The amount that is billed is based on the service and the agreed-upon amount that Medicare or your health insurer has contracted to pay for that particular service.
You can look up a procedure by a common procedural technology CPT code to see how much Medicare reimburses for it. Private insurance companies negotiate their own reimbursement rates with providers and hospitals. Your health insurance may require that you pay a co-pay or co-insurance for a medical service, and this amount is typically made very clear in your coverage contract.
If your healthcare provider accepts your insurance for services, that means your payer's reimbursement for that service has already been agreed upon and that your healthcare provider will accept it without an additional cost to you beyond your co-pay and co-insurance. Billing you for an additional amount, unless you were informed ahead of time, is called balance billing.
Under normal circumstances, balance billing is illegal. Even when you are covered by health insurance, you may have to pay out-of-pocket for procedures and services that are not covered by your insurance. This fee is your responsibility and is not the same as balance billing.
If you choose to go out of network, your insurer might not cover the cost of your care, especially if they insist that you have an option for the service within your network. In that type of situation, your provider is permitted to bill you an additional amount above what your insurer pays. Concierge care , in which you contract with a healthcare provider or practice to get extra attention, usually involves substantial costs that are not covered by your health insurer. If you are paying for your health care out-of-pocket, your healthcare provider is required to provide you with information about the cost of services.
However, keep in mind that there may be some unpredictable costs. For example, if you have a diagnostic test, you may develop an allergy to the contrast material. This could necessitate another service—treating your allergic reaction. The cost of that service could not have been anticipated before your test if you did not know about the allergy ahead of time. Health reimbursement arrangements HRAs are an employee health benefit offered by some employers in the United States.
They reimburse employees for their out-of-pocket medical expenses. They are not offered as the sole benefit and must be part of a group health insurance plan.
An HRA is funded by the employer and the employer gets the tax benefit, while the employee is not taxed on the money as income. An HRA can be an advantage if your health plan has a high deductible, allowing you to be reimbursed for your healthcare expenses before you reach the deductible amount. Medical bills can look simple or complicated, depending on how many services you have had.
Hospitals are paid based on diagnosis-related groups DRG that represent fixed amounts for each hospital stay. When a hospital treats a patient and spends less than the DRG payment, it makes a profit. When the hospital spends more than the DRG payment treating the patient, it loses money. Increasingly, healthcare reimbursement is shifting toward value-based models in which physicians and hospitals are paid based on the quality—not volume—of services rendered.
Providers may submit claims directly to payers, or they may choose to submit electronically and use a clearinghouse that serves as an intermediary, reviewing claims to identify potential errors.
After a claim passes successfully through the clearinghouse, a payer reviews the claim and either adjudicates fully towards the allowable amount or rejects all or a portion of the claim. Payers communicate healthcare reimbursement rejections to providers using remittance advice codes that include brief explanations. Providers must review these codes to determine whether and how they can correct and resubmit the claim or bill the patient. Other times, they reject services due to a lack of medical necessity or because those services take place during a specified timeframe after a related procedure.
Rejections could also be due to non-coverage or a whole host of other reasons. Healthcare reimbursement is also often a shared responsibility between payers and patients. Still, compensation, the way workers get paid for what they do, is widely understood to have known and unknown consequences.
Nonetheless, concern about compensation is only natural and it can negatively influence physicians. Loewensten and Larkin suggest that a new approach to practicing medicine in the US would make the health care system and the individuals it serves healthier, while making doctors happier.
By providing your email, you agree to the Quartz Privacy Policy. Skip to navigation Skip to content. Discover Membership.
Editions Quartz. More from Quartz About Quartz.
0コメント