May 21, I have been in contact with CareFirst since December of trying to get claims paid.
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It may be difficult, if not impossible, to find out the price of health care ahead of time, especially for complex services such as elective surgery.
There are ways to protect yourself against being blindsided by a huge bill. Rachel Collier, 41, a sales executive from San Jose, Calif. She went to the emergency room of a hospital in the Cigna network and was given blood tests, a CT scan, and an IV.
She went home with a couple of medications, and the pain let up after a few hours. He needs two common blood tests every six months to monitor the safety of a cholesterol-lowering medication that he takes.
None of the three local network labs he called was able to supply his in-network price for the tests. Jerry Diffley, who was then director of billing compliance for Quest Diagnostics, one of the labs involved, says that it had contracts with 75 Aetna plans.
See our advice on HMOs vs. That can leave patients on the hook for the balance—the amount not reimbursed by their plan. Julie Lindgren, 47, a nuclear-medicine technologist from Seattle, chose an out-of-network doctor and hospital in when she was facing a risky surgery to treat kidney cancer.
The surgery was a success, but the bills that came afterward were a shock. What is a reasonable price? Traditionally, insurers have based UCR prices on what providers charge.
Some rely on proprietary internal numbers, and some use national data collected and analyzed by Fair Health, a nonprofit organization based in New York City.
A March investigation by the New York State Department of Financial Services found that most plans that use this method pay between percent and percent of what Medicare pays. We used an online calculator at fairhealthconsumer.
So a plan that based its 60 percent reimbursement on percent of Medicare would leave patients with a balance bill more than twice as high: Of course, the financial damage can be even worse when, as frequently happens, the out-of-network hospital or doctor charges more than the fair price—sometimes a lot more.
We spoke with a man in a Northeastern state whose wife chose an out-of-network neurosurgeon for a complex procedure to correct a severe case of scoliosis.
She asked not to be identified because she is working with a state consumer advocate to negotiate a settlement. Bills out of the blue An obvious way to avoid getting hit with stratospheric out-of-network bills is not to use out-of-network providers.
Sometimes, especially in the hospital, you can be seen by an out-of-network provider without even knowing it. Annmarie Bragdon, 41, from Farmington Hills, Mich.
And the insurance company knows they're going to pay what they're going to pay.AUTHORS This Health Care Report, “The Consumer Reimbursement System Is Code Blue,” was prepared by the Attorney General’s Healthcare Industry Taskforce as follows. Background.
Health insurance exchanges in the United States expand insurance coverage while allowing insurers to compete in cost-efficient ways and help them to comply with consumer protection laws. Exchanges are not themselves insurers, so they do not bear risk themselves, but they do determine which insurance companies participate in the exchange.
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