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>Fast forward a few weeks, and they got the bill. They ended up charging his insurance $2,200, and the insurance company valued the trip at $3,500 (presumably t

>Fast forward a few weeks, and they got the bill. They ended up charging his insurance $2,200, and the insurance company valued the trip at $3,500 (presumably to bump up his co-pay? not sure). This makes no sense. Insurance companies NEVER pay more than they are asked to pay. It's half the reason why medical billing is such a royal pain. A doctor or pharmacy knows they've left money on the table if they get exactly what they ask for from the insurance company. And there's no way that increasing the coinsurance for the patient (co-pays are fixed dollar amounts so there's no "bumping it up") does anything for the insurance company. If your coinsurance is 20%, the insurance company is still paying paying 80% whether that's 80% of the $2200 or the $3500. Even if the person had an HDHP plan and was paying all of that out of pocket, all the insurance company raising the the cost from 2200 to 3500 would have done was move the patient $1300 closer to their deductible and out of pocket limits and make it more likely the insurance company is paying out more money in the future. More likely is that the ER billed $3500 and the insurance's allowed amount was $2200.

zdragnar 4y ago
This was a point of contention for a minute on the radio show- the host was flummoxed as well that the insurance company "valued" the trip higher than what the hospital billed for. It's possible that the (clearly upset) father on the phone had the story mixed up, but I'm not sure that NY law would allow an estimate for a medical bill to end up being billed at more than double the original estimate. Hell, in my state car repairs can't exceed 10% of the original estimate without approval from the customer. Either way it shakes out, if the story is real the state commissioners are going to have fun with it.
- HCDevid 4y ago
  On US healthcare bills there is: Billed Amount - what the provider/health system tags as the “billed amount” Allowed Amount - what the insurer sets as the actual total $ allowed to change hands for the visit Patient Responsibility - the portion the patient is responsible for. The Billed Amount is supposed to exceed the Allowed Amount by 2.5-5x typically so that the Allowed Amount the insurer/provider has negotiated “saves” money thanks to Insurance ostensibly in how the bill is displayed. Put differently, your provider/health system is supposed to per the billing contract put in an inflated value well in excess of expected payment so your insurance company can reduce it so you can “save money” superficially on your bill. It is as smoke and mirrors as it sounds. Sounds like your provider / HS forgot healthcare billing 101 in this case. The Billed - Allowed Amount value is also usually called Contractual Adjustment

zdragnar 4y ago

This was a point of contention for a minute on the radio show- the host was flummoxed as well that the insurance company "valued" the trip higher than what the hospital billed for. It's possible that the (clearly upset) father on the phone had the story mixed up, but I'm not sure that NY law would allow an estimate for a medical bill to end up being billed at more than double the original estimate. Hell, in my state car repairs can't exceed 10% of the original estimate without approval from the customer. Either way it shakes out, if the story is real the state commissioners are going to have fun with it.

HCDevid 4y ago
On US healthcare bills there is: Billed Amount - what the provider/health system tags as the “billed amount” Allowed Amount - what the insurer sets as the actual total $ allowed to change hands for the visit Patient Responsibility - the portion the patient is responsible for. The Billed Amount is supposed to exceed the Allowed Amount by 2.5-5x typically so that the Allowed Amount the insurer/provider has negotiated “saves” money thanks to Insurance ostensibly in how the bill is displayed. Put differently, your provider/health system is supposed to per the billing contract put in an inflated value well in excess of expected payment so your insurance company can reduce it so you can “save money” superficially on your bill. It is as smoke and mirrors as it sounds. Sounds like your provider / HS forgot healthcare billing 101 in this case. The Billed - Allowed Amount value is also usually called Contractual Adjustment