Are You Paying to Get Ripped Off?


Are You Paying to Get Ripped off?

Health insurance is designed to cover large costs. So why are employers regularly paying more for procedures through network discounts?

In May 2019, our client was expecting a large medical claim on their April claims report. One of the client’s employees had a procedure that the provider had estimated beforehand to cost approximately $20,000 all-in.

So, when the claim came through at $55,500, it was a little surprising.

Handling questionable claims is part of doing business with large health insurance carriers. Wincline regularly intercepts excessive claims and asks the insurer and provider for details. Sometimes large claims check out — often they do not for a wide array of reasons, including:

  • The provider or a physician is out-of-network;
  • The insurer has made an error while processing the claim; or
  • The billed charges are unreasonable when compared to Medicare.

Identifying large claims is the easy part. What’s difficult is pressing the insurer and provider for details and knowing how to push back against resistance (usually coming from the insurer side).

In this client’s case, the problem was on the provider side. Functional Neurosurgical Ambulatory Surgery Center (FNASC), an in-network provider, carried out the procedure. FNASC states on their publicly available Cash Pay Costs for Common Procedures document that it “believes in being transparent in its pricing.” It also lists the cash price of the procedure plainly at $16,800.

Thank you FNASC for being transparent with us about the fact that you only charge $16,800 for a procedure that our client paid $55,500 for. We now know that if we pay cash, we could have 2 more patients get that procedure for free and have $5,000 left over.

Bottom line:

  • Wincline is not going to stand by and watch our clients pay more than triple what a service really costs. We’ll be giving our client options about how to prevent unreasonable billing in the future.
  • Providers need to bill fairly for their services (i.e., not up-charging if a patient uses insurance).
  • Insurance carriers should not be lining up to pay these inflated rates.
  • Employers: Wake up! You need an independent advisor who will represent you and design a plan to unbundle your company’s plan from restrictive PPO networks that do not lower your costs.

Want this article in pdf form?

Scroll to Top