Question:
How much does the insurance pay the MD opposed to the self pay for the surgery?

I am a self pay, I am curious. I ahve waited for about three weeks for a $ amount for the MD to quote what he would charge for the revision of a distal RNY and now I am quoted approx 1,500 more than they stated a month a go. How much do MD's get paid by the insurance to do surgery? Thanks in advance.    — train (posted on June 15, 2005)

June 15, 2005
I am not sure anyone is really going to be able to answer that question for you to the exact $ amount. You see most insurance companies negotiate the price with the provider. So, it may be one amount with one insurance company and a different amount with another insurance company. The $ amounts are not a set price. Maybe there will be someone who handles insurance claims that is one the board that can help you with your question. I do know this for a fact that a self pay person will pay far above what the negotiated price is that an insurance company pays the doctor.
   — ChristineB

June 15, 2005
Cheryl, the surgeon gets a contracted rate if he is contracted with your insurance. If not, then he is paid off what the insurance company feels is reasonable and customary. Typically the provider gets paid somewhere between 40%-75% of his usual billed charges. The hospital on the other had gets paid MUCH MUCH less than the billed charges.<br>If you call your insurance company and actually get a competent person on the phone, ask them what the contracted rate or the max fee they will pay on a specific procedure. You will need to provide the CPT code and the Diagnosis code for your exact procedure. The contracted amount or max fee is what is subject to your coverage. For example, if your plan pays 80% leaving you with 20% of the bill....you are responsible for the 20% of that contracted amount. (if the provider is on your list) If not on you provider list, you will pay the 20% + whatever the provider billed about the max fee.<br>I hope I didn't cloud the water. Rebecca
   — RebeccaP

June 15, 2005
Ooooops...<br>whatever the provider billed ABOVE the max fee.
   — RebeccaP

June 15, 2005
Hi, again, perhaps I didn't ask the question correctly. I completely understand he % with the insurance. My question was intended to try to find out a ball park figure of how much over the top do the MD want from the self payer. They want to charge me $6,400 for the surgery. Does the insurance pay the MD that much for the same surgery or is this price gouging to the self pay person?
   — train

June 15, 2005
Cheryl, I did address that in my previous reply. It is different for each doctor with each insurance company. Like I said doctors typically get between 40% and 70% of billed charges for their services. It completely depends on what they signed that contract for. You can find out what the dollar amount is by calling your insurance company and asking what the contracted amount is for X doctor with X procedure under X diagnosis. You will have to have the CPT and ICD9 codes, your surgeons name, and a VERY well educated phone representative from the ins company.
   — RebeccaP

June 15, 2005
Cheryl, I work for my surgeon. For self-pay patients this is what he charges, Open Bypass,Band or revision $3,000 and for Lap Band or Bypass (he only does revisions open)its $5,000. That does not include the hosptial charges because those are separate from his fees.
   — Jessica D

June 16, 2005
Hello, If I am understanding your clarified question, you are trying to figure out what the difference in payment is between insured and non-insured patients... this is a long answer so bear with me :) As it has been said, in previous posts, unless you are inquiring about a specific insurance company, what the doctor gets paid for a given procedure depends on his or her contract with the insurance company. Generally, a contract will pay 40%-70% of what the doctor charges... You said the doctor wants to charge you $6400... If an insurance company's contract says they will pay 40%, they would pay $2560... you would be paying $3840 more than that insurance company. If a different insurance company pays 70%, they would pay $3840 and you would paying $1920 more than that insurance company. But it seems like you get this part! :) A little more explanation: Doctors generally have a set fee schedule (essentially a price list)...This dictates how much gets charged for each procedure regardless of who is picking up the bill. Because a doctor knows that they are not going to get what they charge (because of the ins. companies practice of only paying a percentage), the fee schedule is designed to maximize payment from the insurance company.. I guess maximize isn't the word I mean... but if the doctor deems a procedure being worth $10 dollars (the price being based on the doctors time, cost of supplies, and a generic fee that pays for the office space, employees, cost of billing, etc.), he or she might charge $20 for it, because some insurance companies will pay him 40% ($8), 50% ($10), 60% ($12), etc..... the goal being to end up with an average of $10 for each procedure done. Of course, this is a big simplification but you get the idea. The crappy part, in my opinion, is that people without health insurance get charged the $20 and essentially are subsidizing the health care of those with health insurance. This is why some doctors offer a discount to uninsured patients or patients who have medical coverage but are self-pays. If you don't think $6400 is a reasonable (or affordable amount), you might want to talk to the doctor, tell him that you are self-paying and financially strapped and ask for a discount or a price similar to what he/she would get from an insurance company. One thing to be aware of, the $6400 the doctor is quoting you may include the charges of people beyond him or herself--such as hospital fees (if the revision is being done in a hospital), fees for the anesthesiologist, fees for another doctor/physicians aid who may be assisting in the surgery, etc. One thing I have learned the hard way is the need to get everything in writing. That way, a month later when the price has suddenly gone up $1,500, you have some protection. I hope this is helpful. If not or you have more questions, feel free to email me.... my address is mrsidknee at gmail dot com (where at = @ and dot = . ). Best wishes, Sid A concrete example: if he knows the insurance company will only pay 50% of X, he might set his fee at
   — mrsidknee

June 16, 2005
PS. Ignore what comes after "Best wishes, Sid" -- I often write and then re-write what I am going to say and I guess I didn't get rid of all of the edited text. LOL.
   — mrsidknee

June 16, 2005
I can not believe I am walking into this thread again. LOL<br><br>Sid, you are correct, however, the insurance companies will not pay a percentage of billed charges, they will pay either contracted rate or a percentage of what the insurance company feels is a reasonable charge. What the provider bills for any procedure NEVER comes into play when an insurance company pays the claim. (well ok, I shouldn't say never)<br><br>My surgeon billed 4000 for surgery, UHC paid him 1200. Is this more of what you are looking for? Mind you, these figures are from nearly 4 years ago.
   — RebeccaP

Click Here to Return