AboutTricia Expertise Has your medical insurance company denied your claim and refuses to pay? Have
you received a pre-authorization and still your insurance company
refuses to pay? How can you get your insurance company to reverse a
denied claim? How do you get a provider to waive your copayment if you
are financially unable to pay? Can a provider sue you for a unpaid bill and
will they? Can a provider send me to a collection agency for a medical bill?
If my insurance company does not pay, am I responsible? If you have these questions or others on why your insurance company is not paying your bills, I can help. I can give you "tricks of the trade" to get your insurance company to pay.
I have limited knowledge on Medicare and Medicaid and that is not my expertise. Each state is very different regarding Medicare and Medicaid so you need to review their website when you have questions. So please no Medicare or Medicaid questions!!
Experience In the medical field for over 20 years spending majority of time in the collections aspect.
Question QUESTION: If is a claim denied, would I have to pay "list price" of a procedure or the insurance company's negotiated rate?
For example, if a procedure costs $10K and the insurers negotiated rate is $5K, would I pay $10K or $5K?
Is there a clear standard for how this works?
ANSWER: Hi Spencer!
It depends-------your Explanation of Benefits that showed that your claim was denied will show you what amount you are responsible for. Look under "patient liability". If it does not show on your EOB, then call your insurance company and ask.
If the provider billed your insurance company a negotiated rate than that is the only amount they can bill you if you carrier denies........they have to charge you what they charged the insurance company.
If they billed your insurance company their UCR (usual and customary rate) but would accept a negotiated rate if your insurance company paid, then they can charge you the higher amount.
Hope this helps!
Good Luck!
Tricia
---------- FOLLOW-UP ----------
QUESTION: Thank you for your thoughtful and thorough answer.
Hypothetically, let's say the provider charger a UCR and I approached my insurance company and asked what they would typically pay. And, then approached the provider with that as a negotiating target, do you think I would have any chance of success?
Answer If your insurance carrier denies a procedure and you either know a negotiated rate or if you are aware of what the insurance company would have paid per their contract, you can go to the provider and request that you pay this amount.
Many providers will do that for a patient who insurance company denies. We have done that at the medical company I work for as a courtesy to the patient.
So give it a try..........definitely worth a shot!!
