurance company. We then get a check in the mail along with records detailing how much the dentist billed, and then how much they are paying (though us). We then send the check along, and every time that we have then talked to them they say that we don't have to pay the remainder. This is just a negotiation tactic between our dentist and the insurance company. They are just trying to make sure that they capture every dollar that the insurance company will possibly pay. They never expected to get everything that they billed, that was more like an opening position in bargaining.

gfxgirl 5y ago
My dentist charges me the full amount. I then get a check for about 1/3rd from the insurance company. The dentist got the full amount. I work for a FAAMG company so supposedly my dental insurance is considered good. She billed $3000 for a deep cleaning and a crown and I paid her $3000. I got back $1162 from insurance
- lotsofpulp 5y ago
  Dental insurance is really weak insurance. It is mostly a mechanism that allows employers that can afford the paperwork of offering benefits to give you the benefit of being able to pay for your dental expenses with pre tax money. The maximum benefit amount is usually $1k to $2k. Maybe $3k at a generous employer. So if you ever had a really bad dental problem that exceeded those amounts, you are not insured from having to spend on dental problems that cost a lot of money. Contrast with health insurance, where due to out of pocket maximums, you can suffer a very expensive healthcare event, and you are insured against having to pay $500k for the bypass surgery or NICU stay.
  - hamburglar 5y ago
    Yes, as someone with extreme outlier dental costs, I have come to the realization that dental insurance is not insurance at all, it’s simply a routine maintenance plan. The point of insurance is to act as a buffer for large unexpected expenses, and dental explicitly excludes those from coverage.
  - gumby 5y ago
    I was hit on my bike and had some broken teeth and such. The dentist asked for my regular insurance carrier to pay for the work.
throwawayboise 5y ago
That confirms my suspicion that the business of present-day medicine is milking insurance companies and patients for every dollar that can be billed. The incentive is to keep patients sick, but alive, for as long as possible, hopefully managing to time the patient's death with the exhaustion of benefits/assets. I'm not saying that doctors have this goal. I am saying that this is what the system incentives are, and we all know how systems respond to incentives.
- btilly 5y ago
  Can I make it worse? Of course I can! Obamacare requires that at least 80% of money must go to medical costs. Profits and administration come out of the rest. So the only way to keep profits rising for insurance companies is to arrange for payments to rise at a predictable rate. And therefore insurance companies are happy to be complicit in rising medical costs, so long as it is predictable and other insurance companies wind up with comparable rates.
  - lotsofpulp 5y ago
    Pretty much all businesses earn a percentage of revenue as profit, so the same condition of higher revenue resulting in higher profit (all else being equal) exists in all businesses, regardless of the Affordable Care Act regulations. As long as there are competing businesses, and/or sufficiently low barriers to entry, then this mechanism to earn ever increasing profits is mitigated by the fact that a competitor will come in and take your business. Managed care organizations (MCOs), i.e. health insurance, has many competitors, UNH/Anthem/Cigna/Humana/CVS/Molina/Centene, etc. Either they are all colluding to keep prices going up, or they actually are trying to negotiate the best prices they can with healthcare providers for their customers in order to offer the best value to continue to win business. Considering all of the above companies have many years of single digit profit margins, almost all 5% and below, I would say the business line is quite competitive, and barring evidence of collusion, it seems spurious to claim they are profiting off of regulations requiring minimum medical loss ratios.
    - AnthonyMouse 5y ago
exhilaration 5y ago
If your wife's dentist in-network? Because if s/he is, then what you're describing is a "contractual write-off" - that's the amount the doctor or dentist has to give up because they contractually agreed to a negotiated rate with the insurance company. You may or may not see it on your final bill. I just happened to have paid a bill with that! Here it is, right out of the trash: https://imgur.com/a/NDFSeeF https://imgur.com/a/NDFSeeF These guys wanted a $708 "emergency room" payment for an urgent care visit (it was not an ER! We saw a physician's assistant, not even a real doctor!) plus $157 for a lab test. The insurance gave them $140, the remaining $690 is considered a contractual write-off.
refurb 5y ago
You last paragraph is exactly the problem. All the massive mark ups, etc are negotiations between hospital and insurer. The problem is that patients are being pulled into BS that normally they wouldn’t with other insurance. When my car got damaged, I just brought it to a garage and gave them my insurance details. If they didn’t get paid it wasn’t on me.
- dredmorbius 5y ago
  Auto repair shops face competition and few operate as networks which would deny you access across a broad geographical area. Those seeking repair have alternative and are not a risk of death or permanent disability when shopping for services. Hospitals don't. Patients are.
  - refurb 5y ago
    Those seeking repair have alternative and are not a risk of death or permanent disability when shopping for services. I most certainly have options for my in-network healthcare provides and no, a crappy auto repair can certainly include an element of risk of death or permanent disability. Maybe not to the same degree, but if some shop forgets to reconnect the brakes it ain’t good.
    - dredmorbius 5y ago
      In the case of healthcare services, it is the delay involved in shopping for a willing provider which imposes the constraint. Care delayed is itself a direct risk factor. In the case of an automobile repair, this is virtually never the case. Tow services if you've broken down on the road might be an exception, but few if any auto-repair issues (standard maintenance, component failure, collission repair) *will not suffer additional harm if repair is delayed by hours, or days, even months or years in many cases. That's not the case for medical treatment. This is fully independent of the quality or appropriateness of treatemnt / repair itself. I do hope I've made the distinction sufficiently clear.
      - 5y ago
short12 5y ago
That definitely sounds like lots of fraud and probably so e tax complications
skeeter2020 5y ago
It's not as dramatic but this is the same thing that happens when you have an automobile accident and need repairs. The cost to the insurance company is much higher than what you'd pay directly, but then you end up paying it through premiums with the added margin that goes to the insurance company. This is also a highly regulated market like healthcare, yet once again some of the most egregious behaviour is observed. The legislation in these industries reminds me of the jokes about central control on manufacturing by the USSR.
IG_Semmelweiss 5y ago
Two things to note. 1) >>>>>>>> and every time that we have then talked to them they say that we don't have to pay the remainder. This is actually in default of the contract between doctor and insurer. However, lots of physicians do it anyway. The minimum legal requirement is that physician must attempt to bill difference 3 times. If insurance audits and finds a pattern of these "writeoffs" it will claw back insurance claims. IN short, insurance doesn't want to pay more than the patient. Of course, the doctor will side with the patient, and then lose a bunch of money during an audit. 2) >>>>>This is just a negotiation tactic between our dentist and the insurance company. They are just trying to make sure that they capture every dollar that the insurance company will possibly pay. You get half right. Its not a negotiation tactic. Its straight up capturing 100% of the potential reimbursement. Doctors have an extremely hard time maintaining different pricing for every contract, by CPT code. If doctors could easily maintain different pricing for different services, they would, because it would "true up" their AR Aging. Therefore they instead have 1 price, the highest possible, and just work to writeoff any underpayments. This is why healthcare costs keep going up. Doctors have no market incentive, they only have a maximizing incentive. That's why an increasing number of doctors do not take medicare or medicaid. Something as simple as making doctor visits ("fee for service") payable via pre-tax dollars would probably make a big dent in the insurance game. HSAs were a step in the right direction, but its incredibly expensive from the employer perspective. You can have an stellar insurance plan and an avg one that offers HSA, and the premiums for the latter will be more expensive! Source: Working in a healthcare startup that lets doctors not play these games. Former exec for brick and mortar healthcare companies.

gfxgirl 5y ago

My dentist charges me the full amount. I then get a check for about 1/3rd from the insurance company. The dentist got the full amount. I work for a FAAMG company so supposedly my dental insurance is considered good. She billed $3000 for a deep cleaning and a crown and I paid her $3000. I got back $1162 from insurance

lotsofpulp 5y ago
Dental insurance is really weak insurance. It is mostly a mechanism that allows employers that can afford the paperwork of offering benefits to give you the benefit of being able to pay for your dental expenses with pre tax money. The maximum benefit amount is usually $1k to $2k. Maybe $3k at a generous employer. So if you ever had a really bad dental problem that exceeded those amounts, you are not insured from having to spend on dental problems that cost a lot of money. Contrast with health insurance, where due to out of pocket maximums, you can suffer a very expensive healthcare event, and you are insured against having to pay $500k for the bypass surgery or NICU stay.
- hamburglar 5y ago
  Yes, as someone with extreme outlier dental costs, I have come to the realization that dental insurance is not insurance at all, it’s simply a routine maintenance plan. The point of insurance is to act as a buffer for large unexpected expenses, and dental explicitly excludes those from coverage.
- gumby 5y ago
  I was hit on my bike and had some broken teeth and such. The dentist asked for my regular insurance carrier to pay for the work.

throwawayboise 5y ago

That confirms my suspicion that the business of present-day medicine is milking insurance companies and patients for every dollar that can be billed. The incentive is to keep patients sick, but alive, for as long as possible, hopefully managing to time the patient's death with the exhaustion of benefits/assets. I'm not saying that doctors have this goal. I am saying that this is what the system incentives are, and we all know how systems respond to incentives.

btilly 5y ago
Can I make it worse? Of course I can! Obamacare requires that at least 80% of money must go to medical costs. Profits and administration come out of the rest. So the only way to keep profits rising for insurance companies is to arrange for payments to rise at a predictable rate. And therefore insurance companies are happy to be complicit in rising medical costs, so long as it is predictable and other insurance companies wind up with comparable rates.
- lotsofpulp 5y ago
  Pretty much all businesses earn a percentage of revenue as profit, so the same condition of higher revenue resulting in higher profit (all else being equal) exists in all businesses, regardless of the Affordable Care Act regulations. As long as there are competing businesses, and/or sufficiently low barriers to entry, then this mechanism to earn ever increasing profits is mitigated by the fact that a competitor will come in and take your business. Managed care organizations (MCOs), i.e. health insurance, has many competitors, UNH/Anthem/Cigna/Humana/CVS/Molina/Centene, etc. Either they are all colluding to keep prices going up, or they actually are trying to negotiate the best prices they can with healthcare providers for their customers in order to offer the best value to continue to win business. Considering all of the above companies have many years of single digit profit margins, almost all 5% and below, I would say the business line is quite competitive, and barring evidence of collusion, it seems spurious to claim they are profiting off of regulations requiring minimum medical loss ratios.
  - AnthonyMouse 5y ago

exhilaration 5y ago

If your wife's dentist in-network? Because if s/he is, then what you're describing is a "contractual write-off" - that's the amount the doctor or dentist has to give up because they contractually agreed to a negotiated rate with the insurance company. You may or may not see it on your final bill. I just happened to have paid a bill with that! Here it is, right out of the trash: https://imgur.com/a/NDFSeeF https://imgur.com/a/NDFSeeF These guys wanted a $708 "emergency room" payment for an urgent care visit (it was not an ER! We saw a physician's assistant, not even a real doctor!) plus $157 for a lab test. The insurance gave them $140, the remaining $690 is considered a contractual write-off.

refurb 5y ago

You last paragraph is exactly the problem. All the massive mark ups, etc are negotiations between hospital and insurer. The problem is that patients are being pulled into BS that normally they wouldn’t with other insurance. When my car got damaged, I just brought it to a garage and gave them my insurance details. If they didn’t get paid it wasn’t on me.

dredmorbius 5y ago
Auto repair shops face competition and few operate as networks which would deny you access across a broad geographical area. Those seeking repair have alternative and are not a risk of death or permanent disability when shopping for services. Hospitals don't. Patients are.
- refurb 5y ago
  Those seeking repair have alternative and are not a risk of death or permanent disability when shopping for services. I most certainly have options for my in-network healthcare provides and no, a crappy auto repair can certainly include an element of risk of death or permanent disability. Maybe not to the same degree, but if some shop forgets to reconnect the brakes it ain’t good.
  - dredmorbius 5y ago
    In the case of healthcare services, it is the delay involved in shopping for a willing provider which imposes the constraint. Care delayed is itself a direct risk factor. In the case of an automobile repair, this is virtually never the case. Tow services if you've broken down on the road might be an exception, but few if any auto-repair issues (standard maintenance, component failure, collission repair) *will not suffer additional harm if repair is delayed by hours, or days, even months or years in many cases. That's not the case for medical treatment. This is fully independent of the quality or appropriateness of treatemnt / repair itself. I do hope I've made the distinction sufficiently clear.
    - 5y ago

short12 5y ago

That definitely sounds like lots of fraud and probably so e tax complications

skeeter2020 5y ago

It's not as dramatic but this is the same thing that happens when you have an automobile accident and need repairs. The cost to the insurance company is much higher than what you'd pay directly, but then you end up paying it through premiums with the added margin that goes to the insurance company. This is also a highly regulated market like healthcare, yet once again some of the most egregious behaviour is observed. The legislation in these industries reminds me of the jokes about central control on manufacturing by the USSR.

IG_Semmelweiss 5y ago

Two things to note. 1) >>>>>>>> and every time that we have then talked to them they say that we don't have to pay the remainder. This is actually in default of the contract between doctor and insurer. However, lots of physicians do it anyway. The minimum legal requirement is that physician must attempt to bill difference 3 times. If insurance audits and finds a pattern of these "writeoffs" it will claw back insurance claims. IN short, insurance doesn't want to pay more than the patient. Of course, the doctor will side with the patient, and then lose a bunch of money during an audit. 2) >>>>>This is just a negotiation tactic between our dentist and the insurance company. They are just trying to make sure that they capture every dollar that the insurance company will possibly pay. You get half right. Its not a negotiation tactic. Its straight up capturing 100% of the potential reimbursement. Doctors have an extremely hard time maintaining different pricing for every contract, by CPT code. If doctors could easily maintain different pricing for different services, they would, because it would "true up" their AR Aging. Therefore they instead have 1 price, the highest possible, and just work to writeoff any underpayments. This is why healthcare costs keep going up. Doctors have no market incentive, they only have a maximizing incentive. That's why an increasing number of doctors do not take medicare or medicaid. Something as simple as making doctor visits ("fee for service") payable via pre-tax dollars would probably make a big dent in the insurance game. HSAs were a step in the right direction, but its incredibly expensive from the employer perspective. You can have an stellar insurance plan and an avg one that offers HSA, and the premiums for the latter will be more expensive! Source: Working in a healthcare startup that lets doctors not play these games. Former exec for brick and mortar healthcare companies.