How do I find out what discounts hospitals offer insurance companies?

Question

Mom had an emergency surgery four months ago plus three set backs. Needs another major surgery to finish the first procedure once she is healthy enough. She is under 60 so does not qualify for medicare or medicaid. Applied for disability but that will take at least 3 mos to process, and if approved still won't be enough to meet the $3300/mo payment plan. Current monthly income is $911.00 from dad's social security. House is paid for but cannot get a reverse mortgage (too young) or a home equity loan (income too low). Parents have cashed in their IRAs and stocks (losing 40% in fees, penalties and taxes). NOTHING is left. About to be turned over to collection tho they've always had the best credit rating. Hospital has offered a 25% discount if they could pay the entire initial bill, but there wasn't enough stock/IRA money to cover even that.

Can we get the bill down to what an insurance company would pay for the same services? How do I find out what are "customary and reasonable fees"?

Answer 1

You're not likely to find out exact contracted rates. Hospitals don't even have the same rates across all insurers. (And they have some incentive to keep those rates somewhat secret - don't want to let Insurer A know that you're giving Insurer B a better rate, otherwise Insurer A will be knocking on your door to renegotiate.)

When I worked in a contracting department, we'd try to ballpark the rates that other insurers were getting by using EOBs that we had access to.

This strategy might work for you - if you know others who have used services at this hospital and who will let you see their EOBs, you can compare the billed charges to the insurance allowed amount to get an idea of what kind of discount the hospital is giving to insurers. It won't be scientific or exact, but at least it will get you in the ballpark.

Answer 2

You can ask for that discount, but it's unlikely you'd get it - those are a contract between provider and insurance, not you and the provider.

Google "Medicare Fee For Service" - that is the pricing scale that pretty much every insurance company bases their payments on. It changes every year - slightly.

BUT - unless it's a teaching hospital, you should call the hospital and ask for the social workers - they can often put you in touch with various charites or get you some kind of emergency help in this situation. (They don't advertise that they do this - and some teaching hospitals don't do it at all.)

Answer 3

The hospital I'm employed at is a charity hospital. We have special programs to assist those who absolutely can not afford it. If you do not qualify for charity, you are required to set up some sort of payment plan and deposit. If you do not, we cancel elective surgeries.

If push comes to shove, we have a hardship program. A board reviews your case, sets a price, and that must be paid in full.

Answer 4

You can ask for a cash price.

Each insurance company pre-negotiates with "in network" hospitals, what the fee is for each service. So it's going to vary by insurer.

The easiest way to find out what "usual & customary" is in your area, is to go to your state medicare website - and there should be someplace there that lists it. That, also, varies by state.