The #Negotiated Fee – Rate is the amount of payment that an Insurance Company has negotiated with the Participating Provider as the maximum they can charge both the Insurance Company and YOU! * Page 42 Blue Cross EOC  & 167   More explanation

So, NO a doctor on the Insurance Companies Participating Provider list, can NOT make you pay the difference!  That’s why it’s important to double check with the doctor and the LIST!

Excerpt from Blue Shield Explanation

Excerpt from Blue Shield Explanation

It’s the  secret number the insurance company and the provider have worked into their contract. The industry often calls that number the “adjusted rate” or the “negotiated rate.”

View an actual Specimen Policy Explanation EOC Evidence of Coverage – Page 42 Blue Cross EOC  & 167 More explanation– 


How do I know that the amount I’m being billed
is the correct amount?


Once your insurance carrier pays their portion of the bill, they will send you an explanation of benefits (EOB) to show how the claim was paid. You can compare your EOB to the statement sent by the hospital. How the carrier paid the claim is based on their contract with us and their contract with you. If you feel the insurance company should have paid a higher amount, please contact them directly for resolution. Patient Billing FAQ’s

Todd Friedman, Esq. can help if debt collectors are harassing you when you don’t owe the $$$

Does the negotiated rate apply to #prescriptions Rx too?

That is, if I have Blue Shield Bronze Plan with no Rx coverage till the $7k OOP Out of Pocket Maximum has been met, do I get the lower negotiated – contracted rates?


Yes, see excerpts from EOC below.

Blue Shield Bronze PPO EOC – Relevant excerpts

Blue Shield Participating Providers

Blue Shield Participating Providers include primary care Physicians, specialists, Hospitals, and Alternate Care Services Providers that have a contractual relationship with Blue Shield to provide services to Members of this Plan.  Participating Providers are listed in the Participating Provider directory.   See below, thus Pharmacies are participating providers.

Participating Providers agree to accept Blue Shield’s payment, plus the Member’s payment of any applicable Deductibles, Copayments, and Coinsurance or amounts in excess of specified Benefit maximums as payment-in-full for Covered Services, except… Page 2 of EOC

Blue Shield negotiates contracted rates with Participating Pharmacies for Drug. If the Member’s Plan has a Calendar Year Pharmacy Deductible, the Member is responsible for paying the contracted rate for Drugs until the Calendar Year Pharmacy Deductible is met.

The Member must pay the applicable Copayment or Coinsurance for each prescription when the Member obtains it from a Participating Pharmacy. When the  Participating Pharmacy’s contracted rate is less than the Member’s Copayment or Coinsurance, the Member only pays the contracted rate. Page 25 of EOC

Learn More===>  EOC explains all about Rx benefits


#Out of Network Problems

Insure Me on MD’s using bait and switch to mess with the networks 6.18.2016

Pending Legislation to block surprise medical bills 89.3 KPCC  6.20.2016    AB 72 

 Provider Directories

SB 137  Insurance Code §10133.15  Effective 7.1.2016

  • Health plans must update their printed directories at least every quarter and their online directories at least every week if providers report changes.
  • Provider directories must be posted online and be available to anyone, not just enrollees. Print directories must be available upon request.
  • The directories must “prominently” display directions for consumers who want to report inaccuracies. Upon receiving complaints, plans have 30 business days to makes changes, if necessary.
  • Providers must inform plans within five business days if they are no longer accepting new patients — or, alternately, if they will start accepting them.
  • Health plans can delay payments to providers who fail to respond to attempts to verify information.

The law also gives consumers recourse. Let’s say you use a provider directory to find a doctor but you’re billed the out-of-network price because the directory was wrong. In that case, health plans must reimburse you the amount beyond what you would have paid to see an in-network doctor. CA Health Line 8.26.2016

Bay Area – Blue Cross – virtually no providers – Insure Me 8.25.2016


Out of Network Provider

The use of health care providers who have not contracted with the health plan to provide services. HMO members are generally not covered for out-of-network services except in emergency situations. Members enrolled in preferred provider organizations (PPO) and point-of-service (POS) coverage’s can go out-of-network, but will pay some additional costs.  Learn More ==>  Specimen Policy Definition page 168

Get FREE #Instant Individual & Family  California  Quotes – Including Tax Subsidy Calculation – Guaranteed Issue – No Pre-X Claus

Get FREE Instant Quotes - Including Tax Subsidy Calculation - Guaranteed Issue - No Pre-X Clause

Full Instructions to use Individual Quote Engine
Takes all the complexity out of CFR §1.36B-3 *

how to get quote - full instructions video by steve

#Balance – Surprise Billing

Balance Billing is when an insurance plan covers less than what a doctor, hospital, or lab service wants to be paid.   The health-care provider demands, bills the balance from the patient. Uncertain and fearing the calls of a debt collector, the patient pays up.  Business Week 8.27.2008 is NOT allowed in CA for Emergency Care, even if out of network.   See our provider finder 

The No #Surprises Act

The no surprises act contains key protections to hold consumers harmless from the cost of unanticipated out-of-network medical bills. Surprise bills arise in in emergencies – when patients typically have little or no say in where they receive care. They also arise in non-emergencies when patients at in-network hospitals or other facilities receive care from ancillary providers (such as anesthesiologists) who are not in-network and whom the patient did not choose.



AB 72 Bonta

Doctors at Hospital #must take hospital negotiated rate

AB 72, Bonta. Health care coverage: out-of-network coverage.
This bill would require a health care service plan contract or health insurance policy issued, amended, or renewed on or after July 1, 2017, to provide that if an enrollee or insured receives covered services from a contracting health facility, as defined, at which, or as a result of which, the enrollee or insured receives covered services provided by a noncontracting individual health professional, as defined, the enrollee or insured would be required to pay the noncontracting individual health professional only the same cost sharing required if the services were provided by a contracting individual health professional, which would be referred to as the “in-network cost-sharing amount.”
The bill would prohibit an enrollee or insured from owing the noncontracting individual health professional at the contracting health facility more than the in-network cost-sharing amount if the noncontracting individual health professional receives reimbursement for services provided to the enrollee or insured at a contracting health facility from the health care service plan or health insurer.
Learn More ===>
Emily Bazar CA Healthline 6.26.2017 Plain Language Explanation
Blue Cross Group – Announcement

Blue Shield – Announcement

California Assembly Bill (AB) 72 Out-Of-Network Coverage and Member Cost-Sharing

New California law Effective July 1, 2017, this new state law protects individuals from receiving unexpected “surprise or balance” medical bills from an out-of-network (OON) doctor when receiving inpatient and outpatient non-emergency care and services at an in-network healthcare facility such as a hospital, clinic, lab, imaging center or other healthcare facility.

Changes to out-of-network coverage and cost-sharing When individuals go to an in-network facility for care but receive services from an out-of-network doctor or healthcare provider, they only have to pay their in-network cost-sharing amount that counts toward the annual deductible and annual out-of-pocket maximum limits according to their health plan. An out-of-network doctor should only bill individuals after both parties have received a copy of the Explanation of Benefits (EOB) that reflects the correct in-network cost-sharing amount owed for the care received. If for any reason the out-of-network doctor or healthcare provider receives payment that is more than the cost share allowed, the out-of-network doctor must refund the overpayment within 30 days. Below is a list of affected Blue Shield health plans

More explanation from Blue Shield in a private email 8.14.2017

ALL hospitalizations require pre-auth unless they are an emergency.  In this pre-auth process, the provider(s) and the Plan are coordinating and acknowledging in-network.  This process prohibits people from using out of network providers for procedures ~  If while in the hospital, a person requires additional care that was outside the original scope of the intent, they cannot be charged as out of network.  I used anesthesiologist’s as an example in the meeting as it is that issue that we have all been dealing with for years and years.

Members will receive an endorsement letter.


#Advocates Guide to Surprise Medical Bills

Advocates guide to surpize medical bills

Specimen Policy #EOC with Definitions

It's often so much easier and simpler to just read your Evidence of Coverage EOC-policy, then look all over for the codes, laws, regulations etc!  Plus, EOC's are mandated to be written in PLAIN ENGLISH!

Specimen Policy with Definitions

Steve Explains how to read EOC

#Transparency-in-coverage regulation

Another set of transparency rules, the 2020 final transparency-in-coverage regulation, will require large employer-sponsored plans and insurance issuers to publicly disclose extensive price and cost-sharing information beginning in 2022. Among other details. the disclosure must provide certain prescription drug pricing information, including a prescription drug’s net price after manufacturer rebates, discounts, chargebacks and other reductions. HHS has released some information on the form and manner of this public disclosure in data collection notices published last year. Those templates set out the data elements for disclosures by HHS-regulated insurers. Whether DOL will create different templates for ERISA plans is unclear.

Hospitals will be required to #post online their standard charges!

This was to have started in 1.1.2018 I’m not sure if it really has.    Did you know they are already required to do this if requested?  Cal Broker 8.7.2018 * The Hill *    CMS is looking for a contractor to create a price comparison tool.  Modern Health Care 8.28.2018 LA Times 6.10.2016

On the other hand hospitals have asked the courts to through the rule out!  Modern Health Care 5.7.2020 * New York Times 12.4.2019 *

Trump Executive Order 

Trump Executive order directs federal agencies to issue guidance that would:

  • Require hospitals to disclose information about negotiated rates in a format that’s understandable and usable by patients and consumers.
  • Require insurance companies to provide patients with information about the cost of their care, including out-of-pocket costs before they receive services.
  • Develop a comprehensive roadmap for consistent, limited, and consumer-centric quality metrics.
  • Expand the availability and use of HSAs to cover direct primary care arrangements and healthcare sharing ministries. It also seeks to include more preventive services that can be covered in the deductible period.

Issue guidance on the number of funds that can be carried over at the remainder of the year for FSAs.  WhiteHouse.Gov *

Rules issued – Modern Health Care 11.15.2019  *  *

For a fact sheet on the Calendar Year (CY) 2020 Outpatient Prospective Payment System (OPPS) & Ambulatory Surgical Center (ASC) Price Transparency Requirements for Hospitals to Make Standard Charges Public final rule (CMS-1717-F2), please visit:

For a fact sheet on the Transparency in Coverage Proposed Rule (CMS-9915-P), please visit:

The final rule (CMS-1717-F2) can be viewed here – PDF

The proposed rule (CMS‑9915‑P) can be viewed here – PDF

Healthcare Payments Database,

Some  argue that negotiated prices are proprietary — that is, legally protected trade secrets — and that their disclosure could foster collusion between providers. Other observers maintain that disclosure could help policymakers understand what is driving cost increases and how best to target efforts to make care more affordable.

The Secret of Health Care Prices: Why Transparency Is in the Public Interest, analyzes, for the first time, the legal and economic implications of collecting and releasing this data, including a review of trade secret statutes and case law regarding the protection of negotiated prices as trade secrets and data dissemination practices from the 18 states with mandatory APCD collection programs.

Accompanying the report, a blog post  examines recent developments in price transparency policy, the arguments for and against the release of proprietary price information, and steps California could take to help ensure its new database is a success

Links & Resources



Treatment Cost #Estimator Tool

The tool is for all Kaiser Members that are enrolled on Deductible or  Health Savings Account Plans.  The cost estimates are for services that are marked "after deductible" to give members an idea of the cost of  those services.

Kaiser Estimates Tool


2 comments on “Negotiated Rates – Balance Billing? Transparency No Surprises

  1. After contacting my providers, it isn’t going to make much difference to them what I am on – Grandfathered or ACA Obamacare, because, unbelievably to me, my present Grandfathered costly plan reimburses them less than Medicare does!

    This is a complete reversal of the 90s when my husband’s health insurance switched from private individual market to Medicare. After the switchover to Medicare, I had to fight for his treatment and doctors saw him as a one payment body in a bed. You wouldn’t believe how bad it was, all due to the difference in insurance..

    Now I am hearing just the opposite — Medicare has less restrictions on authorizations and better reimbursement than private health insurance! Unfortunately for us seniors the anticipated cuts to Medicare due to the newly passed tax bill could put us right back to the 90s Medicare scenario.

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