Has anyone ever looked at their Claims on Medicare site?

[jayerose]

I have a supplement (United Health Care (UHC)

Stayed in the hospital in Ocala for two days

From their website:

Provider Billed Plan $7,898.50

Total Cost (Allowed Amount) $37.00

Plan Paid $107.28

Your Share $0.00

So am I to believe that while the hospital billed UHC almost $8000, all they got paid was $107?

[Bjeanj]

Yes.

[jayerose]

How can hospitals stay in business?

[JMintzer]

Is this really news to anyone? :shrug:

[BrianL99]

I have a supplement (United Health Care (UHC)

Stayed in the hospital in Ocala for two days

From their website:

Provider Billed Plan $7,898.50

Total Cost (Allowed Amount) $37.00

Plan Paid $107.28

Your Share $0.00

So am I to believe that while the hospital billed UHC almost $8000, all they got paid was $107?

No, that's not correct.

I have no clue what you're actually looking at, but the odds are 100,000:1 your characterization is accurate.

Medicare paid their portion and your Insurance may have paid some portion, but you can be assured, if you spent 2 days in the hospital, the hospital was paid at least $5000, probably more.

The hospital never would have kept you there, if they weren't going to be paid for the majority of the bill.

[JMintzer]

No, that's not correct.

I have no clue what you're actually looking at, but the odds are 100,000:1 your characterization is accurate.

Medicare paid their portion and your Insurance may have paid some portion, but you can be assured, if you spent 2 days in the hospital, the hospital was paid at least $5000, probably more.

The hospital never would have kept you there, if they weren't going to be paid for the majority of the bill.

They may be only looking at the Medicare Part B charges (that is the physician's fees...)

[walterray1]

I have a supplement (United Health Care (UHC)

Stayed in the hospital in Ocala for two days

From their website:

Provider Billed Plan $7,898.50

Total Cost (Allowed Amount) $37.00

Plan Paid $107.28

Your Share $0.00

So am I to believe that while the hospital billed UHC almost $8000, all they got paid was $107?

they pay, I do not get a bill. I am ok. Move on.

[Dave5]

they pay, I do not get a bill. I am ok. Move on.


Amount billed can be whatever the providers (either hospital or doctor) bills to the insurance (a single hospital stay can generate bills from multiple providers). If the provider is contracted with your insurance, they are bound by contract to accept their allowed amount. Your insurance may pay this allowed amount in full, or you may be responsible for some or all of it, depending on if you have a deductible or a copay.

Supplemental plans cover part of all of the balance left.

Even though you have a supplemental plan, you can still have a deductible or copay due from the supplemental plan. Sounds like your supplemental plan covered your balance in full (for this provider).

Please note: there may be multiple bills coming from doctors or specialists who treated you.

If you still have more questions, feel free to ask. I will gladly review your Explanation of Benefits (EOB) and explain it to you if you are still confused about something.

[djplong]

How can hospitals stay in business?

It's pretty simple. Ridiculous overcharging. Rates set that have aren't tethered to reality. This is something I learned when I was working in healthcare (back office IT development).

The best example that I can give is a personal one to demonstrate. Ignoring the other issues I had to go through to get an MRI, suffice to say that, after enough pain and wasted effort with useless therapies that an insurance bureaucrat thought were appropriate, I got an MRI that immediately showed what was going on.

Initial price on the statement: Over $6000
"Adjustment" for insurance company: Reduced to over $4000
Remaining co-pay for me: $685
Keep in mind, I couldn't "shop around" for the best price as nobody would tell me what an MRI costs (I live in Southern NH).

Just for the heck of it, I looked to see if there were walk-in clinics in Montreal, Canada (just under a 4 hour drive away). And there were. MRIs are not always covered by their Medicare system so it's easy to find several clinics - AND THE PRICE THEY CHARGE (I think it's a law that they have to divulge that).

Retail price for a walk-in MRI, after the exchange rate: $475

My insurance company paid several thousand dollars, plus what I paid, for the same machine and diagnostic ability as I could get for under $500 in Canada.

THAT is how hospitals stay in business. Charging 10x what something actually costs and keeping their books obscure.

[retiredguy123]

How can hospitals stay in business?
I doubt that you are looking at the Medicare Part A invoice submitted by the hospital.

[Burgy]

That does seem out of bounds. You had no copay etc? It would be helpful to know if you are in HMO,PPO or purely supplemental. My bill last year was over $100K for a same day surgery hip replacement and the EOB statement showed payment of $11K total to hospital, surgeon,anesthesia. My copay was $250. Post op.nursing and PT home visits were fully paid. This is UHC HMO.

[Wondering]

I have a supplement (United Health Care (UHC)

Stayed in the hospital in Ocala for two days

From their website:

Provider Billed Plan $7,898.50

Total Cost (Allowed Amount) $37.00

Plan Paid $107.28

Your Share $0.00

So am I to believe that while the hospital billed UHC almost $8000, all they got paid was $107?
Yep! That's the fee structure the hospital agree to when they accepted your insurance/Medicare. Don't complain - you paid nothing other than what comes out of your Social Security for your Medicare.

[FredTheHead]

All of the answers were slightly correct. First off, you said you were looking at your supplemental medical insurance statement. You also have to get your Medicare A and your Medicare B coverage statements. Each statement is separate and available on their own processing timeline. If you set-up a Medicare online account you will get an email telling you when your statement is ready for viewing. Your Medicare coverage is responsible for paying first. That means your supplemental insurance only covers what they know Medicare will not consider covering. Medicare statements that are sent to you in the mail are usually delayed for long periods after the billing period. Contact your county seniors organization. They can be trusted to help you set-up online accounts since you will be sharing all of your sensitive personal information with anyone who helps you with Medicare or insurance sites. Due to so much identity fraud do not share your personal information with anyone unless you trust them with your life, money and your future happiness. Be careful and choose financial helpers wisely. Ken.

[roadrnnr]

Amount billed can be whatever the providers (either hospital or doctor) bills to the insurance (a single hospital stay can generate bills from multiple providers). If the provider is contracted with your insurance, they are bound by contract to accept their allowed amount. Your insurance may pay this allowed amount in full, or you may be responsible for some or all of it, depending on if you have a deductible or a copay.

Supplemental plans cover part of all of the balance left.

Even though you have a supplemental plan, you can still have a deductible or copay due from the supplemental plan. Sounds like your supplemental plan covered your balance in full (for this provider).

Please note: there may be multiple bills coming from doctors or specialists who treated you.

If you still have more questions, feel free to ask. I will gladly review your Explanation of Benefits (EOB) and explain it to you if you are still confused about something.

Can you tell me does Medicare cover physical therapist?

[nn0wheremann]

Yes.
Hospital billing is an accounting insanity. If your plumber or auto mechanic tried those shenanigans you would take them to court and prosecute them for fraud.

[retiredguy123]

Can you tell me does Medicare cover physical therapist?
Yes, under Part B

[DonnaNi4os]

I recently had joint replacement surgery of the carpometacarpal joint (base of thumb) and carpal tunnel surgery at Ocala Regional. It was an outpatient procedure. The cost? $85,000. Medicare will only pay what the mean average is for this area and these procedures. Depending on the area that average could be greatly different. 80% of that given amount will be paid by Medicare, the remainder of 20% will be picked up by my secondary insurance which is United Healthcare. My guess is that it will be much less than $85k.

[retiredguy123]

I recently had joint replacement surgery of the carpometacarpal joint (base of thumb) and carpal tunnel surgery at Ocala Regional. It was an outpatient procedure. The cost? $85,000. Medicare will only pay what the mean average is for this area and these procedures. Depending on the area that average could be greatly different. 80% of that given amount will be paid by Medicare, the remainder of 20% will be picked up by my secondary insurance which is United Healthcare. My guess is that it will be much less than $85k.
What do you mean the cost is $85,000? Whose cost? If the surgeon and the facility accept Medicare, then the cost is whatever Medicare agrees to pay. There is no other cost.

[rothbear]

Start by going to Medicare.gov and look at your EOB (Explanation of Benefits) for your stay. The EOB will show the date of the hospital stay, but the EOB will probably be dated 1-2 months after. You will see there what Medicare paid for and what was submitted to your UHC supplement. You didn't state which supplement plan you have, but you can see what they paid for out of what was submitted to them from Medicare. Then you can look at your supplement EOB and see what was submitted to them and what they paid. If you have UHC "F" plan, they pay all "Medicare approved charges" that Medicare didn't pay. Note that if Medicare didn't approve the entire amount, which they almost never do, the supplement isn't required to pay any of the unapproved amount, either. If for some reason any of the providers at the hospital (radiologist, pathologist, etc.) aren't participating (yes, that can happen, rarely, but it does) then you will get a bill from them. But as long as it says you don't owe anything on your EOB then they shouldn't come back and charge you.

Be aware of providers that don't accept Medicare doing business with places that do. I went to an off site hospital ER one time and had to be transported to the main hospital by ambulance. They wouldn't allow hubby to take me even though I wasn't that sick. The hospital CHOSE and called the ambulance service, but never said that it wasn't participating, even though the ER was. I ended up with a huge bill that I had to fight for about 6 months until I finally convinced Medicare that I had NO choice in the ambulance and wasn't told they didn't participate. What a pain.

Yes, pricing is ridiculous. I used to work for a company who sold medical laboratory equipment so I knew how much the hospitals paid per test. And how many "free" tests, i.e. free reagents, the lab got. Believe me the average of what they paid us for the reagents was mere pennies compared to what they got from insurance companies.

[keepsake]

The only one that pays that high price is the soul that has no insurance. Believe it ? They will sue them for all that dough.
Such a racket.

[keepsake]

"They wouldn't allow hubby to take me even though I wasn't that sick. "

F --- them, drag her out the door and in your car. It's a racket.

See if they can get the sheriff or LEO to stop you.

[JMintzer]

This thread just reinforces what I've seen in 35+ years of practice...

Most people have NO IDEA how their health insurance (including Medicare) works...

[Sage327]

I have a supplement (United Health Care (UHC)

Stayed in the hospital in Ocala for two days

From their website:

Provider Billed Plan $7,898.50

Total Cost (Allowed Amount) $37.00

Plan Paid $107.28

Your Share $0.00

So am I to believe that while the hospital billed UHC almost $8000, all they got paid was $107?

It sounds like one or more of the charges were denied. The hospital would have to appeal with Medicare if that is the case. You can always call Medicare because their Explanation of Benefits can be confusing.

[Glewellen]

You can lookup a non-profit hospital's income tax return. It is a form 990. Latest available are a couple of years old. You'll find many make a 20% - 30% profit margin (a non-profit calls it excess). It is all a billing strategy. The hospital has to bill that much because some insurances will pay that; which makes up the difference for very low payors.

[JMintzer]

After re-reading the OP's post, something doesn't seen right with their numbers...

Total Cost (Allowed Amount) $37.00

Plan Paid $107.28

Why would they pay $107.28 if they only allowed $37.00?

You're not reading the EOB correctly...

[petsetc]

Another rant today from me -

A few years ago (2021) my wife had a serious issue and we went to the free-standing Ocala Emergency Room on 466A. They transported her to their associated hospital in Ocala, when we got the EOB for the incident there was a line item charge of $28,060.25 of which Medicare Approved $0.00 and her Plan F paid the $1,484. deductible on that line item.

On same EOB was another significant event, but the front page of the OB showed;
Total amount billed 65.541.
Medicare Approved 3,103.
Plan F paid 3103. (includes 3 or 4 days in hospitals)
You May Owe -0-

So what's wrong with this system ?!?!?!?!?

[retiredguy123]

After re-reading the OP's post, something doesn't seen right with their numbers...



Why would they pay $107.28 if they only allowed $37.00?

You're not reading the EOB correctly...
Obviously. $37 wouldn't even pay for a Kleenex tissue at a hospital. $107.28 "may" cover it.

[Dave5]

Can you tell me does Medicare cover physical therapist?

Usually, yes, but it could be a limited dollar amount or limited number of visits.

There’s Medicare and then there’s Medicare. Please note that there is Medicare Part A (hospital coverage), Medicare Part B (physician coverage) and Medicare Part C (Medicare Advantage Plans, ie. Medicare farmed out to commercial insurance carriers). Each has their own rules of what they allow, with Medicare Advantage plans varying the most from one carrier to the next and even from one plan to another within each carrier.