SUMMARY:  A lot of us are newly on high-deductible plans. Those plans work differently for different insurance companies: some want you to pay the entire sticker price for a procedure until you meet your deductible, while some want you to pay the contracted or negotiated rate for an in-network procedure, which is generally lower, and sometimes a lot lower. Know which your plan calls for, and … be sure what you’re paying for before you write a check.



One of my friends who’s newly on a high-deductible plan told me the other day about an increasingly common occurrence: She got a bill for an episode of care that seemed incredibly high to her under the circumstances. She called the provider and was told “Oh, no, you don’t have to pay that.” No explanation was offered.

A similar thing happened with treatment her husband received. So … what should you do?

One suggestion: call both provider and payer (insurance company) to find out what happened. Do you really need to pay? Are you supposed to pay the charged price, or should you expect to get the lower, contracted rate?

Call. Ask. Take notes. Take names.

Here’s a snippet from a recent Reuters piece

” ‘Our guidance is to not pay until you get your explanation of benefits,’ says Mark Smithson, vice president of provider process and services at health insurer Humana Inc.

“Insurance companies put every claim through a repricing engine, where they figure out the difference between what the provider charges and the negotiated discount rate – and that is supposed to happen even if you have not met your deductible.

“Yet sometimes people get bills from doctors and pay them without thinking about it.

” ‘Consider any bill from a provider as the beginning of a negotiation rather than like a bill from a plumber or Visa,” advises [Evan] Dudik, [a patient whose bills were renegoatiated].

“And sometimes the repricing never happens. Pat Palmer, founder of Medical Billing Advocates of America, says she has seen cases where insurance companies did not bother to put bills through repricing, since they were not paying them anyway.

” ‘They take whole amount and apply it to deductible, and they neglect to put on the explanation of benefits that there is a different amount that you should be paying,’ Palmer says. ‘We have had some insurance companies tell us that “it costs us money to put a claim through repricing, so we just process the claim.”‘” Beth Pinsker, via YOUR MONEY-Beware of pitfalls in high-deductible health plans | Reuters.

Jeanne Pinder

Jeanne Pinder  is the founder and CEO of ClearHealthCosts. She worked at The New York Times for almost 25 years as a reporter, editor and human resources executive, then volunteered for a buyout and founded...