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Health Insurance Dodges The Bill Again

Posted Sep 13 2005 12:00am

This week I received the EOB (Explanation of Benefits) from a case I did in the emergency room a number of weeks ago. EOB is certainly a misnomer here as the insurance company applied the amount of the bill in its entirety to her deductible.

Patients are often surprised when their PPO plans pay nothing and proceed to get angry at the surgeon that came out on the weekend at night to put their face back together. In this case, the young lady split her lip open surfing.

“Don’t blame me for your insurance company woes. You signed up for that policy.”

People often don’t understand the stipulations of their insurance plans. They just know that the plan costs them money; frequently a lot of money considering these plans pay out so little. My belief is that insurance plans are often constructed in a confusing way so that people don’t know what they are getting themselves into.

A few basic points:

“Deductible” – This is the amount you agree to pay (usually yearly) before the plan pays out a dime. Patients frequently increase this number to bring their premium down.

“POS” – Point of Service – These plans frequently have both HMO and PPO aspects allowing access to Out Of Network providers but better coverage for in plan providers. This is your best policy (as far as I am concerned) in the Emergency room. I get to bill at my rate and patients usually have little or no cost (in emergency room care that is).

“Co-pay” – More of your money that you agree to pay at office visits on top of the deductible.

“Provider” – A doctor that agrees to let the insurance company regulate his fee structure. This is not the good doctor Di Saia anymore thankfully. I was collecting about a third of my charges back then. Can you say “revenue negative?” Your share of cost will be less with a provider doctor. Then again as a provider doctor I was losing money and had very little time to spend with my patients. This has changed along with my newfound freedom. :)

Generally as Co-pays and Deductibles get larger, the premium gets smaller. Then again you are agreeing to less insurance really. Beware that which you sign as this seals your fate.

Until Later,

John Di Saia MD


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