Insurance Reimbursements

Many Insurance companies have one overriding priority, to make as much money as possible. 

One way they can make as much money as possible, is to have the unsuspecting patient pay out of their own pocket for covered services, that the insurance company has responsibility for and should have paid for themselves. 

Another way they can make as much money as possible, is to rip off the healthcare provider, who provided the care on good faith, simply by not paying them. 

These unpaid bills increase healthcare costs for every one of us by making all healthcare rates go up to cover the unfair losses.  Remember, whatever the insurance companies do not pay out for you, they get to keep for themselves.  It is that simple.

Tricks of the trade – How insurance companies get patients to pay more than they should.

The low ball payment

The lowball payment is often the first payment made by an insurance company to cover your medical bill.  This payment usually covers less than half of the bill and in many cases less than 1/3 of the charges. 

The Insurance Company can make some great profits here, as long as the patient does not wise up and contest the absurdly low reimbursement.  The insurance company doesn’t care whether the patient pays the difference out of their own pocket, or if the patient stiffs their healthcare provider.  It doesn’t matter either way to the insurance company.  The money they should have paid out for you is still in their bank account.

To help get the insurance company to pay everything they owe, the patient has to complain directly to the insurance company, often in writing.  The Healthcare provider cant do much because they have no leverage with your insurance company. 

For some employer provided health insurance policies, it is smart to let your boss know that things are not getting paid and ask your employer to call the insurance company and advocate for full payment on your behalf.   Insurance companies will begrudgingly listen to the people paying the bills.

If you get a lowball payment, Appeal …Appeal …Appeal.  Many insurance companies will immediately pay the full bill if the patient calls or writes.

“Usual and Customary”    “Allowed amounts”    “Fair and Reasonable”

These are just some of the clever terms coined by the insurance industry to trick patients into thinking they have been overcharged by a healthcare provider.  The goal here is to convince or dupe the patient into thinking they are being over charged by the healthcare provider when in reality they are being underpaid by the insurance company.

The simple logic test to this would be that if a charge is “Usual and Customary” or “Fair and Reasonable” then a majority of the healthcare providers in that area should be charging rates somewhere in the ball park.  If Ambulance A charges $1200., Ambulance B charges $1300, and Ambulance C charges $1250, an insurance check claiming that $500. is “Usual and Customary” or “Fair and Reasonable” is completely absurd.  Yet this happens all the time and you already know why.  Patients end up paying for services themselves that should be covered by the insurance company, because these decent people believe the insurance company is telling them the truth when they say things like “Usual and Customary” or “Fair and Reasonable” or "Allowed Amount".

For them, the goal here is to get the patient to either pay the bill or to not pay the healthcare provider.  Either way the insurance company wins.  The solution is to Appeal, Appeal and Appeal.  Make them justify their numbers of what is fair and reasonable.  Make them pay what they owe.

To give you an idea how fake these “Usual and Customary”  or “Fair and Reasonable” or “Allowed amounts” can be, take a look at the Ingenix scandal.  Ingenix was a company started by an insurance company to make up“Usual and Customary”  or “Fair and Reasonable” rates for healthcare providers.  Basically they made a company that set rates that had no bearing on reality.  It appears they suceeded in getting patients or healthcare providers to pay their bills for them, at least for a while.  This unfair practice was a $350 million dollar mistake for Aetna, but it appears the practice or similar dishonest tricks may continue at some insurance companies.

Check out these links.

This explains it best.

http://www.amednews.com/article/20090126/business/301269997/1/ is the nitty gritty

http://www.apapracticecentral.org/update/2012/12-18/ingenix-lawsuit.aspx Is another view of the practice,

To get them to pay what is fair for you, get the rates in your area from several providers.  Compare them to the reimbursement.  Have the insurance company tell you where they came up with their numbers.  If their numbers came from an all volunteer ambulance squad in Mississippi, it probably has no bearing on what things cost in New Hampshire.  If it has no correlation to what is being charged in your area, it is in no way fair, reasonable or customary.

If the $350 million dollar settlement in the Ingenix case is an example, State Insurance Regulators appear keen to protect patients from this underhanded practice, and are willing to stomp on insurance companies who make ridiculous below cost reimbursements, calling it “Usual and Customary”  or “Fair and Reasonable”  If all else fails, Click here for the New Hampshire Insurance Department's website.

As always, we do our best to minimuize the impact of ambulance costs onto our patients.  Please give Michelle a call at our office 603.527.3553.  Even if your insurance company refuses to pay what they should, we can often provide zero interest, low cost payment plans.