I have previously suggested that anyone who is able to do so should get a good managed-care healthcare plan (as regarding which, there are two varieties: PPOs and HMOs; mine is the former). That is because there are contractual agreements between the healthcare providers and the insurance carrier that can result in the deep attenuation of the Submitted Charges. Today, I received three different EOBs (Explanations Of Benefits) for services rendered in January. One showed Submitted Charges in the amount of $604.00 Another showed Submitted Charges in the amount of $990.00. And the third showed Submitted Charges in the amount of $2,310.00. This was the final resolution thereof: The $604.00 was knocked down to a Plan Allowance (i.e. what the healthcare provider contractually agreed to accept as payment in full) of just $166.28. Of that, Blue Cross/Blue Shield paid $141.34, leaving a Patient Balance of just 24.94. The $990.00 was reduced to a Plan Allowance of just $80.37--no, that is not a misprint--and BC/BS paid the entire $80.37. And the $2,310.00 was diminished to a Plan Allowance of just $167.16--again, not a misprint--and BC/BS, once again, paid this amount in its entirety. Total Submitted Charges (for all three combined): $3,904.00 Total Patient Balance: $24.94. I believe that insurance adjustments are truly the lifeblood of managed-care plans. And a good managed-care plan should have a wide array of doctors within its network--including many of the very best. So if I seem to be crusading for them, it is because I am.
