>Does a patient have any recourse if their medical insurance claims the fee
>for recent Mohs surgery for skin cancer was $600 above what is considered
>"reasonable and customary" for my region (San Diego)?
>
>If I have no option but to pay I can grudgingly accept this. But not
before
>doing a little research.
A lot of my medical insurance claims (with in-network doctors) say
that the fee is over what is allowed, the allowed amount is $x, and
the PATIENT DOES NOT HAVE TO PAY THE DIFFERENCE, and the patient
may be responsible for $y (the co-payment or percentage of the
allowed amount). In this situation, there's not much point in
arguing unless the doctor keeps billing you. The insurance company
just argued your case for you, and they're on your side. If the
provider claims to be an in-network doctor, show him a copy of the
statement of benefits from the insurance company.
It isn't all that uncommon to have a statement with something like:
Billed: $400. Allowed: $80. Patient responsibility (copay): $15.
>Don't some medical insurance companies offer an op****tunity to appeal?
All of them *should*, although I don't know if a law requires it.
I think if they don't offer an op****tunity to appeal, or you exhaust
it, you still have remedy in the courts or binding arbitration.
I'm not sure you'd want to go there over $600, though.
The statement of benefits you get from the insurance company should
tell you how to appeal, if it comes to that.
>Or should one try to negotiate with the provider (surgeon-hospital)?
First have the provider check over the claim carefully to make sure
it is coded right. Insurance companies live by these codes. A
one-digit slip might change a heart transplant into an in-office
EKG, or a comprehensive physical into a brief visit or a flu shot.
Tell him what the insurance company said and ask him to check for
a mistake, at first without arguing over *whose* mistake it is. At
this point it's just a possible clerical error. The provider can
re-submit a corrected claim. If the provider says that there's no
mistake, and yes, I charge that, tough noogies, you can try to
negotiate and consider changing doctors in the future.
You also might want to ask the insurance company to describe what was
claimed, and see if it's very different from what you thought was done.
It might be hard for a patient to spot errors unless they are really
out of line.
>Any other ideas?
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