Are HDHP policyholders actually "disallowed" from self-paying?

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Artful Dodger
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Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by Artful Dodger »

paws wrote: Wed May 31, 2023 2:50 pm
Artful Dodger wrote: Tue Apr 25, 2023 4:01 pm I'll be interested in finding out what your EOB says, how much discount you received, and how that compared to the cash pay estimate you were quoted.
I received the EOB and bill and am here to update you.

As a quick recap, I previously:
1) called the provider ahead of the visit and was estimated a $200-250 cash price
2) asked the office admin immediately after my visit while still in the office. She looked at her computer and said the charge would be (I think) ~$210. I no longer recall the exact amount, sorry, but I remember it was unsurprising vis a vis the phone estimate.

Today horizonblue.com tells me (* edited to hopefully not doxx myself):

Image

A mystery $325 appears.

Image


A $122.37 discrepancy. Where did that come from?

Let's look at the provider's bill.
Image

Each line item has an identical 9 character prefix, no idea if it's sensitive so I snipped but if you're interested please DM me. The part I left, 99204, appears to be the CPT "Under New Patient" procedure code.

While I didn't bring a stopwatch to my visit (feels like I should next time) I recall it being closer to 10 minutes, 15 tops. It was a routine visit to get a doxy prescription, no tools, no lights/lenses/taking pictures, just talking. The time with the provider was nowhere near 45-59 mins. Why was it billed that way?

EDIT: I'm also curious about this $122.37 "adjustment" on the last line of the bill. @Artful Dodger Is this what you mean when you say the doctor submits a bill and the insurance company doesn't pay the full amount?

I find this all terribly opaque and resent being forced into such an ugly and complicated "system" that seems to benefit middlemen, whom have seemingly no relationship on patient outcomes.
The $122.37 is the PPO network / negotiated discount. I wouldn't call it "ugly" though possibly complicated. It does work in your favor because the provider having agreed to participate in the network has accepted the insurance company discount and has agreed not to bill you above the agreed upon charge.
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paws
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Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by paws »

toddthebod wrote: Wed May 31, 2023 3:11 pm
paws wrote: Wed May 31, 2023 2:50 pm While I didn't bring a stopwatch to my visit (feels like I should next time) I recall it being closer to 10 minutes, 15 tops. It was a routine visit to get a doxy prescription, no tools, no lights/lenses/taking pictures, just talking. The time with the provider was nowhere near 45-59 mins. Why was it billed that way?
They are allowed to bill based on the entire time spent on you that day, including charting, reviewing records, etc.
Sure, I understand there is additional work beyond the time in the room. It's interesting that the cash price estimate they gave me was different from the insurance price by 30%, but "post adjustment" ends up being similar.

I presume that's not a coincidence. I would be interested to read a provider/insurance company contract (or "plan" agreement), are there any I can download?
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paws
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Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by paws »

jeam3131 wrote: Wed May 31, 2023 3:19 pm The complexity definitions are put forth my CMS (medicare), which all insurances follow.
If "all insurances follow CMS anyway", why do providers use AMA CPT codes as evidenced by my bill?

jeam3131 wrote: Wed May 31, 2023 3:19 pm Might be worthwhile to watch some YouTube videos to understand the process.
Thank you. If you are willing to share any you'd recommend I'd be obliged
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neurosphere
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Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by neurosphere »

paws wrote: Wed May 31, 2023 2:50 pm While I didn't bring a stopwatch to my visit (feels like I should next time) I recall it being closer to 10 minutes, 15 tops. It was a routine visit to get a doxy prescription, no tools, no lights/lenses/taking pictures, just talking. The time with the provider was nowhere near 45-59 mins. Why was it billed that way?
1) The "time" in the title is a shorthand. Time is just one way they can bill the visit, but if they use time...

2) It's not face to face time or time in the room. It's the total time on the date of the visit that the provider did work for you:
-- reviewing your chart to see what information exists prior to the visit, such as meds, allergies, forms you've filled out, other medical records
-- time in the room
-- time writing your note or discussing the case with others
-- placing orders
-- review labs if they come back that day
-- calling pharmacies or other entities

When I was a physician I had very long days because I could only bill for my time on the day I saw the patient (in many cases). So I had to make sure to get up early to review the chart, and stay late to make sure all the notes were written. Otherwise my employer did not get paid for my time and the bean counters did not credit me for the work.
If you have to ask "Is a Target Date fund right for me?", the answer is "Yes" (even in taxable accounts).
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paws
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Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by paws »

neurosphere wrote: Wed May 31, 2023 4:45 pm
paws wrote: Wed May 31, 2023 2:50 pm While I didn't bring a stopwatch to my visit (feels like I should next time) I recall it being closer to 10 minutes, 15 tops. It was a routine visit to get a doxy prescription, no tools, no lights/lenses/taking pictures, just talking. The time with the provider was nowhere near 45-59 mins. Why was it billed that way?
1) The "time" in the title is a shorthand. Time is just one way they can bill the visit, but if they use time...

2) It's not face to face time or time in the room. It's the total time on the date of the visit that the provider did work for you:
-- reviewing your chart to see what information exists prior to the visit, such as meds, allergies, forms you've filled out, other medical records
-- time in the room
-- time writing your note or discussing the case with others
-- placing orders
-- review labs if they come back that day
-- calling pharmacies or other entities

When I was a physician I had very long days because I could only bill for my time on the day I saw the patient (in many cases). So I had to make sure to get up early to review the chart, and stay late to make sure all the notes were written. Otherwise my employer did not get paid for my time and the bean counters did not credit me for the work.
Thank you, I understand that there is more time than what goes into the actual face to face portion.

FWIW this was a first time visit. There was no chart to review, no lab work to look at, no orders to place. There was a prescription, which was the point of the visit, and of course that took time. I know it was automated because I didn't even get a paper prescription.

I just find it disappointing that the AMA has 10,000 procedure codes, but the provider pushed all this "total time" behind a solitary procedure code. I'd have preferred an itemized bill by default with a higher level of detail. As a consultant myself I am very detailed with billing because it's something I consider important to my client relationships. And yes, it takes time, but I know my clients value the transparency.
Last edited by paws on Wed May 31, 2023 5:28 pm, edited 1 time in total.
hachiko
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Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by hachiko »

As far as practical considerations, are you upset about the total amount you're paying? If so, focus on that and not how it was charged. Of course, they told you the price was an estimate, and the fact that it didn't come out exactly to the estimate doesn't exactly mean the estimate was "wrong".

If you're just generally upset about medical billing practices, amounts charged, etc., you are in good company, and I put myself in that category, but I'm not sure there's much you can really do to solve that.
Made money. Lost money. Learned to stop counting.
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paws
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Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by paws »

Artful Dodger wrote: Wed May 31, 2023 3:32 pm The $122.37 is the PPO network / negotiated discount. I wouldn't call it "ugly" though possibly complicated. It does work in your favor because the provider having agreed to participate in the network has accepted the insurance company discount and has agreed not to bill you above the agreed upon charge.
If my deductible reflected this fantasy $122.73 "discount" I might have more sympathy for it working in my favor, but I just checked and nope, it's not included. The reason I find it ugly is because this is a vestige of a negotiating game dependent on the patient, being played around the patient, but a game that doesn't improve medical outcomes. (or does it? I'll be happy to learn if you disagree)
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paws
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Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by paws »

hachiko wrote: Wed May 31, 2023 5:14 pm As far as practical considerations, are you upset about the total amount you're paying? If so, focus on that and not how it was charged. Of course, they told you the price was an estimate, and the fact that it didn't come out exactly to the estimate doesn't exactly mean the estimate was "wrong".

If you're just generally upset about medical billing practices, amounts charged, etc., you are in good company, and I put myself in that category, but I'm not sure there's much you can really do to solve that.

Thank you @hachiko :)
Upset is maybe too strong a word but yeah, I'm experiencing American healthcare for the first time in a while, and finding the schism between quality of care (which is good) and the opaque system + middlemen all leeching off it perplexing and frustrating. Sooo many markups, complexity, and costs that don't clearly benefit the patient.

[Unnecessary comment removed by moderator oldcomputerguy]
Lyrrad
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Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by Lyrrad »

hachiko wrote: Mon Apr 24, 2023 7:53 pm
I'm not sure how Cigna benefits directly from this. It would be the doctor doing better on the lab test charges having you go through insurance. Cigna does benefit in part in that they're presumably able to decrease the margin on the visit cost and increase the margin on the lab work. Whether that works out better for the doctor or not would depend on the actual numbers, but other than Cigna having good rates, I don't see how it benefits them.
I understand some pharmacy benefit plans have rebates or “kickbacks” from drug manufacturers. So, if you pay $500 for a medication under insurance, the manufacturer may pay the insurer some percentage of the price. I’ve had drugs cost most than the list price under insurance, so the pharmacy shows a negative insurance discount.

I see a webpage that claims these rebates averaged 24% for brand name drugs and 13% for specialty drugs in 2019.
Artful Dodger wrote: Tue Apr 25, 2023 2:09 pm
If you reread the first post, the OP says he was never told what the insurance company would pay. He only reported an estimated cost if paid in cash.
"When I called ahead to inquire about my derma visit, she said self-pay cash price was $200-250, but she wouldn't/couldn't say the insurance side."
Negotiated prices can and do change on some plans multiple times a year. I’ve had identical labs and medications change price, sometimes significantly when billed repeatedly over a year.

I also tried calling the insurer once with the exact procedure code, but the actual negotiated amount ended up being less than what I was quoted.
Yarlonkol12
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Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by Yarlonkol12 »

I don't know the answer, but my insurance also has a pharmacy plan with a big chain pharmacy. The meds we get are 150% more expensive with insurance vs the GoodRX price, so we just use GoodRX but it requires a manual adjustment by pharmacy each time we pick up

I'm just lucky I thought to check as it saves a few thousand per year, I imagine some folks just go with the insurance rate for pharma because they didn't check, seems messed up to me
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AnEngineer
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Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by AnEngineer »

paws wrote: Wed May 31, 2023 5:17 pm
Artful Dodger wrote: Wed May 31, 2023 3:32 pm The $122.37 is the PPO network / negotiated discount. I wouldn't call it "ugly" though possibly complicated. It does work in your favor because the provider having agreed to participate in the network has accepted the insurance company discount and has agreed not to bill you above the agreed upon charge.
If my deductible reflected this fantasy $122.73 "discount" I might have more sympathy for it working in my favor, but I just checked and nope, it's not included. The reason I find it ugly is because this is a vestige of a negotiating game dependent on the patient, being played around the patient, but a game that doesn't improve medical outcomes. (or does it? I'll be happy to learn if you disagree)
The provider is incentivized to bill insurance as much as possible due to the variatuon in the allowed amount by insurer. For some things there can be huge variation (probably not so much for normal visits). They only expect to get something around the post discount price, which is probably why they'd be willing to give a similar discount to cash payers. It'll get reduced automatically by the insurer, so there's no penalty for listing a higher price, but a chance you might get more. Most people aren't on HDHPs, so the patient doesn't see a short-term cost impact of the practice.
jeam3131
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Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by jeam3131 »

paws wrote: Wed May 31, 2023 4:40 pm
jeam3131 wrote: Wed May 31, 2023 3:19 pm The complexity definitions are put forth my CMS (medicare), which all insurances follow.
If "all insurances follow CMS anyway", why do providers use AMA CPT codes as evidenced by my bill?

jeam3131 wrote: Wed May 31, 2023 3:19 pm Might be worthwhile to watch some YouTube videos to understand the process.
Thank you. If you are willing to share any you'd recommend I'd be obliged
Billing guidelines that determine level of service and CPT codes are two separate things.
Young Boglehead
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Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by Young Boglehead »

paws wrote: Wed May 31, 2023 5:07 pm
neurosphere wrote: Wed May 31, 2023 4:45 pm
paws wrote: Wed May 31, 2023 2:50 pm While I didn't bring a stopwatch to my visit (feels like I should next time) I recall it being closer to 10 minutes, 15 tops. It was a routine visit to get a doxy prescription, no tools, no lights/lenses/taking pictures, just talking. The time with the provider was nowhere near 45-59 mins. Why was it billed that way?
1) The "time" in the title is a shorthand. Time is just one way they can bill the visit, but if they use time...

2) It's not face to face time or time in the room. It's the total time on the date of the visit that the provider did work for you:
-- reviewing your chart to see what information exists prior to the visit, such as meds, allergies, forms you've filled out, other medical records
-- time in the room
-- time writing your note or discussing the case with others
-- placing orders
-- review labs if they come back that day
-- calling pharmacies or other entities

When I was a physician I had very long days because I could only bill for my time on the day I saw the patient (in many cases). So I had to make sure to get up early to review the chart, and stay late to make sure all the notes were written. Otherwise my employer did not get paid for my time and the bean counters did not credit me for the work.
Thank you, I understand that there is more time than what goes into the actual face to face portion.

FWIW this was a first time visit. There was no chart to review, no lab work to look at, no orders to place. There was a prescription, which was the point of the visit, and of course that took time. I know it was automated because I didn't even get a paper prescription.

I just find it disappointing that the AMA has 10,000 procedure codes, but the provider pushed all this "total time" behind a solitary procedure code. I'd have preferred an itemized bill by default with a higher level of detail. As a consultant myself I am very detailed with billing because it's something I consider important to my client relationships. And yes, it takes time, but I know my clients value the transparency.
The point of billing by time is that it’s simpler, if you see 30+ patients it can take an enormous amount of time if you don’t bill by time. That’s why they changed the coding recently.
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celia
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Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by celia »

paws wrote: Wed May 31, 2023 2:50 pm I received the EOB and bill and am here to update you.

Image

A $122.37 discrepancy. Where did that come from?
The insurance was billed $325 but only $203.63 is allowed since that is the contracted rate between the dr and insurance. The dr wrote off the excess $122.37 balance.

Since all the dr did was fill a prescription, insurance didn’t pay for the office visit and you owe the $202.37.
Let's look at the provider's bill.
Image
You appeared to pay $30 upfront and now just owe the remaining $172.63.

Easy to understand since each column is labeled.
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rob
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Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by rob »

It's one of those tricks that health care in the US has managed to avoid legislation... Anti-competitive/price-fixing behavior like that would be illegal in other settings.
| Rob | Its a dangerous business going out your front door. - J.R.R.Tolkien
miket29
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Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by miket29 »

celia wrote: Wed May 31, 2023 9:49 pm Since all the dr did was fill a prescription, insurance didn’t pay for the office visit and you owe the $202.37.
There is no indication they didn't pay for this reason, an uncovered visit. The OP earlier wrote
I'm still learning in this world, but yes, that was one of the assumptions I made when deciding to try an HDHP plan this year. (i.e. "avoid middlemen to lower costs").
The most likely explanation is the OP is under the HDHP deductible. While seeing in-network doctors the OP will have to pay the negotiated rate with no help from the insurance until she/he hits the HDHP deductible
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Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by Young Boglehead »

rob wrote: Wed May 31, 2023 10:09 pm It's one of those tricks that health care in the US has managed to avoid legislation... Anti-competitive/price-fixing behavior like that would be illegal in other settings.
Someone should let the EM docs know they don’t need to treat everyone without considering payment (EMTALA)… :?
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celia
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Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by celia »

miket29 wrote: Wed May 31, 2023 10:37 pm
celia wrote: Wed May 31, 2023 9:49 pm Since all the dr did was fill a prescription, insurance didn’t pay for the office visit and you owe the $202.37.
There is no indication they didn't pay for this reason, an uncovered visit. The OP earlier wrote
I'm still learning in this world, but yes, that was one of the assumptions I made when deciding to try an HDHP plan this year. (i.e. "avoid middlemen to lower costs").
The most likely explanation is the OP is under the HDHP deductible. While seeing in-network doctors the OP will have to pay the negotiated rate with no help from the insurance until she/he hits the HDHP deductible
I agree! That finally occured to me when I was writing the next post.

Thanks for clarifying.
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celia
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Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by celia »

paws wrote: Mon Apr 24, 2023 8:56 pm
ScubaHogg wrote: Mon Apr 24, 2023 8:40 pm
paws wrote: Mon Apr 24, 2023 8:32 pm
…even when neither party consents to involve the insurance company.
I’m not a lawyer, but I’m guessing both parties consented under the terms and conditions of the insurance agreement they each signed up for

You are free to change your insurance coverage of course
In this case it sounds like the provider might have agreed, but unless I'm mistaken I'm pretty sure I never did.
The fact that you and the provider signed up for your plans means you agree to having the insurance. Who would sign up but not use insurance for which they (or their employer) is paying for? That doesn’t even make sense. That’s the whole point of having insurance—so you can share the costs, especially if you have a financially catastrophic year.

safari wrote: Mon Apr 24, 2023 10:30 pm
paws wrote: Mon Apr 24, 2023 10:20 pm I'd be curious on tips for finding a good family doctor :) Word of mouth?
I found my doctor on Yelp. He has over 500 5-star reviews.
I heard there was a very popular pediatrician in another state from me who was willing to write a note for any parent who didn’t want their child to be vaccinated. All the locals knew who he was as word got around and he was even in the news a few years ago. But I also wonder about the prevalence of common infectious diseases in their school district.

paws wrote: Tue Apr 25, 2023 3:03 pm I'm still learning in this world, but yes, that was one of the assumptions I made when deciding to try an HDHP plan this year. (i.e. "avoid middlemen to lower costs").
I think you misunderstand the whole point of High Deductible Health Plans. These plans are for those who can afford to pay for a higher amount of their health care each year. The patients accept a higher deductible (the amount the patient pays before the insurance pays anything). In many years the insurance doesn’t need to pay any of their bills. But when larger claims appear (like hospitalization), they will start to pay. Of course, they need to see ALL your claims even if they didn’t pay anything to know when you’ve met the deductible and thus it is their turn to start paying. And in exchange for paying more of your bills upfront, you have lower premiums and are allowed to contribute to a Health Savings Account (HSA) where the unspent money can roll over to future years.

Note that none of this has anything to do with “middle men”. It is just the financial agreement you have with the insurance carrier.



This is a good spot to say I’ve been confused about this thread from the very beginning because of the thread title. None of the discussion so far has been about the HSA account which I thought the OP would be asking about. I figured s/he would be asking if you were required to use your HSA account for current-year medical expenses. As far as I know, the answer is “NO” and have seen threads where the HSA is treated like a Roth IRA with the expectation the account would be spent down on medical expenses during retirement.

paws wrote: Tue Apr 25, 2023 3:12 pm @ArtfulDodger do I understand you right, the doctor performs whatever service, and sends their invoice, and everyone gets charged the same amount.
But the money the doctor actually gets paid is less than their invoice? Why? I'm not aware of any other context in which that would be legal. If you could explain why it works like that I'd be obliged.
Why?
That was the whole point of the doctor signing up with selected insurance carriers with an agreement to accept the negotiated price as payment in full for each kind of service.


In practice, the doctor can charge anything he wants. But each insurance carrier starts by knocking the bill down to the negotiated price and the insurance company and patient pay a total to the doctor that adds up to that negotiated price. No-one needs to pay the excess.

For example, all doctors who do heart transplants might as well bill all the insurance plans 1.3M for a heart transplant, since there is at least one insurance that will pay that amount, but most of them will knock the price down closer to $31K. That doesn’t mean the patient owes the rest! In fact, patients who need heart transplants probably met their yearly out-of-pocket earlier in the year.

(your chargemaster post)

Does this all make sense now? This is how medical insurance works.
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Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by Lyrrad »

celia wrote: Thu Jun 01, 2023 12:32 am
I think you misunderstand the whole point of High Deductible Health Plans. These plans are for those who can afford to pay for a higher amount of their health care each year.
I don't think this is true in general, though it may be true for some (or perhaps many) employer plans.

For example, my employer offers both a PPO and HDHP with the same network. The PPO has significantly higher premiums and the HDHP includes a HSA seed with lower premiums. I cannot construct a realistic scenario where I would end up paying more on the HDHP over an entire plan year since the additional premiums on the available PPO plan, plus the HSA seed, is approximately the same as the OOP max on the HDHP.

For this reason, I think it's difficult to make generalizations about the value of HDHPs compared with PPO or other types of plans. The lowest cost plan may differ from employer to employer, and a more expensive plan may be more suitable for some patients.
AnEngineer
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Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by AnEngineer »

Lyrrad wrote: Thu Jun 01, 2023 3:15 am
celia wrote: Thu Jun 01, 2023 12:32 am
I think you misunderstand the whole point of High Deductible Health Plans. These plans are for those who can afford to pay for a higher amount of their health care each year.
I don't think this is true in general, though it may be true for some (or perhaps many) employer plans.
In my experience, HDHP often have a lower best case and worst case scenarios. In the middle, you likely pay more. The difference is you pay more of the marginal cost until you hit your deductible. It can feel like more because a doctor's visit costs more, but you have to look at the total annual cost.
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paws
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Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by paws »

miket29 wrote: Wed May 31, 2023 10:37 pm
celia wrote: Wed May 31, 2023 9:49 pm Since all the dr did was fill a prescription, insurance didn’t pay for the office visit and you owe the $202.37.
There is no indication they didn't pay for this reason, an uncovered visit. The OP earlier wrote
I'm still learning in this world, but yes, that was one of the assumptions I made when deciding to try an HDHP plan this year. (i.e. "avoid middlemen to lower costs").
The most likely explanation is the OP is under the HDHP deductible. While seeing in-network doctors the OP will have to pay the negotiated rate with no help from the insurance until she/he hits the HDHP deductible
@miket29 you are correct.
celia wrote: Thu Jun 01, 2023 12:32 am The fact that you and the provider signed up for your plans means you agree to having the insurance. Who would sign up but not use insurance for which they (or their employer) is paying for? That doesn’t even make sense. That’s the whole point of having insurance—so you can share the costs, especially if you have a financially catastrophic year.
@celia Are you asking why someone would become a member of a plan but choose not to use it? Because
  • The provider charges the plan a different cost than individuals who self-pay.
    Being subject to a deductible and blocked from learning financial details ahead of my visit, I'm on the hook for an unknown cost. It's an awful feeling.
  • The plan may exclude things based on reasons that don't include my medical interests
  • For certain visits I might value my time more than dealing with insurance company shenanigans e.g. fighting denied claims
  • As the patient I simply might not wish to cede my agency to a for-profit private third party, whose executives are probably vying for another yacht
Anyway, in this case, fortunately, the self-pay price and post-"adjustment" plan price were similar. The problem continues to be, I have no way of knowing if that will be true in future.
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