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elspeech's Message:

I'm not an insurance expert by any means, but my impression is that the provider bills and the insurance then pays whatever they have agreed with the provider which is usually much less. I know my MS treatment is close to $100,000, but insurance pays less than 1/3 of that and I pay nothing, since it is considered major medical. Not sure what happens to the extra 2/3 that is billed. Does the drug company eat it, or more likely, is the drug company really overcharging by 2/3?

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Discussion Review (newest messages first)
1totravel 12-12-2020 09:53 AM

Yes, I believe districts do know how much each employee costs, insurance wise. It has been a topic of discussion at my district when they consider raising our rates, going out to bid (or not) on other insurance companies, etc.

juliet4 12-07-2020 10:06 AM

That cost $953.00. Ouch! Then, I got another bill for 32.00. That was easier. Now that I have Medicare, cost for emergency room is only $75.00. Wish I had that in September!

TAOEP 12-06-2020 08:11 PM

Insurance companies has contracts with hospitals and other providers that govern how much they will pay for various services. The first thing that happens with your bill is that it gets knocked down to that amount. Then you are expected to pay any copay and/or percentage and the insurance pays the rest.

Perhaps the original amount was $10,000. Then, by the agreement $4000. Lucky you, no deductible, but your insurance covers 90% and you have to pay 10%. So the insurance company pays $3600 and you pay $400.

Sometimes there are problems when a doctor (or dentist) charges more than the "usual and customary" amount for a service. Occasionally the patient is liable to pay that excess amount. Other times, the agreement between the insurance company and the provider limits the charges to "usual and customary."

Unless your school district is self-insured and only uses an insurance company to handle the claims and paperwork, I don't think they are entitled to personally identifiable medical cost information (remember HIPAA!). I'm not sure exactly how it would work for a self-insured district. There might be an employee who sees more medical info, but that person would be bound by HIPAA not to share that info.

klarabelle 12-06-2020 08:04 PM

My aunt works in a doctor's office she is the office manager. I was telling her how bad I felt when I saw how much my doctors were being paid by my insurance. She told me not to feel bad that doctors get all types of incentives from insurance companies and actually get more money then you know.

elspeech 12-06-2020 07:03 PM

I'm not an insurance expert by any means, but my impression is that the provider bills and the insurance then pays whatever they have agreed with the provider which is usually much less. I know my MS treatment is close to $100,000, but insurance pays less than 1/3 of that and I pay nothing, since it is considered major medical. Not sure what happens to the extra 2/3 that is billed. Does the drug company eat it, or more likely, is the drug company really overcharging by 2/3?

Song of Joy 12-06-2020 03:32 PM

My insurance was billed $101,000 for my hip replacement surgery which was on an outpatient basis so no hospital care at all. My insurance paid about $15,000. Something is really wonky.

marguerite2 12-06-2020 03:23 PM

Dentist can bill any amount, but that is not what insurances pay. They have set procedure payments and that is what the insurance will pay the dentist.

If the dentist is a participating provider all is good. The problem comes in when your dentist is not a participating provider. Then you can legally be billed for what the insurance didn't cover.

The district won't see your individual bill for dental or medical. HIPPA prevents that.

kahluablast 12-06-2020 03:20 PM

Connie, I am being nosy, but are you saying your surgery cost you $33000 out of pocket after Medicare and supplemental? I am totally taken back by that. I know for my uncle and my momís cancer treatments they had much better coverage than that. I was actually surprised how well things were paid. If you had to pay even close to $33000 that is outrageous. Unless you were having a face lift, maybe....something totally unnecessary, I could see that. But not for something medically necessary.

OP. I am sure that districts try to watch the end user cost, but it is probably balanced by cost to the district, too.

Haley23 12-06-2020 03:15 PM

Do schools have access to how much each individual employee spends? If so, that seems like kind of a scary thing! That makes me think they would try to push people who have health issues out.

I do know that this year when we got an explanation of our benefits, we were told that we were "extremely lucky" that our health insurance cost didn't go up, and something to the tune of, "Good job employees! This means people are making sure they're taking preventative measures to stay healthy!" AKA, the reason our price didn't go up is because not too many people are getting expensive procedures done. But IDK if they would know individuals who are getting expensive stuff done, or just how much money overall is being spent by the entire employee group. It seems like a privacy violation for them to know how much an individual is spending, although I guess maybe if it were just an amount and didn't say what the procedure was, that might be different.

ConnieWI 12-06-2020 02:43 PM

If your school uses a company (like Humana) for your insurance, your insurance company has a contract with doctors, hospitals, and dentists on how much is allowed for each procedure/visit/q-tip.

Wait until you reach Medicare age. I had surgery in August and the hospital bill was $41,000. I was in the hospital 24 hours, and this did not include the surgeon or anesthesiologist. Medicare and my supplemental insurance paid less than $8,000...and we wonder why health insurance is so expensive.

guest8593478 12-06-2020 10:01 AM

Do schools care about how much you spend on insurance? I recently moved to a new school, and I saw that my (new) dentist charged my insurance $600 for a cavity, x-rays, and an exam. I get the feeling that the dentist was really trying to charge for as much as possible. I'm probably going to switch from them. Do schools ever look at how much individual employees are spending on insurance and say "wow that person is expensive"?




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