Insurance dispute question

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Zanne
Veteran Member


Date Joined Apr 2005
Total Posts : 3763
   Posted 3/7/2010 9:51 AM (GMT -7)   
At the beginning of the year we switched from an HMO to a high deductible insurance plan. Except for prescriptions, I hadn't gotten any of the bills for appointments until today. I just opened my first Explanation of Benefits and my first bill, came in the mail together. I have not seen either of these types of documents in the last 20 years. HMO's don't send you these. I was watching bills be processed on the insurance website, so I knew where we stood from a deductible stand point. We met our deductible last week, chronic illness is expensive.

One of my doctor's offices just billed me for the full amount of the office visit, even though the explanation of benefits says I owe about 1/3 the amount, due to insurance adjustments. I thought they had to accept the negotiated insurance amount. Of course its Sunday and I can't call the insurance co. or the doctor's office until tomorrow, so I'm just going to sit here and fume, because if all the doctor's I've seen in the last 2 months do this, I'm screwed. Can the doctor's office do that?
Suzanne

CD 20 years officially, 30 unofficially. 3 resections '93, '95 '97
Managing with strict low residue diet, keeping symptoms to a minimum. All test show small amount of ulceration, still have occasional blockages. But still have a great time with my 2 daughters and husband!


Prednisone, 6MP,Prevacid, B12 shots, Bentyl, Xifaxan.....


nawlinscate
Veteran Member


Date Joined Jan 2007
Total Posts : 656
   Posted 3/7/2010 11:02 AM (GMT -7)   
Always--always--question and fight when dealing with insurance companies and doctors' offices. However, people who have worked in the insurance industry say that you can get a LOT farther when you're being nice than when you're screaming and yelling and hostile. So be very nice, but keep pushing.

You need to call your doctor's office first and ask them why they're billing you for the full amount when the EOB from your insurer states that you only owe a third of that amount. Chances are, they sent out the bill before they received payment from your insurer. If they insist that you owe them the full amount, tell them that you want to send them a copy of your EOB, which will show that you don't owe them that much. If they say that they haven't received payment from your insurer, ask them to resubmit your claim.

If your insurer EVER denies one of your claims, call them and ask them to explain exactly why they've denied it. Ask if the diagnostic code is correct. (I've had claims denied because the doctor's office put the wrong code on the claim--for example, using a code for a condition--instead of Crohn's--for which the treatment/procedure isn't recommended.) If they tell you that there's a coding problem, ask your insurer to tell you very slowly exactly what the problem is--and write it down word for word. Then call your doctor's office, read them what the insurer said, and ask them to correct the error and resubmit your claim.

It's standard practice for an insurer to deny almost any claim, in the hopes that the patient will just shrug and pay the whole amount. They'll almost always back down if you call them and--again, very patiently (and being upset and concerned, rather than furious)--question them. But, in your case, the insurer is indicating that they've agreed to pay for 2/3 of the claim. So you need to speak with your doctor's billing people to let them know exactly what your insurer has told you.

This constantly stressful, screwed up health care system is why we need legitimate health care reform. NOW.

Good luck!

Zanne
Veteran Member


Date Joined Apr 2005
Total Posts : 3763
   Posted 3/7/2010 11:11 AM (GMT -7)   
The insurance isn't paying ANY of the amount. I am responsible for ALL bills until I meet my deductible, BUT the insurance has an agreed upon discounted rate that the EOB says I am suppose to pay instead of the billed amount. My question is can they actually make me pay the un-discounted rate?

I have a lot of bills out standing, some that the EOB says I owe about 1/10th of, if I can actually be billed at the real rate, then I have made a terrible mistake in choosing not to go with the higher cost of the HMO this year. The high deductible insurance worked out to be cheaper on my husband's company worksheet than the HMO we went against our gut instinct and went with that instead for the first time in over 20 years. So instead of a $3000 deductible I could end up paying over $10,000.
Suzanne

CD 20 years officially, 30 unofficially. 3 resections '93, '95 '97
Managing with strict low residue diet, keeping symptoms to a minimum. All test show small amount of ulceration, still have occasional blockages. But still have a great time with my 2 daughters and husband!


Prednisone, 6MP,Prevacid, B12 shots, Bentyl, Xifaxan.....


jujub
Forum Moderator


Date Joined Mar 2003
Total Posts : 10392
   Posted 3/7/2010 11:15 AM (GMT -7)   
I hate to admit doing this, but I've even gotten prompt attention from insurance companies by crying. Tears of frustration after I'd spent a whole day talking to various people all over the country, trying to get them to pay for a treatment they had pre-approved. The person I was crying to promptly gave me the number for someone who really could help me.

One of the problems is that they try very hard to keep you from talking to anyone who can change a bill or make a decision.

pimfram
Veteran Member


Date Joined May 2009
Total Posts : 506
   Posted 3/7/2010 11:36 AM (GMT -7)   
If anything ever looks incorrect, definitely call your insurance and get it sorted. My family has had numerous health issues recently, the insurance folks know my mother by name lol.
Diagnosed with CD July 2007
Currently on Remicade, Imuran, probiotics, folic acid, multivitamin.
Resection December 2009

Amor fati - Nietzsche


Chasity102304
Regular Member


Date Joined Nov 2007
Total Posts : 165
   Posted 3/7/2010 1:25 PM (GMT -7)   
I believe (and I may be wrong as I'm only speaking from my experience) that if your insurance isn't paying any of a claim, you are responsible for the total amount billed, not the reduced rate the insurance would normally pay. This is how my insurance works. Also only the amount that you actually pay is applied toward the deductible. For example(IF it works the way you are thinking it does) if the drs office bills you $100 but the insurance company reduces the bill to $50 .. only $50 is applied to the deductible. So you may want to check into that as well because your deductible may not be met if it works the way mine does.

Hope you get it all figured out!!! GOODLUCK!!
Fibromyalgia DX March 2003
Crohn's DX Jan 2006 (Symptoms since 96-Misdiagnosed as "female" problems-Major flare during pregnancy in 05 which lead to DX)
1st resection July 2007
Currently on Remicade/8 weeks

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