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Re: OT - Deposit on surgery question (doctor your opinion please) Attn: NadiaFrom: Garry Siegel, MD (anonymous@obgyn.net)Tue, 30 Apr 2002 17:56:39 -0500 (CDT)
Here is the short version of how it works. If you are on a managed care plan, such as an HMO, PPO, or POS, and the doctor is in the network, then the doctor may charge, say, $2000 for a procedure. The insurance company has an agreement with the doctor to pay a certain amount, and the patient also has a certain amount. This varies from plan to plan. For example, for a $2000 charge, the doctor may collect (from the patient and the insurance) anywhere from $400 to $1500. The better the plan (i.e, PPO versus HMO), the better the payment, in general. Once the bill is submitted, the insurer sends an explanation of benefits to the doctor and the patient, and it says who pays what to whom, and includes the payment to the doctor. The doctor is bound to follow that analysis unless he disputes it(due to incorrrect processing, etc.), and, guess what, you rarely win those. Many offices "know" up front what the explanation will show, what your deductible is, etc., and try to pre-collect it so that there will be no surprises. That is reasonable and proper. Listers, doctors collect a low percentage of what is charged, and have to spend money to collect it by having lots of computers, staff, etc. To my knowledge, there is no other field of professionals that are subject to this arbitrary set of rules. While a few doctors may try to not be on plans (and thus charge and collect without restraint), the reality is that most people must play by the insurance rules. For the same work that I did years ago, I collect 20% less. Would anyone like to get a 20% cut in their pay and work the same? I don't think so. Garry
-- Garry E. Siegel, M.D., F.A.C.O.G. Roswell, GA Private Practice
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