Are there health providers that still charge insurance contract rates when Blue Cross denies coverage?

[hawiovi]

It is bad enough to have a doctors procedure deemed "not medically necessary" by the insurance company, but what really makes me mad is when the provider (usually a hospital) then bills the much higher "amount charged" (sticker price) instead of the Blue Cross contracted rate "allowed amount".

Here is Michigan the difference can be 4 to 1 or higher. We a have screwey no fault car insurance system here where all medical bills from car accidents are paid for by manatory car insurance fees, resulting in the highest car insurance rates in the country. There is an effort to overturn this law and the TV add say the hospitals charge the state insurance pool 4 or more times what they charge say Blue Cross. The hospitals and doctors are running counter ads, so I expect they are making out like bandits on this car insurance scheme. But as a result I suspect the sticker price for procedures are much higher than the rest of the country, and the Blue Cross contract amount as a result. Thus my question may be a bit more important here in michigan than the rest of the country.

Here is a case at hand:
1) I had a persistently sore knee and wondered if I needed meniscus surgery. I verified that that the hospital and doctor took my Blue Cross Blue Shield of Michigan (BCBSM) insurance. The doctor chose to take 2 x-rays, one of each knee. The reason, I believe, was so he could compare the space between the knee bones back-to-back. BCBSM paid for one x-ray at $12 allowed (contract amount) for $40 "amount charged" (sticker price). The other x-ray was rejected as not medically necessary. I was charged the full $40. I worked with the hospital and BCBSM and they won't budge.

There is an appeal process but I want to get a sense of what others think of this practice before I go through that bureaucracy.

It seems to me that is a hospital and doctor accept BCBSM, and they use a procedure that is rejected, they should: 1) fight for me against BCBSM, 2) and if they still loose they should at least bill me the lower, contract price. I told them this on the phone and let me just say they did not agree.

We have a lot of health care providers around here (Detroit) and I would think that in order to gain customers someone would have such a common sense and fair policy.

Thanks for any insights.

[abelard29]

First of all, your information is WAY incorrect. Michigan doesn't even rate in the top ten, for car insurance rates. Your system isn't screwey at all - it's just very STRONGLY no-fault. All no fault means, is you buy your own insurance, to cover your own injuries. YOU choose how much coverage you have, period.

Michigan, in fact, does NOT have higher medical bills than other parts of the country, they're actually not even in the top third. Providers are allowed to charge whatever they WANT to charge - it's up to YOU to try to shop around, and be prudent about what services you choose to buy.

If you had the doctor take an Xray of an uninjured knee - that was unnecessary treatment, pretty clearly. Your beef is with this doctor.

Buying a service you don't really need, just because you think someone ELSE is paying for it, escalates claims costs and creates EXACTLY the problem you are complaining about.

Buy your medical care as if YOU are paying for it. If EVERYONE did that, insurance rates would go way down.

You can always file the complaint with your state medical board.

[weiford]

Hospitals can charge what they want. That is why the hospitals have an average profit margin of 6% while the insurance company has an average profit of 2%

[eoforwic]

Just because your hospital and doctor accept your insurance, does not mean they will pay.

When you went into the hospital for these x-rays, before they did this, you signed a form that stated:
"If insurance does not pay, I will be personally responsible for any treatment". I guarantee you signed this, or otherwise, they would not have done the x-rays, so you are on the hook.

It was NOT medically necessary to have the 1 good knee x-rayed for comparison. That was for the doctors benefit, not yours. Your insurance covered for a x-ray on your bad knee.

I agree with the other poster, that you should be fighting with the doctor for suggesting that both knees being x-rayed. .

good luck