I always loved patients with cash!

Having said that, most hospitals will first try to negotiate with the insurer to reach an equitable agreement. This might look something like 80% of the usual and customary fee paid by the insurer and the remainder as an out of pocket by the patient.

It would be extremely unusual for a hospital to completely turn down a sincere effort by an insurer to cover an out of network patient. In fact most health plans have a summary document which explains to a patient what % of a bill they can expect to pay as an out of pocket fee. And that % is always greater then what a patient would pay if they had stayed in network.


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I don't think that matter, as far as Shands is concerned, someone with UHC TV MA is uninsured. Let's see what DB has to say, he is the real expert on these type of referrals. All I can say is that I have made hundreds of out of network referrals, had 100% of them approved, and never had a patient give me feedback that they spent big bucks as a result.

Remember, UHC is an insurance company. They never lose. They look at their overhead, look at the cost of paying claims, look at their investment income then set a premium. What I've generally found is that any resistance comes from someone relatively low on the food chain that is guarding the insurer's money as if it were their own. Once you get to a higher level, you get a more reasonable response.

A hospital would rather receive some payment than receive nothing. But, this assumes the care is delivered in an emergent situation. I doubt Shands would provide a significantly reduced payment for an elective procedure. However, even in an elective situation one can usually negotiate a firm price.

Cosmetic procedures come to mind. Many hospitals that perform these procedures have developed (with the docs) a package price which includes combined hospital and physician fees.


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Now IF there is no provider in network that does the same procedure, and IF it is considered medically necessary to have that specific procedure, don't they cover it as though it were in network?

Did my post # 91 above answer you? If not I'll take a crack at it again. So many posts I'm having trouble keeping up!


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Yes, but the patient typically is still expected to pay a larger out of pocket fee by the insurer, since the insurer will almost always pay the out of network providers more than in-network providers. The former has no contract and the latter does, hence the difference in treatment.


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I guess the big question that people, including myself, would like to know is whether the UHC MA plan $4400(option 1) or $1900(option 2) maximum annual out of pocket expense still applies if the costs were incurred as a result of an approved out of network referral. (I assume if you just go without approval, you're on your own)

Don't know how many ways I can say the same thing. 🤔
1. Shands does not accept the Advantage Plan with or without an out of network approval.
2. Shands does not accept cash payments from an insured person.

The Medicare site says that an Advantage plan has to cover any procedure that traditional Medicare does.

"Medicare Advantage Plans must cover all of the services that Original Medicare covers. ...."

That's pretty unequivocal. If MA didn't work that way it seems like they would really be pretty iffy.

It also says

"The plan can choose not to cover the costs of services that aren't medically necessary under Medicare. If you're not sure whether a service is covered, check with your provider before you get the service."

The kinda' implies that UHC must pay for medically necessary services.

But the people who manage web site content are typically not the ones who write rules. But it seems like full Original Medicare coverage is what was intended for MA...

Medicare Advantage Plans cover all Medicare services | Medicare.gov

BTW UHC MA allowed my wife go out of network for some small services (~800.00) just because the in network provider was inconvenient to go to. Covered 100% after co-pay.

I believe you are correct. The key, as you note, is that the out of network referral is approved by the insurer and/or referring practice. It should work just as it would in a similar circumstance if an HMO referred a patient to a non network provider.


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Was the co-pay greater than or the same as if she had stayed in-network? Interested as a point for personal education?


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The same.

I was surprised. We literally told UHC that 45 min was to far to go when there was a provider in the bubble (well, The Villages) 15 min away. Took just two days to get it approved, no questions, no hassles.

The Villages Health - Survey
 

I could not find evidence of either point on the Shands website, but I did find the following information:

"1) Most health insurance companies, as well as Medicare, pay UF Health directly. Any portion of your hospitalization or care not covered by insurance will be your responsibility.

2) Coordination of Benefits (COB)
Coordination of Benefits, referred to as COB, is a term used by insurance companies when you are covered under two or more insurance policies. This usually happens when both husband and wife are listed on each other’s insurance policies, or when both parents carry their children on their individual policies, or when there is eligibility under two federal programs. This also can occur when you are involved in a motor vehicle accident and have medical insurance and automobile insurance. Most insurance companies have COB provisions that determine who is the primary payer when medical expenses are incurred. This prevents duplicate payments. COB priority must be identified at admission to comply with insurance guidelines. Your insurance may request a completed COB form before paying a claim and every attempt will be made to notify you if this occurs. The hospital cannot provide this information to your insurance company. You must resolve this issue with your insurance carrier for the claim to be paid.

3) Medicare
UF Health Shands Hospital and the University of Florida are approved Medicare providers. All services billed to Medicare follow federal guidelines and procedures. Medicare has a Coordination of Benefits clause. At the time of service you will be asked to answer questions to help determine the primary insurance carrier paying for your visit. This is referred to as an MSP Questionnaire and is required by federal law. Your assistance in providing accurate information will allow us to bill the correct insurance company. Medicare deductibles and co-insurance are covered by your secondary insurance. If you do not have secondary insurance you will be asked to pay these amounts or establish a payment plan. If you are unable to pay these amounts, we will help you determine if you qualify for a state-funded program."


Most hospitals will provide a list of insurances they accept, or the General type of information I found and noted above.

It would be very unusual for a major teaching hospital to NOT take MA plans. Teaching hospitals need educational material (I.e., patients) for Med students, residents, faculty and researcher.

I've run two, and know Shands well, but times change I guess.



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Interesting! That's good for patients though. Thanks.


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