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Your Medical Facility Charges are based on what insurance you have!

As an insurance agent a common question I am asked almost everyday is how much do procedures actually cost? Let's start from the beginning, I specialize in Non-Government funded health plans. These are plans that pay first dollar coverage and have, in my opinion, greater benefits for the healthier class of folks. These are folks that don't need to see a doctor every month, a specialist a few times a month, and don't have any pre-existing conditions like Cancer, heart attacks, diseases. My clients also don't need maternity coverage.


The rates are based on your age, your home zip code, and your tobacco usage. Yes some carriers penalize you for smoking ;( However you are rewarded for making smart healthcare decisions. A smart decision would be staying in the network, price shopping procedures, and using medical facilities that care more about patient care than the bottom dollar. Wouldn't you want that anyway?


I recently helped a new family reducing their monthly premiums when Mom decided she wanted to raise her child and stay home for the first few years. A choice a lot of us parents wish we could do! She had her baby under her Blue Cross policy and the policy paid well. They had an out of pocket cost of $1000 deductible and another facility fee of $400 per day for 3 days of care. The babies first well visit was covered under the plans 30 day infant grace period, or was it? Turns out her previous broker did not submit the appropriate forms to Blue Cross with in the 30 day grace period. This caused her babies first pediatrician appointment to be denied by the carrier after the fact. After the appointment.

That's right! She went to the pediatrician thinking everything would be covered until a bill showed up for $880. This is highway robbery! This is Legal Legitimate Theft!






My new client called me right after she spoke to the pediatrician office about the insane bill. I decided to use some techniques I have learned throughout my years of selling insurance. I called the pediatrician as a new patient without insurance, said I had just moved to the area and would prefer to pay cash for services until I straighten out my life. "OK, No problem lets get you on the schedule" Before I allowed her to get in detail I simply asked what the visit and 2 month old immunizations would cost me. "It's 105.00 for the visit and well baby exam, and then $68.70 for the 2 month old immunizations" I ended the call and sat for several minutes completely perplexed. Why would a cash pay person be charged $173.70 for the same service as someone that showed their card to the facility?


I spoke to my client and we 3-way called the office manager and questions their insane billing practices. She repeatedly said she has to look out for the best interest of the medical practice and this is what she was told to do. If you show your insurance card we automatically have

a set of prices for each carrier. Blue Cross happens to be the most expensive that we charge for, its nearly a 700% markup and the law doesn't state we can't do this. I asked do you get compensated for price gouging and hurting the public? "My compensation or pay is not any of your business" Ok, that is fair. But she basically answered my question.


Conclusion: After several phone calls and attempts to contact the owner and doctors of the office, we ended up filing a former complaint to the medical board, we also sent a certified letter explaining a motion to file in small claims court will be coming if this matter is not resolved in a timely manner. The office did agree to charge the "cash pay" price only plus a $75.00 office fee for their reimbursement of time spent filing a claim to a carrier. Although I still felt this was unfair, my client agreed to pay them and take her baby elsewhere.


Lessons are typically learned the hard way. I always ask for the self pay price and I never show them my insurance card until after we have agreed on a price for service. Most offices are happy to provide me with the information I request.



You Must always go about life with the question "What decision is best for me and my family" and never be afraid to ask. You wouldn't pay $120 for a roll of towels that you know only cost $6.99?


Alena Marchant

Saddle Up Health Plans



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