mum 2 3

OK I have no idea how the medical stuff works.
We have insurance through my husbands work. When my son cut his thumb badly and I took him to the ER I thought my bill would be the $125 copay it says on the card next to ER. (Usually at the doctors we pay the $30 as per the card) His thumb was glued and we were out in just over an hour.

I got a statement for $78.40 from the insurance company saying this is not a bill. It showed they were billed $392, paid $313.60 (80%) and we pick up the $78.40 (20%) I thought we would receive a bill for the same amount and that would be the end of it. This letter does show the annual deductible of $1000 and we have used $402 so $597.58 left.

Today we got a bill from the hospital for $579.40. This shows the insurance as paying $107.60?

I called the insurance and an automated voice tells me they were billed $687, paid $417.60 and we owe the hospital $579.40.

I checked before we went to the ER and it was in network.

Going to call back insurance and keep pressing different options to hopefully speak with a human but does anyone have any ideas how this is supposed to work??

If we do owe the $597 I am hoping that uses up the rest of this years deductible and from now on we wont have to pay any more?? Till next year when he does it all again...

Pulaski

I think you need to start with the insurance, because until you know what was actually billed and what they actually paid everything else is variable.

Meanwhile you might want to check what is legal in your state because I heard recently that some states allow hospitals and other medical service providers to pursue patients for the difference between what is billed and what insurance pays. Our medical bills are typically of the form: Billed: $100, Insurance paid: $75, Copay:$10, due from you $8 (where $75+$10+$8 is the maximum allowed by the insurer for the procedure, and depending on the procedure, the "$8" is often $0), and the difference of $7 has to be swallowed by the provider. Some states allow them to come after the patient for the $7.

Duncan Roberts

If you went to the ER you should be looking for 3 or 4 claims, not just 1. The ER might be in network but a doctor might not have been or a service might not be covered under your plan. Each part of the visit will be a separate claim, ER, the doctor, and x-ray or other scans, etc will all be separately billed.

Michael

Deductible means that you pay that amount before the insurance company pays their share of the bills. Maximum annual out of pocket expense means that once you pay that amount, the insurance company pays 100% of the bills. So normally if you had a deductible of $1,000 and a maximum annual out of pocket expense of $2,500, you would pay the first $1,000 and share costs with the insurance company until you paid $2,500 and then the insurance company would pay all bills after that for the remaining part of the year.

However some plans don't have a deductible for certain procedures such as office visits which may have a co-pay of $30 or lab work which may be covered 100% immediately. Unfortunately unless you can understand your plan by yourself or with the assistance of HR, there is no way to determine how a plan works since all work differently. However the co-pays and other medical bills that you have been paying should go towards the deductible and maximum annual out of pocket expense.

Even when your deductible is reached, it can still be confusing since office visits will still have the $30 co-pay, some procedures will bill you a percentage, and other procedures will be paid by the insurance company 100%.

As far as what is going on with the billing, that is anyone's guess and you'll just have to keep questioning the insurance company until you have a satisfactory answer.

penguinbar

If they say that the Dr. was not in network I would fight it. My husband had to go to the ER a few years ago and they said that the Dr was not in network. I argued that the ER was covered for a copay and I was not going stop and ask the Dr if they were in network while my husband is being treated. It took about a year to settle and lots of phone calls and letters but they finally agreed to pay.

penguinbar

Just don't take no for an answer. I had to have some tests last years and I was double billed. I was also billed for a test that I didn't even have!

scrubbedexpat097

I'm having the same problem right now. I was admitted from the ER and my Insurance states that ER fee is waived if this happens. Now I have a bill from the ER for $1,400. The doctors billing company say the ER doctor was out of network, even though the hospital and the ER are in Network.

I have got so frustrated with it that I've given it to the HR dept to try and figure it out for me.

Bob

Joys of healthcare. Expects the bills to keep rolling in for the next year as someone or something else tries to tack on an expense and have some service that might not be in network.

Something as simple as getting an x-ray might involve one company for the machine, another for the space of the machine, the person performing the test and someone to read the results.

Blood test might include someone taking the blood, a company to store the blood, company to test the blood, a doctor to read the results, a company to dispose of the sample.

All of those would have to be in network and all bill your insurance.

This is partly why it is complicated and why billing can go on for ages.

I'm not even talking theory for the above situations as that is exactly what we have experienced and found one in the chain not to be in network make it a big nightmare. This is all from visiting one room in a hospital, one that is a preferred in network related hospital to our PCP.

penguinbar

They tried to bill us seperate for the xrays because they had to take my husband to a different floor than the emergency room. That part actually got sorted out pretty quickly.

Jscl

For my insurance, but I don't know how universal this is, if you go to a facility that is in network and have no say over a particular person that is assigned to you, then you pay for that person as if they are in network, regardless of whether they are signed up with the network or not. I've had the paperwork do this automatically on one occasion and have had to ring them on two other occasions to get them to adjust the bill.

It's worth asking them if nothing else.

Jscl

Mum 2 3, in reply to your original post...

I think this is because of two things - one event very often produces multiple bills from different parts of the hospital, and because of your deductible. Different plans work in different ways but by the look of it, yours is a plan that makes you pay the deductible FIRST before the copay or percentage part comes in.

So the basics: what happens is the hospital bills the insurance their rack prices. Because the hospital was in network, the insurance says no you can't charge us that, you can only charge us this, this is the 'negotiated' price. Then the insurance decides what portion of the negotiated cost you have to pay, and that will depend on your plan and how much you have paid on other things this year.

Some things (annual preventable exams mostly) you pay $0 for.
Some things you pay co-pays for (NOT SUBJECT to deductible).
Some things you pay co-pays for (SUBJECT to deductible).
Some things you pay 20% of negotiated cost for (NOT SUBJECT to deductible).
Some things you pay 20% of negotiated cost for (SUBJECT to deductible).

NOT SUBJECT to deductible means you just pay the 20% of the negotiated amount billed, or you just pay the flat co-pay, regardless of the negotiated amount billed.

SUBJECT to deductible means you have to have paid the FULL amount of the deductible before the insurance contributes anything. E.g. for an event in the 20% SUBJECT category if you had paid $0 of your annual deductible this year and you were sent a negotiated bill of $1500, your portion would be the full $1000 of the deductible + 20% of the extra $500, for a total of $1100. The insurance company would pay $400.

At the start of the year with your insurance you should have received an information sheet/booklet describing which events are subject to which scenarios. It's usually pretty difficult to understand, unfortunately.

Also different parts of what you think of as one hospital visit might be billed in different ways, depending on what happened and how you were treated.

Have you used any of your deductible this year? What the first statement was saying was that you have paid (or have been billed) for $402 for covered services so far this year (docs appts, prescriptions, other hospital visits). That figure is either made up of any co-pays or percentages or anything else you have paid (or recently been billed) up until that point. Note: it might be that that $402 includes a billing you haven't actually received yet, but that the insurance has just processed.

You may get billed by the ER, the hospital, the doctor, maybe for consumables (I don't know how it works in the ER), and they might send you separate bills. You might get another statement or bill tomorrow (or within the next month or so) from a different department/person that makes the current bill make more sense, but it seems to me that the bill you've received from the hospital is regarding a different billing to the one on the insurance statement. It seems like the insurance statement is for something the insurance pays 80% of NOT SUBJECT to deductible, and it seems like the hospital bill is for something the insurance pays either as a co-pay or percentage SUBJECT to deductible. That's why you're having to pay the first $500+ of it.

Things you need to check:
1) that what you think of as an ER visit was actually what the hospital thinks of as an ER visit, and they didn't (correctly or incorrectly) bill it as something else (like an outpatient visit).
2) what you're meant to pay for an ER visit and whether it is subject to the deductible (while you're there maybe check how they charge for outpatient visits, as that might be the issue here)
3) check your last statement (in 2013) from the insurance company before this happened and see how much of the deductible you have outstanding (note: there might be different deductibles for individuals and for the family as a whole)

IF the billing was correct and the $500+ they've billed you fulfils your deductible for the year then from now on you will only pay the co-pay or percentage, even on events subject to deductible, because you've already paid your deductible for the year. Once your TOTAL payment on covered medical expense reaches your annual maximum (should also be stated on your original insurance paperwork, look for something like $2000-$3000 and it might give one figure for individuals and one for the family) only then do you pay nothing more for covered medical expenses this year. Then it all resets for 2014.

Hope that helps but it's late and I might not have made much sense. basically it's all a nightmare, the system is difficult enough and both providers and the insurance companies routinely make mistakes.

doogiemd

Having shadowed docs in the US recently for experience let me say ppl can't afford these bills even with insurance! So u think locals pay up?? Hell no. Payment plans are set up but rarely adhered to. Lots I mean lots is written off. I have seen hosps accept 10% of bill as payment. Better that than nothing. Can tell u plenty don't pay a dime.

Bob

Depends on the hospital, or local one even sold a $5 bill to a collections agency when they sent the bill to the wing address and we never got it. This stuff affects your credit history.

Mallory

For a cut thumb it's cheaper to go to an urgent care center. ER's are a very expensive and sometimes unnecessary option. My grandson fell and cut his head, and they glued it up fine at the urgent care center. Make sure it's in network though. It's usually much quicker to be seen too.

Giantaxe

Good advice. Unfortunately, you can't always find one that's "in-network" for your insurance. When I fell and sprained my ankle and injured my knee, there wasn't a single urgent care center in San Francisco that was on my insurance. So I ended up costingthem more than $3k going to the emergency room. Now there is a single urgent care center downtown that's on my insurance.