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Understanding Insurance

High Deducible Insurance 

Many health insurance policies today have high deductibles that are required to be paid by you before they will pay out any coverage for your care.  In theory, high deductible plans keep premiums lower but require you to pay a lot of upfront costs. 


However, the annual out-of-pocket costs are increasing for individual and family plans every year.  Even with the implementation of the Affordable Care Act, the maximum out-of-pocket cost for any individual Marketplace plan for 2017 is $7,150 for an individual plan and $14,300 for a family plan (source).

Going Out-Of-Network 

Going out-of-network has always been taboo thanks to the insurance companies and healthcare providers.  Guess what?  It's by design. Most health insurance companies will warn against going out-of-network and here’s why. 


"In-network" healthcare providers have contracted with your insurance company to accept certain negotiated "discounted" rates. You typically will pay less with an in-network provider because they are limited on what they can charge. "Out-of-network" providers have not agreed to the discounted rates. You typically will pay more with an out-of-network provider because they are not limited on what they can charge.


Advance Patient Imaging is changing this concept. We charge less than the negotiated rates offered by health insurance companies. We provide true price transparency with our all inclusive pricing. We have no additional charges or hidden fees. You always know your out-of-pocket expenses before the procedure. 


Another reason health insurance companies will advise against going out-of-network is due to deductibles. You may have a higher deductible for out-of-network coverage and some policies may not apply out-of-network cost to your deductible at all.  However, it's a fact that 75% of people never reach their annual in-network deductible so it becomes a moot point. Again, that's by design.


Do yourself a favor and get involved with your healthcare decisions!  Pick up the phone and talk to your insurance company about your deductibles and how to save money that's coming out of your pocket. 

Fixed Price vs. List Price

Most insurance companies negotiate contracts with medical providers behind closed doors and are not primarily concerned about getting the most affordable, quality care for their members. Additionally, they are not overly concerned with high annual deductibles that you are responsible to pay out-of-pocket before the benefits kick in.  The main concern for the insurance company is subscriber premiums, since this is the source of their revenue.


If you have insurance, the insurer negotiates on your “behalf” with hospitals and outpatient diagnostic centers for a contractual rate.  This contractual rate is the maximum amount that a provider can collect for a covered service, i.e. an MRI or ultrasound exam, but the contractual rate is not the same for all medical providers, even in the same town.  


Medical providers have “List Prices” which are the base prices they charge before the application of any discounts or reductions to reflect the rates negotiated by insurance companies.  These “List Prices” matter because that's where negotiations begin, the same way car dealers bargain down from the sticker price.


What is not widely known is hospitals use these List Prices as leverage when negotiating with insurance companies and to convince self-pay patients of a higher perceived savings when they apply discounts to their prices. 


The chart below illustrates the average “List Price” for a very common MRI exam (lumbar spine without contrast) at several local hospitals compared to the fixed charge of Advanced Patient Imaging.  


list price chart


As illustrated in the chart above, Advanced Patient Imaging offers you a significant savings over all the local hospitals in the Cincinnati area. Based on the List Pricing above, you will save between 63% and 80% for a lumbar spine exam, regardless if it's with contrast or without contrast and we include the radiologist report at no additional cost.  Keep in mind, you will pay more for contrast exams at local hospitals and the radiologist report is billed to you separately. 


Even when you apply the discounts from the hospitals or insurance companies, you will still, most likely, be paying too much for medical imaging exams.  If you have not met your deductible for the year or have a co-insurance, then all or part of the charges for your imaging exam will be your responsibility, which could cost you hundreds or thousands out-of-pocket.   

Time To Get Engaged In Your Healthcare

Do you really think the insurance companies are worried about the high cost of healthcare? No, they are concerned with salaries, stock options and other forms of compensation. Do you really think the government is worried about the high cost of healthcare? No, they are concerned with collecting more taxes and penalties through healthcare.


Like it or not, healthcare is a consumer product and you should treat it as such. Advanced Patient Imaging is offering a real solution to overpriced healthcare. Bottom Line: It’s time to become your own consumer/patient advocate and shop around for the best service and price that fits your budget.


Insurance Terminology

All companies have their own specific terminology they use day-to-day to conduct routine business. Health insurance companies are no different. Understanding the terminology used by health insurance companies will cut down on a lot of the confusion you may have about their products and how they work for you. 

Below we explain some of the common terms used by a health insurance company. This is a basic guideline; with so many variations of insurance policies it’s impossible know the details of every plan and how they work.  You should always consult your insurance company for final clarification regarding your policy.    

Cost Sharing

When both you and your health insurance company pay part of your medical expense, it’s called cost sharing. Premiums, in-network/out-of-network, deductibles, co-insurance, out-of-pocket maximums and copayments are all examples.

In-Network / Out-Of-Network

An in-network provider is one contracted with the health insurance company to provide services to plan members for specific pre-negotiated rates. An out-of-network provider is one not contracted with the health insurance plan.


Deductible is the amount you pay for health care services before your health insurance begins to pay in a calendar year.

For example, if your deductible is $4,000 and you have three $1,500 procedures in a year, you will have to pay the full bill for the first two procedures and $500 of the third…your insurance will cover half of the third procedure.  After that, some services you receive may be covered at 100% but most likely you may have to pay co-insurance.


Co-insurance is a health care cost sharing between you and your insurance company. Typically, you start paying co-insurance after you've paid your plan's annual deductible.  The cost sharing is expressed as a percentage rather than a fixed dollar amount. If your co-insurance is 80/20, that means that your insurer covers 80% of annual medical expenses and you pay the remaining 20%. The cost sharing stops when medical expenses reach your out-of-pocket maximum, which is higher than the annual deductible amount. 

For example, let’s say you have already paid out (or met) your $4,000 annual deductible and your co-insurance is 20%.  Your doctor orders a MRI of the brain (with and without contrast) that cost you $2,524.00, which is the average list price in Cincinnati.  Once you receive the bill for $2,524.00, you would pay $504.80 and your insurance company would pay $2,019.20. 

Out-Of-Pocket Maximum

    Out-of-Pocket Maximum (also known as Out-Of-Pocket Limit) is the maximum amount of money you pay for medical service (including co-pays, deductibles and co-insurance) in a calendar year before your health insurance starts to pay 100%.

    The difference between your deductible and an out-of-pocket maximum is subtle but important. Out-of-pocket maximum is typically higher than your deductible to account for things like co-pays and co-insurance.

    For example, you may have a deductible of $4,000 but your out-of-pocket maximum could be $6,500.  If you hit your deductible of $4,000 but continue to go for office visits with a $25 co-pay, you’ll still have to pay that co-pay until you’ve spent your out-of-pocket maximum, at which time your insurance would cover everything.


    Co-pay is a fixed amount you pay for a health care service, usually when you receive the service. The amount can vary by the type of service. You may also have a co-pay when you get a prescription filled.

For example, a doctor’s office visit might have a co-pay of $30. The co-pay for an emergency room visit will usually cost more, such as $150.

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