In the case of this specialty genetic laboratory test, the lab billed $8,000 for the test. The health plan determined that the Allowable Amount was $3,000 for the test. The health plan paid 50% of the allowable amount in the form of a check to the plan member. Oddly, the Evidence of Billing indicated that none of the $8,000 claim was covered, even though they sent a check to the plan member for 50% cost-sharing for the test. Regardless, the plan member is still responsible for full $8,000 to the lab for the test.
While the Affordable Care Act has brought transparency for consumers to compare health insurance plans, it has failed to lift the veil of secrecy surrounding how much health care services actually cost. This is particularly important for consumers who have high deductible PPO Bronze plans who would like to learn the health plan’s negotiated rate for a health care procedure.
Health Net of California announce on January 11th that because they were unable to reach agreement on reimbursement costs, specific Tenet Hospitals will no longer be a part of their network of service providers for certain Medicare, Medi-Cal and commercial health insurance plans.