INSURANCE out-of-pocket question

[mafibisha]

I had a necessary medical procedure a few weeks ago. All is well, thank God.

But the bill is more painful than the procedure. Only 1/3 was covered by insurance, and we owe over 2K out-of-pocket.

I have been treated for this before and it's medically necessary, so was shocked, to say the least. Our insurance has changed lately (paying more for obviously less coverage ugh) but this is shocking and seriously painful.

For anyone knowledgeable about insurance: do I have any recourse? I have read that some doctors will adjust the charge, but when or how does that happen? Anything else I can possibly do?

Would be very grateful for any advice. TIA.

 

[mistysue]

The amount you owe- is it your deductible plus some additional percentage ("co-insurance")
If so, not really any recourse but the good part is that money all goes toward your maximum out of pocket amount for the year. Once you meet your max. out of pocket you no longer pay any coinsurance, so the most you will pay even for huge catastrophic events would be a small copayment. (generally in the $10-$100 range) They aren't supposed to but you can always talk to the doctor to see if they can waive part of it. Technically, if they waive it they are supposed to tell the insurance company- which would result in the insurer paying less because your contract with them is that you pay "x" amount and they pay anything over that. Occasionally there are doctors who will waive it and not tell them meaning you never have to pay the amount you are essentially under contract to pay for the year.

If part of the claim was rejected you need to find out why. Two of my kids have had rejected claims because somebody at the doctor's office used an incorrect code which is an issue you need to take up with the person with that office who does the billing. They have to correct it and resend the information for you, the insurance company will not adjust it for them.

 

[Marionnette]

I had a necessary medical procedure a few weeks ago. All is well, thank God.

But the bill is more painful than the procedure. Only 1/3 was covered by insurance, and we owe over 2K out-of-pocket.

I have been treated for this before and it's medically necessary, so was shocked, to say the least. Our insurance has changed lately (paying more for obviously less coverage ugh) but this is shocking and seriously painful.

For anyone knowledgeable about insurance: do I have any recourse? I have read that some doctors will adjust the charge, but when or how does that happen? Anything else I can possibly do?

Would be very grateful for any advice. TIA.

We have always paid OOP for our own medical insurance, so it has always been kind of crappy for anything other than routine well visits and procedures. My current office copay for a visit to my primary is $40.

If your insurance paid out on the procedure at all, then they have accepted that it was medically necessary. You are responsible for your deductibles and copays as outline in your EOB.

The provider is under agreement with the insurance company to "accept assignment". This means that he has already agreed under contract to accept the amount that the insurance company has dictated to be a "reasonable & customary" fee for the service provided. In some cases, that amount is less than half of what the provider would have charged a patient with no insurance. IOW, you have already received a discount which has been negotiated on your behalf by the insurance company.

Some providers will work with you to allow monthly payments on the bill. They are not supposed to offer any further discounts as per their contract with the insurance company but will often make exceptions for those who choose to pay their bill in full rather than stretch out the payments. It seems to be acceptable to the insurance companies. It would not hurt to ask if this would be an option for you.

 

[ilovemk76]

Take to the bill owner. I have had many reduce what we owe if I paid in full, via CC, at the time of the call. I have had others reduce it to $0, as they have a certain amount of money allocated for "hardship".

You need to call before the bill is due and you must be ready to pay in full.

 

[JeremyGNJ]

Also keep a record of ALL medical receipts for the year. When you spend a lot on medical expenses, you can get a tax write-off.

Usually the normal expenses wont reach the threshold, but you never know. It also helps to do some planning.

Lets say this year, you had a few thousand dollars of medical expenses. Now your child needs braces. If you can afford to, pay for the braces 100% upfront in the same tax year as your medical expenses, rather than being on a payment plan. Because next year, you might not reach the threshold.

 

[Marionnette]

Take to the bill owner. I have had many reduce what we owe if I paid in full, via CC, at the time of the call. I have had others reduce it to $0, as they have a certain amount of money allocated for "hardship".

You need to call before the bill is due and you must be ready to pay in full.

In the past, "hardship" money was generally reserved to help out those who are uninsured. You're going to see a lot less of it available now that carrying insurance is mandatory in this country. Providers will also be less inclined to cut patients a break on their bills when their own reimbursements from insurance companies remain stagnant or become reduced.

 

[ilovemk76]

In the past, "hardship" money was generally reserved to help out those who are uninsured. You're going to see a lot less of it available now that carrying insurance is mandatory in this country. Providers will also be less inclined to cut patients a break on their bills when their own reimbursements from insurance companies remain stagnant or become reduced.

We had insurance and the Dr knew it. We never asked for the hardship write-off. They offered when they saw we owed $2k.

It really depends on lots of factors. One never a knows the outcome unless they ask.

 

[Mrs. Bradbury]

My advice would be to pick apart the medical billing, and insurance explanation of benefits. Did insurance deny anything? If so, appeal it. Does what the EOB says you owe line up with what the medical bill says you owe? Sometimes medical offices make mistakes with payments (and insurance write-offs). Finally, make sure the insurance company paid as they were supposed to according to your policy, and if you have a question about how they arrived at the amount they paid, call them and ask them to explain it. Review you policy first so that you can be "on point" during the call. Question everything politely, in other words.

Unfortunately, I have way too much experience dealing with the medical field and insurance companies. Good luck.

 

[Gumbo4x4]

We had insurance and the Dr knew it. We never asked for the hardship write-off. They offered when they saw we owed $2k.

It really depends on lots of factors. One never a knows the outcome unless they ask.

The other thing is sometimes the insurance company simply has not paid yet. Always ask, because once they have your money, good luck getting it back.

OP, I'm in the same boat. Things that cost me $75 10 years ago are $2-3,000 today. And the insurance premium is 4X what it cost back then. Terrible.

 

[mafibisha]

Thank you ALL for your replies.

I will make some calls.

So, who should I speak to at the insurance company? Do I ask for a specialist or supervisor or just whomever answers the call?

Also in the Doc's office. Do I ask for the billing / accounting person? Office manager? Should I wait until a follow up appointment and ask the Doctor?

Thank you again. Sort of reeling from this!

 

[ilovemk76]

Thank you ALL for your replies.

I will make some calls.

So, who should I speak to at the insurance company? Do I ask for a specialist or supervisor or just whomever answers the call?

Also in the Doc's office. Do I ask for the billing / accounting person? Office manager? Should I wait until a follow up appointment and ask the Doctor?

Thank you again. Sort of reeling from this!

I started with the phone number on my bill. My bills came after the insurance had already paid. I did not call the insurance company, since they paid exactly as I knew from my policy.

 

[ceecee]

I would start with the insurance company then the billing at the Dr. My OB appt.was rejected and applied to my out of network deductible ($4000) because they billed under another Dr in their practice who was not a PPO. Their mistake, so it was rebilled and paid. Maybe you owe more because you have a PPO plan now and didn't before? Your ins co should be able to tell you, good luck.

 

[APiratesLifeForMe2]

Thank you ALL for your replies.

I will make some calls.

So, who should I speak to at the insurance company? Do I ask for a specialist or supervisor or just whomever answers the call?

Also in the Doc's office. Do I ask for the billing / accounting person? Office manager? Should I wait until a follow up appointment and ask the Doctor?

Thank you again. Sort of reeling from this!

Call the insurance company first. They likely have a large phone tree that will send you to a billing department. Once you get connected to a human being explain that you wanted to know the reason why only $$$ was paid. Ask if an part of the procedures were denied. This will help you gain information. If there is an error that they are resolving make sure to get their name and ask for a confirmation number so you can follow-up in the future. Depending on the insurance company you may have to fill out an appeal form with documentation from the doctors office. These are an absolute pain and you typically have a VERY short time frame to submit them in.

Once you have that information I would call the doctors office. Ask to speak with someone who can answer questions about your bill. If something was denied by the insurance company (you would have received this in your first call) it may have simply been miscoded. Ask the doctors office to review and if something was miscoded they likely just need to rebill.

Things like this happen all the time and unfortunately it is in the hands of the patient to do the footwork to resolve it. My uncle once went to the ER and ended up being diagnosed with salmonella. They received a bill from the hospital saying insurance denied 100% since it was not a medically necessary trip to the ER. Obviously that's a bunch of phooey so it took a lot of phone calls and leg work but in the end it was all covered.

Good Luck

 

[Arielle22]

Did you receive a bill from the doctor or an explanation from insurance on what was paid? Most insurance companies send out a form explaining what was charged, what was paid and what you need to pay.

By comparison the doctor's bill may originally have the standard rate listed rather than the insurance negotiated amount.

 

[tvguy]

Our insurance changes on January 1, 2013. We have to pay $2,500 before the insurance pays a penny. But the premium went down by $3,000 a year because we have the higher deductible. Our out of pocket last year was $2,800, so we ended up $200 ahead of the game.

 

[bumbershoot]

In the past, "hardship" money was generally reserved to help out those who are uninsured.

That has never been my experience in the past with us or friends I was close enough to to talk to about these things.

My advice would be to pick apart the medical billing, and insurance explanation of benefits. Did insurance deny anything? If so, appeal it. Does what the EOB says you owe line up with what the medical bill says you owe? Sometimes medical offices make mistakes with payments (and insurance write-offs). Finally, make sure the insurance company paid as they were supposed to according to your policy, and if you have a question about how they arrived at the amount they paid, call them and ask them to explain it. Review you policy first so that you can be "on point" during the call. Question everything politely, in other words.

Unfortunately, I have way too much experience dealing with the medical field and insurance companies. Good luck.

Absolutely YES to all of this.

Do not rest until you completely understand it.

If your insurance recently changed, are you in a brand new plan year? That might sound funny to those of you who have Jan-Dec insurance years, but our insurance year just started YESTERDAY. So as of yesterday we get to meet our deductible again, etc.

Is that the case for you, OP? Are you starting fresh, and thereofre while it seems it's a 1/3 cover, perhaps it's just your deductible and then the proper percentage of the allowable expense AFTER the deductible is, um, deducted?

1/3 is a weird amount to have insurance pay on something. So get to the bottom of this.

I once spent a year dealing with an ambulance company who had offered a discount and then taken it away, and who didn't believe me that my insurance company had paid anything. I had a high ded plan when they were relatively new, and the way it worked for non preferred providers (and no ambulance company was a preferred provider) was that they sent ME the money and I sent it on. Back and forth, and that rep is out of the office on sabbatical and blah blah blah.

And one brilliant day I managed to get a rep from my insurance company that looked just a touch deeper and realized that they had covered it as though the ambulance ride was NOT for an emergency. (why anyone would take an ambulance ride in a non-emergency when our county gets to PAY for ambulance rides I have no idea...a cab is a heck of a lot cheaper!) Ambulance had sent insurance the bill before the ER or doctors did, so their computers covered it at x percent. Bing bang boom she changed the coverage to y percent, and sent me another check. Same time the ambulance people gave in and gave me the discount they had offered a year earlier. Done.

I'm still battling with MIL's supplemental insurance people over a hospital bill from Fall 2012. (the info Medicare sent them was *blank* and their systems read that as Medicare didn't pay...Medicare paid 1000s and supplemental owes the rest!)

Don't give up! And don't stop until you understand it.

Our insurance changes on January 1, 2013. We have to pay $2,500 before the insurance pays a penny. But the premium went down by $3,000 a year because we have the higher deductible. Our out of pocket last year was $2,800, so we ended up $200 ahead of the game.

Nice!

 

[3boymthr]

I used to work for a major insurance company. There are some things to check on your EOB against the wording of your policy.

I know you said you have a deductible and OOP. Is it a coinsurance policy? Usually if this is the case it's X% of Reasonable & Customary or X% of the negotiated amount. If X% of R&C you are on the line for the additional amount over R&C unless you can get the dr/facility to accept R&C. If a negotiated amount check the wording of your policy because you may still be responsible for the amount over the negotiated amount - that one just depends upon the contract wording. Again, if you ask, the dr/facility may be willing to accept just the negotiated amount.

Also check your deductible wording, because sometimes a deductible is per treatment/procedure sometimes per day/admission. If two different "procedures" were done (even if they were both part of the same overall procedure) you may be paying double on the deductible.

Also where was the procedure done? This will drive the cost. If done in an OP facility you are going to pay more than if it was done in a doctor's office and even more if it was done inpatient. If it was done in the doctor's office did they pay for it as if it was done in an OP facility? Same for the OP vs. Inpatient. If either is the case call the insurance company and contest the payment. You may have to call where ever it was done to make sure that the facility codes and procedure codes are changed and rebilled.

 

[mafibisha]

I used to work for a major insurance company. There are some things to check on your EOB against the wording of your policy.

I know you said you have a deductible and OOP. Is it a coinsurance policy? Usually if this is the case it's X% of Reasonable & Customary or X% of the negotiated amount. If X% of R&C you are on the line for the additional amount over R&C unless you can get the dr/facility to accept R&C. If a negotiated amount check the wording of your policy because you may still be responsible for the amount over the negotiated amount - that one just depends upon the contract wording. Again, if you ask, the dr/facility may be willing to accept just the negotiated amount.

Also check your deductible wording, because sometimes a deductible is per treatment/procedure sometimes per day/admission. If two different "procedures" were done (even if they were both part of the same overall procedure) you may be paying double on the deductible.

Also where was the procedure done? This will drive the cost. If done in an OP facility you are going to pay more than if it was done in a doctor's office and even more if it was done inpatient. If it was done in the doctor's office did they pay for it as if it was done in an OP facility? Same for the OP vs. Inpatient. If either is the case call the insurance company and contest the payment. You may have to call where ever it was done to make sure that the facility codes and procedure codes are changed and rebilled.

OP here. Thank you ALL for your replies. I appreciate them all very much.

After speaking with the insurance company and out-patient 'main' office, my deductible (for the year) is very high (for us anyway) and that was subtracted from the bill.

And then the usual and customary amount was accepted by the Doctor / facility. So it appears we do owe the entire amount.

I could really cry. That might be better than the sleep I've lost over this. And I know we're all being subjected to this, but its still very upsetting. We've always had co-pays and moderate insurance, but this is new and just very scary.
Our premium per month has doubled, and is more than our first house payments were, so that's another reason why this is shocking.

Again, I know everyone is going through this. But it still hurts, and hurts a lot. They are doing a re-check of the codes, just in case, and then will set us up on a payment plan (never had to do that before either) Now I'm praying there's not a huge, high interest rate too

Thanks again everyone for your thoughts.

 

[Mickeyluver37]

OP here. Thank you ALL for your replies. I appreciate them all very much.

After speaking with the insurance company and out-patient 'main' office, my deductible (for the year) is very high (for us anyway) and that was subtracted from the bill.

And then the usual and customary amount was accepted by the Doctor / facility. So it appears we do owe the entire amount.

I could really cry. That might be better than the sleep I've lost over this. And I know we're all being subjected to this, but its still very upsetting. We've always had co-pays and moderate insurance, but this is new and just very scary.
Our premium per month has doubled, and is more than our first house payments were, so that's another reason why this is shocking.

Again, I know everyone is going through this. But it still hurts, and hurts a lot. They are doing a re-check of the codes, just in case, and then will set us up on a payment plan (never had to do that before either) Now I'm praying there's not a huge, high interest rate too

Thanks again everyone for your thoughts.

Is this an official High Deductible health plan and are you eligible for an HSA? We have had this type of insurance since 2007 and while I don't love it, after a few years we just got used to the HSA contribution coming out of the paycheck, and there always being enough to cover the expenses in the account.

Crossing my fingers for you that there aren't any fees or interest associated with the payment plan!

 

[angwill]

OP here. Thank you ALL for your replies. I appreciate them all very much.

After speaking with the insurance company and out-patient 'main' office, my deductible (for the year) is very high (for us anyway) and that was subtracted from the bill.

And then the usual and customary amount was accepted by the Doctor / facility. So it appears we do owe the entire amount.

I could really cry. That might be better than the sleep I've lost over this. And I know we're all being subjected to this, but its still very upsetting. We've always had co-pays and moderate insurance, but this is new and just very scary.
Our premium per month has doubled, and is more than our first house payments were, so that's another reason why this is shocking.

Again, I know everyone is going through this. But it still hurts, and hurts a lot. They are doing a re-check of the codes, just in case, and then will set us up on a payment plan (never had to do that before either) Now I'm praying there's not a huge, high interest rate too

Thanks again everyone for your thoughts.

You are not alone OP and many are in the same situation. I cried all day after finding out the hospital was charging me $11,000 for 2 shots that I could get for $1400 and inject in my muscle myself. It passed my $6000 deductible but in order to get that deductible paid off I have to pay $500 a month on top of the $582 for the insurance. That is more than our mortgage. Now we need to pray my husband or son do not get sick and we have to pay their deductible. We too are on a payment plan and it is going to take us a lot longer than a year to pay it off. I finally decided I can worry about it or I will die of stress. lol I will just pay what we can afford each month and only think of it when paying the bill. It was that or ignore my cancer. We have to do what we have to do. No more Disney trips for us but our health is worth more than that anyway.