What Health Care Consumers Never See

I get emails like the one below almost every day on claims incurred under various Reference Based Pricing plans. The redacted email below shows how egregious health care billing practices are and what consumers are expected to pay in relationship to what Medicare pays.

The sender wants to know if the plan is willing to settle the final negotiated balance bill. Would you settle or fight it?

REDACTED EMAIL:

Below is a provider negotiation for JANE DOE on Claim: 12345 with date of service 12/28/18.  There are two separate calculations because the member has paid a total of $168.52 to the provider but had a zero-dollar responsibility on the EOB.   The percent of Medicare on these is extremely high, but it is a higher discount off billed charges.

Calculation below is for the additional payment of $1,221.00
Billed Amount:	$11,545.79
Plan Allowable (120% of Medicare):	$277.26
Plan Payment:	$277.26
Orig. Balance Bill Amount:	$11,268.53
Discount Applied:	$9,879.01
Additional Payment:	$1,221.00
Total Payment (Plan Allowable + Additional Payment):	$1,498.26
% of Medicare:	648.50% (apx)

 

 

Calculation below is for the additional payment of $1,389.52

Billed Amount:	$11,545.79
Plan Allowable (120% of Medicare):	$277.26
Plan Payment:	$277.26
Orig. Balance Bill Amount:	$11,268.53
Discount Applied:	$9,879.01
Additional Payment:	$1,389.52
Total Payment (Plan Allowable + Additional Payment):	$1,666.78
% of Medicare:	721.50% (apx)