How can I negotiate a medical bill that seems excessive?

Question

My son's pediatrician referred us to an occupational therapist for an assessment. The pediatrician was concerned about the way my son was holding a pencil with both hands. The details aren't that important. We spent 30 minutes with the therapist. The therapist advised that he did not need ongoing therapy and gave us a suggestion to correct at home. Three weeks later, I get a bill for $475 (after the group insurance adjustment). After doing some research, I've come to the conclusion that the typical cost is $90-170 for an evaluation. That seems reasonable. I appreciate any advice on how to negotiate with them.

Answer 1

I think your first step is to be asking for an itemized billing as to exactly what services they claim to have rendered in the half hour that would result in that sort of charges.

These days a lot of medical providers have outrageously high rates if you are not a member of a medical plan that has negotiated rates with the provider. I've heard of instances where someone without insurance was being charged anywhere from 5-8 TIMES more than someone covered by a health plan would be billed. (this seems to be the new tactic to make up for the expenses of covering those without coverage or a means to pay.

Once you have some kind of accounting for the charges, if you can't get them to reduce it to a reasonable level, it might be time to contact a consumer advocate at a local paper or news station.

If you were recommended specifically to this OT by your primary provider, I'd also let them know about these insane charges, and you might want to suggest it would be in the best interests of their patients for them to find someone else (with less egregious fee schedule) to refer patients to for such services in the future.

An important lesson here is to ask about charges and insurance coverage IN ADVANCE and don't be afraid to shop around and check multiple providers. There is very little transparency of pricing in the healthcare industry at the moment, and prices for the very same procedure (such as a consult, or medical imaging) can vary widely (e.g. three maybe even four digit percentage differences) from one provider to another. You really need to be an informed consumer when it comes to health care these days to avoid being taken to the cleaners.

Answer 2

Personally, I have not had much luck fighting bills that felt excessive but were not incorrect. In my case it was "external surgery" for a sore shoulder, where the doctor did nothing except gave me a sling, and charged $1000 or so. It seems like the doctors separate out the billing operation from the treatment operation in order to make it hard to fight.

Billing side:

Me: This is excessive.

Them: We just bill the set amount for the treatment the doctor code, and have no discretion. Let me transfer you to the doctor.

Doctor side:

Me: This is excessive.

Them: We coded what we did, and it would be fraud to change that. We also have no idea how much things cost on the billing side, so we have no way to warn you before having something done that is so expensive. Tough luck.

I recognize this is an example of being unsuccessful, but it's useful to know the script they follow.

Answer 3

For typical insurance, there's a co-pay, e.g. $15 for primary care doctor, $25 for specialist. So long as the doctors you use "accept" the insurance, they agree to accept the insurance company's payment. When you were referred, did you ask if they were on your plan? In my case, the doctor or hospital can charge whatever, but I'm paying $15/$25 (10% for hospital visits) and that's it. If the therapist was "off plan" you can appeal it, but be careful, if you don't get some agreement, they can turn you over to a collection agency.

Answer 4

Scenario 2 is exactly what happened to me. Company took on new insurance provider, I took my daughter to our 19 year long pediatrics office with potential strep and a sore belly button (pierced). PA cultured her for strep and looked at bellybutton, said it looked infected and suggested she take the ring out. Asked my daughter if she wanted to take it out herself or would she like the PA to take it out. My daughter told her she could do it since she had a better angle. The PA unscrewed the belly-button ring and removed it (surgical procedure #1 $196.00). After she removed the belly-button ring, she pressed the area and said yes it is infected and swiped away some pus (surgical procedure #2 $350.00). With that she cultured the belly-button area for strep too (positive for strep in both areas-keep hands away from piercings if your sick!). Strep culture costs and office visit added another $173.00 (no problem with that) to total $719.00. I am contesting but the response is exactly as smackfu has outlined. Our new provider requires us to absorb the first 7k in deductibles before they kick in, Great! But I had no idea our long standing and trusted physician would be ripping us off on basic health care.