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MooseMom
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« on: June 04, 2020, 09:13:39 PM »

For anyone left on this forum, I hope you are well and staying safe.  If you are not, then my "problem" is very minor, and for that, I apologize.  Still, I do have a question if there is anyone (US) left to attempt to answer.

I've been a tx patient at UW-Madison for 12 years now.  I get my insurance via a BCBS HMO through my husband's employer.  UW is out of network for me, so when I go for my annual checkup, I always get a referral.  Every year, it is the same; I have an in office visit, and the blood specimen I get drawn locally is set to UW's HLA lab.  So, I incur two charges.  They are always the same.

My medical group was bought out in 2017 (an employee accidentally on purpose told me), and since then, getting these items paid has become a circus, and not a fun kind.  They come up with all sorts of reasons not to pay.  One year they said my referral was not a referral at all, rather, it was merely an "in office memo", despite the fact that the referral had "REFERRAL" written on it, along with an authorization code.  You get the picture.

It got so bad last year that I actually had a meeting with my US Congressperson who must have done something because it got paid, but it had taken a year.

So this year, I tried to anticipate problems and sought to contact BCBS before I even got a statement from UW.  They contacted the medical group, and this year's excuse not to pay is that the provider listed on UW's bill was not on their list of approved providers.  What, did UW's HLA lab suddenly go on a walkabout?  BCBS is now requiring that I go through their appeals process, which I have done.  No answer yet.

Anyway, that's the boring background bit.  God, I hate having to read about other people's insurance problems.  It makes my eyes glaze over, so apologies for doing the same right back at ya.

But here's the interesting bit.  Today I got a bill from UW for the lab services which always are about $970.  Every year, it's the same amount.  But THIS year, the bill showed that I get a $350 SELF PAY DISCOUNT, meaning that I now only have to pay $600 odd.  Of course I've messaged them asking what in the world is a SELF PAY DISCOUNT and WHY IS THIS THE FIRST TIME I'VE EVER HEARD OF THIS.

Have ANY of you ever seen such a thing as a SELF PAY DISCOUNT?  What sort of new scam is this?  I have to say that I laughed out loud when I saw this because each year, something really weird happens.  Every year I get my referral, get my bloodwork, go for my office appointment, and then sit back and guess which new obstacle will be created to get in my way.

The End.  Thanks for reading. 
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"Eggs are so inadequate, don't you think?  I mean, they ought to be able to become anything, but instead you always get a chicken.  Or a duck.  Or whatever they're programmed to be.  You never get anything interesting, like regret, or the middle of last week."
Simon Dog
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« Reply #1 on: June 04, 2020, 10:14:10 PM »

Self pay discounts are common, and often restricted to advance or very prompt, payments.   This means you sometimes have to roll the dice - "Do I file the insurance appeal and pay $900 if I lose or pay $600 now?".  Think of it like plea bargaining with the finance office.

I have encountered this sort of discount when going in for scheduled (non-renal) surgery.   The local hospital determines the copay/deductible as part of the insurance pre-authoriztion process and offers a 20% on the amount due if paid in advance.  This is nicer than most hospitals that are "prepay or the procedure will not occur".

The billed price is a farce, and a self-pay discount is typical.  The problem is that the self-pay price is generally still WAY above what private insurance would pay and WAY, WAY above what Medicare would pay.   Even with the discount, it is almost certain that the hospital is getting more than it would if the insurance claim were approved.

The purpose is to reduce pushback, encourage payment, and get the customer who is only paying twice rather than three times what would be accepted as "paid in full" under the insurance carrier's contract to say "thank you". 
« Last Edit: June 04, 2020, 10:18:04 PM by Simon Dog » Logged
Cupcake
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a good year for Chevys

« Reply #2 on: June 05, 2020, 06:05:52 AM »

I hear ya, MooseMom. I know that medicine is big business and the lawyers and bean counters are making it all work, but it is still somehow sad. After my transplant, I made it my 'business' to jump through all the hoops and pester the heck out of the billing department and got everything covered. I was no longer working and so every morning I would get up and decide,"Am I gonna call and wait on hold for Humana, Medicare or Barnes Hospital today" That took hours every week and about 9 months. I had a post op abdominal abscess with extra surgeries and protracted period of wound clinic appointments with a wound vac, and somedays those services were being covered by the prior auth for transplant related services, and somedays not. Depended on who you spoke to, what the weather was like, and whether the St Louis Cardinals were playing.

I feel sorry for patients who don't have the time, energy, or intestinal fortitude to slog through that.  I think this forum has helped me, and I hope it helps others.
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PD for 2 years then living donor transplant October 2018.
MooseMom
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« Reply #3 on: June 05, 2020, 08:47:12 AM »

Self pay discounts are common, and often restricted to advance or very prompt, payments.   This means you sometimes have to roll the dice - "Do I file the insurance appeal and pay $900 if I lose or pay $600 now?".  Think of it like plea bargaining with the finance office.

I have encountered this sort of discount when going in for scheduled (non-renal) surgery.   The local hospital determines the copay/deductible as part of the insurance pre-authoriztion process and offers a 20% on the amount due if paid in advance.  This is nicer than most hospitals that are "prepay or the procedure will not occur".

The billed price is a farce, and a self-pay discount is typical.  The problem is that the self-pay price is generally still WAY above what private insurance would pay and WAY, WAY above what Medicare would pay.   Even with the discount, it is almost certain that the hospital is getting more than it would if the insurance claim were approved.

The purpose is to reduce pushback, encourage payment, and get the customer who is only paying twice rather than three times what would be accepted as "paid in full" under the insurance carrier's contract to say "thank you".

I had absolutely no idea that this is a common practice!  So, thanks for enlightening me.  My "date of service" was November of last year, so for UW to surprise me with a "self pay discount" seven months later hints that they may have become aware that I am going through the appeals process with BCBS, but I'm not sure how they would know that.

And yes, you are right that the price is way inflated in the first place, which is why I have no intention of paying it especially since the reason it is being denied is because UW said the named provider was "University of Wisconsin Foundation" instead of "University of Wisconsin Laboratories" or some such nonsense.  I suspect that in the end, I'll have to tell UW's accounts dept to resubmit the statement with whichever provider name the medical group will accept.  I refuse to pay a claim that is being denied for such a frivolous reason that has nothing to do with the actual procedure itself.

I won't lose the appeal.  My records, BCBS's records, and the medical group's records will all show that these are routine, annual charges that they have been paying for 12 years.  For them to suddenly quit paying now, especially seeing as how I explained at length what the referrals were to be for, is acting in bad faith and would not stand up in a court of law.  I've had to sue an insurance company before for a similar thing, and I won.  I know how to do this.  I used to be an insurance broker for Underwriters at Lloyd's of London.  I know my way around an insurance contract.  They've picked the wrong person to mess about with.

"Self pay discount" seven months afterwards my buttinsky. :P
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"Eggs are so inadequate, don't you think?  I mean, they ought to be able to become anything, but instead you always get a chicken.  Or a duck.  Or whatever they're programmed to be.  You never get anything interesting, like regret, or the middle of last week."
MooseMom
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« Reply #4 on: June 05, 2020, 08:49:37 AM »

I hear ya, MooseMom. I know that medicine is big business and the lawyers and bean counters are making it all work, but it is still somehow sad. After my transplant, I made it my 'business' to jump through all the hoops and pester the heck out of the billing department and got everything covered. I was no longer working and so every morning I would get up and decide,"Am I gonna call and wait on hold for Humana, Medicare or Barnes Hospital today" That took hours every week and about 9 months. I had a post op abdominal abscess with extra surgeries and protracted period of wound clinic appointments with a wound vac, and somedays those services were being covered by the prior auth for transplant related services, and somedays not. Depended on who you spoke to, what the weather was like, and whether the St Louis Cardinals were playing.

I feel sorry for patients who don't have the time, energy, or intestinal fortitude to slog through that.  I think this forum has helped me, and I hope it helps others.

I know.  It' disgraceful.  Lots of bad actors, the whole lot of them.
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"Eggs are so inadequate, don't you think?  I mean, they ought to be able to become anything, but instead you always get a chicken.  Or a duck.  Or whatever they're programmed to be.  You never get anything interesting, like regret, or the middle of last week."
Simon Dog
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« Reply #5 on: June 05, 2020, 02:03:20 PM »

A problem is that medical providers use College/Car dealer pricing.  Figure out exactly what each individual customer is good for, and extrave the very maximum possible from that customer while charging customers who are harder targets with lower prices.

My doc billed $1000 for "preparing the donor kidney for transplant" and was paid about $50 by Medicare.   Too bad for him that my time on the waitlist was longer than the private insurance window.
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