Help me insurance

[justcheckingin73]

I recently had an ultrasound done and a mammogram on the same day at the same hospital. Different places in the hospital but they scheduled together for convenience. I had to pay some money out of pocket for the u/s but nothing for the mammogram.

I received a bill from the hospital for additional out of pocket money I need to pay. The details of the bill include both the u/s and the mammogram but I’m pretty sure it’s only for the u/s. When I received my EOB, I saw that they had negotiated a rate with the providers and the amount they say I owe is less than what I paid in the office for the u/s so to me it looks like I should receive money back.

Additionally, I received a bill from a radiologists office related to my u/s for a different amount.

Who the heck do I call first to figure this out? My insurance company or the hospital? And should I expect my insurance company to figure this out with the hospital or will I need to do that (assuming the latter but I don’t insurance very well so I want to make sure I know ahead of time)?

[mommyatty]

You will get one bill/EOB from the hospital for each procedure and one bill/EOB from the doctor for each procedure. So 4 bills with matching EOBs total. Because American medical care sucks and makes no sense. I would call your insurance company first and find out what they say your max out of pocket should have been for each.

[covergirl82]

I had a similar situation where I took DD to an urgent care a few years ago, and the amount I was billed for was higher than the EOB indicated the amount was after the insurance discount. I called the hospital billing office (this urgent care was part of a hospital system), they referred me to my insurance (because hospital billing said it was a negotiated rate with my insurance provider), and then insurance said I needed to talk with the hospital billing office because they said they paid their amount according to the contract with the hospital. I finally got the hospital billing office to listen to me and agree that it didn't make sense that I should pay more than what the EOB indicated.

[xctsclrx]

No advice just wanted to commiserate. I fail at all things insurance and probably way overpay sometimes. I don't have it in me to fight them after the disaster that was my son's birth.

[justcheckingin73]

mommyatty, it does suck. So ridiculous. 

covergirl82, that’s what I’m afraid of but we’re not talking small dollars so I may just have to do it. 

xctsclrx, I’ve been really lucky in that I haven’t had anything other than regular office visits and the occasional sick visit so this is new ground for me. And I agree, I’m sure I’ve overpaid when I had a PPO and the dollars were much smaller. 

Thanks everyone!

[covergirl82]

justcheckingin73, mine was really small dollars too (maybe even less than $5), but I had the time and energy at that point to fight over it (because I was more upset about it on principle, that they would even send out a bill for more than the negotiated rate).

Along the lines of what xctsclrx said, it makes me sad that people who are in situations where they are sick/injured and/or caring for a sick/injured loved one, and don't have the time or energy to look at all their bills and EOBs and reconcile them, so some people are probably being overcharged and subsequently end up overpaying.

[2chatter]

I think y’all know this is a giant soapbox for me.

Bills and EOBs are rarely accurate - think of them as a snapshot of a point in time instead of the final day. I’d almost ignore them in terms of real numbers. I now just call and ask
1) has insurance finalized what they will pay?
(If not, you will pay then insurance will pay and you may or may not get a refund of excess)
2) has insurance paid in full? (For whatever reason sometimes they make multiple payments)
3) have they credited any payments I have already made (regardless of what is on your statement - ask this, as we have had the calculation change with each payment)
4) has everything been billed?

Here’s an example
Cost of service 100
Insurance negotiated rate 80
Insurance pays 60
Paid at time of service 10
Bill for 40 - wrong
I would call and make sure then pay 10 (60+10+10 =80)

We have the most issues after meeting our deductible and the 20% coinsurance rate kicks in. These are the most common errors:
1) they take 20 percent of the total before insurance tells them the rate
2) they don’t count up front payments
3) they don’t count insurance payments and bill for a totally random amount
4) they don’t bill for everything - which then changes what insurance pays and instead of costing more it costs less. I can’t figure this one out. But it’s happened at least twice this year on hospital procedures.

In deductible land the most common error is billing before insurance agrees or pays, so we grossly overpay and then have to beg them to send checks OR due to their special math they send us several checks over time that equal the total.

[k3am]

This thread makes me so happy we have Kaiser. I go, I pay my co-pay, I go home. The only time I ever had to pay anything additional was when I needed an aircast and crutches, which they told me in advance I'd have to pay for, and it was like $30 paid on the way out, and no additional bills, no EOB's, etc.

We've been through 2 deliveries, a surgery for DH, surgery for DS, two brain surgeries for DD, years of MRI's, CAT scans, PET scans, EEGS (in and outpatient), neuropsych testing, etc. The only time we were worried was when they referred us to another hospital out of network since they couldn't get us in quickly enough at a Kaiser and we got a bill from Stanford for $60k. Called Kaiser, and found out we only had to pay our inpatient copay of $250.

[justcheckingin73]

That’s amazing k3am!

Thanks for the info, 2chatter. Looks like I need to make some calls. Sigh. 

[2chatter]

.... or just wait. Sometimes I let them run in circles and pay at the 60-90 day mark. Usually the amount is totally different by then.

[sdlaura]

k3am we have had a similar experience. We just have a blue shield hmo but everything here is through the Scripps network and we didn’t even need a referral to go to the top heart surgeon at the Childrens hospital (not Scripps) for DS1’s open heart surgery. I’ve never paid more than $500 out of pocket for any surgery, delivery, or hospital stay.

[2chatter]

This doesn’t really go here but....it’s insurance related. Last night after moving all the furniture from the new flooring install, and replacing all the books on shelves, I sat down with the fat stack of Cigna mail and a beer. I opened a denial of lab work. It was for specialized STD testing. It was addressed to SD, who is a sophomore in college and just started using our address, so I didn’t even catch that. I was relieved as ... no one here better be getting STD testing! But, yuck.

I didn’t need or want to know that. And I don’t know what to do with it. I punted to DH but now am freaking out because I bet he freaked out on SD. He mentioned in passing that he thought she was dating another football player. Now I wonder if she’s sleeping her way around the football team. Someone who probably isn’t me should probably talk to her about that, but neither of her parents are equipped. It’s super stressing me out. Uggghhhh.

[justcheckingin73]

Oh my gosh, 2chatter. Good thing you can punt to DH but still stressful. Hoping it’s all clear!

[xctsclrx]

2chatter, it could be innocent and she caught the guy sleeping with someone else or condom broke or something like that. Although getting screened every so often when you are not monogamous is probably not a bad idea?

[2chatter]

xctsclrx - the letter says genetic screening not needed; clinical diagnosis suffices, so I know for sure she has at least this STD. My issue is 1) I don’t want to be the one to discuss this with her (I covered “this is your period” and that was bad enough) 2) She is chaos with our very very good insurance. She’s a bit of a hypochondriac so googles and is sure she’s dying alllll the time, and pursues LOTS of elective, out of network medical care. Like, she had a literal splinter, didn’t have tweezers and went to a freestanding ER so it would not turn septic. Or in HS she fell over a fence drunk and went to the ER because her ankle hurt. It could have waited until the next morning and a regular ortho visit - no break, mild strain. It’s all drama all the time with medical stuff, and at a high cost.

[xctsclrx]

2chatter, in that case punt and be done. If you don't have the relationship to discuss it with her then I don't think there is much you can do. Hopefully getting an STD will be enough of a scare to be more careful. If not well again not on you. I might mention to her that you saw the bill and if she is going to be doing that kind of stuff on her dad's insurance then he is also going to know about it.

[2chatter]

xctsclrx - this is the third I know about...her mom has texted DH that “her daughter likes (really inappropriate racial and anatomy acronym) just like” she does.

Yeah, I wish I didn’t know. And this wasn’t happening....