Insurance really a racket. It is. Let's say we have an E/M code, moderate complexity and for the geographical region a "normal charge can be between 90-150 bucks. Providers under contract with that ins. company are going to be reimbursed anywhere from 35-70 dollars for that code.
Most providers would be more than happy to accept that from a non insured person too, but they can't "charge" you that much because ins company lobbying has made it "illegal" for a provider to have 2 different rate scales. You can get around this by having a TOS or time of service reduction and it has to be offered to everybody. There are certain criteria that must be met, like the appt has to be made so much in advance and you MUST pay at the time of service. If you only pay part, make a payment plan, get billed later etc it doesn't apply and legally you must be charged the full amount with no applicable discount or the provider runs the risk of being charged with insurance fraud.
But if the provider is only charging 70 bucks for that same 99203 E/M code the insurers gather that info and it wouldn't be long till the reimbursement for those Evaluation codes went down to 35 bucks, so the charges are always going to be much higher.
They also like to dictate procedure codes. They will continually deny certain procedure codes and make it very difficult to get paid. So the providers must pay staff to call, write letters and do appeals in order to get a procedure code paid that should be paid in the first place no questions asked. Usually it involves sending claims, getting denied and depending on the provider certain things happen from there. A lot of the larger ones will jsut pass it on to the patient and make them responsible, because ultimately they are. They can't or won't spend the extra overhead to fight insurance claims for hundreds of other people. But some will. They then have to send in requested notes, and they get denied again. Then they have to write a letter for an appeal and those go thru various stages. Some just a simple phone call, after a 30 minute wait, the adjuster will say, yep, you're right, and then pay it.
Some say up, you're right, the claim will be reprocessed and payment should be recieved in 10-15 days. 15 days later it was denied again and the process starts over and they say, oops. our mistake, we'll have to reprocess, fun stuff.
Others will tell you outright that you can appeal and we'll keep denying it, but if you use "X" code we'll pay. So a lot of providers will just do that, easier and less hassle. The problem in doing that is INS. companies are gathering all that info to deny future claims. they gather all the data and say, "see, nobody is using this procedure code anymore so the therapy or procedure must not be effective" and use that gathered info to deny more claims and other insurance companies latch on.
It's really sad game of back and forth and trying to get paid and deny, but I guess necessary becaus so many try to screw the system in the first place.