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Critical Questions about ACA Fallout: Flips in Price and Power

Critical Questions about ACA Fallout: Flips in Price and Power

You do have options. Don’t you?
By Tom Mullaney


With more people moving into high-deductible health insurance programs, it will pay to become a smarter consumer of health services. The questions that follow should help you save money as healthcare providers begin to adapt to a more consumer-friendly world. Answers are provided by Michele Kadlec, CEO of Health Plus Physicians Organization.

Do I need to have a procedure where my physician refers me?
Not necessarily. Sometimes you do have to use a specific specialty care physician and hospital referral network. However, you may have options as to the place of service. At times, your insurance coverage will dictate where you can go, and at other times, if you use certain providers or go into the hospital when there are alternatives, your out-of-pocket (OOP) costs may be more.

What amount do I owe for services performed within a hospital?
When you receive care within a hospital that otherwise can be provided within a physician’s office, it usually comes at a higher cost. There are hospital charges as well as the hospital physician(s) charges in addition to your own physician’s charges. Healthcare payers negotiate reimbursement rates with each provider, and rates from payer to payer vary. For outpatient services, many payers negotiate a discount on the billed charges. Billed charges are at the discretion of each hospital. If the service can be performed within a participating physician’s office, it will most likely be significantly cheaper.

Does the place of service make a difference?
You should ask whether the physician or facility is participating in your health plan, whether the tests and/or procedures are within your coverage benefits and what amount is your OOP. Furthermore, you should determine whether the physician and place of service for the appointment is the most cost-effective. Frequently, an office visit consultation by a hospital-employed physician is more expensive than an office visit with a private physician, especially if the place of service is within the hospital, a surgical center, an emergency department, a clinic or a treatment room.

Do all physicians and hospitals charge the same amounts?
No. How do I know whether a service is covered, and how do I read all of my bills? Before you schedule your appointment, make sure that the physician and/or facility are participating with your health plan, are within your benefits coverage policy and are approved by your insurance company. After your appointment, be sure that you receive a list of the service(s) provided. You can ask for a billing statement (superbill). The bill(s) you will receive should list all services provided and their charges. If there are services listed that were not provided to you, immediately contact the office or facility.

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