"Charges not covered"

[Bikerdude]

I recently have incurred medical bills due to an accident. The insurance statements are starting to roll in. As usual some of the charges are "not covered" by the ins. co. and are put in my column to be paid.

My question is has anyone else had this problem? If so what tactic did you use to combat the ins. co.. What was the outcome?

TIA.

 

[F-One]

First we currently have a really comprehensive policy. When similar billing happened to us, we contacted the insurance company first and were told we were not liable for the charges outside co-pays for the covered items. We then contacted hospital / lab and told them what insurance company had said and followed up with letter stating that and we would not be paying that portion of the bill along with check for co-pay amount. A couple of times we got a bill back with same charges and we again sent copy of original letter with bill and a follow-up call. So far they either refile with insurance (using a different code) or wiped it off the bill.

Good Luck - insurance billing is such a scam. We get lab charges for blood work for $400 but then insurance says the amount they have negotiated is $100 and our co-pay is $5. The kicker is the lab accepts the $105 for $400 charge without a problem.

 

[TromboneAl]

News story here says that emergency room docs at our local hospital will no longer accept Blue Cross, so I'll have to figure out what that means for us.

Thanks for the tip, F-one.

 

[cantlogin]

I recently have incurred medical bills due to an accident. The insurance statements are starting to roll in. As usual some of the charges are "not covered" by the ins. co. and are put in my column to be paid.

My question is has anyone else had this problem? If so what tactic did you use to combat the ins. co.. What was the outcome?

TIA.

I feel your pain
My accident was almost thirteen months ago and I think the biggest shock was receiving a $16,000 bill for a 17 minute helicopter ride. Blue Cross/ Blue Shield paid just over half of that and I was let off the hook for the rest. I literally have accumulated a couple of pounds of indecipherable statements from the insurance company and the service providers. My solution was to pay the bills that insurance wouldn’t.

Maybe that was a mistake?

 

[cute fuzzy bunny]

This is why I love my HMO. Office visit: $5. No charge for any labs, tests, xrays, MRI's, etc. $250 to be admitted to the hospital, no cost after that. $50 for an emergency room visit unless they admit you. $5 for a 100 day supply of any medication. I can make an appointment to be seen the same day most of the time, get whisked in to the doctor within 5 minutes of my appointment, and by the time I walk back downstairs in the building any prescriptions the doctor wrote are filled and ready.

Al - The kicker here is you might have to submit your ER claims to blue cross yourself. Good luck with that. I tried it when we were on Cobra and BC didnt send us our insurance cards, so I paid cash and filled out the BC forms myself.

They rejected the claims because they lacked claim codes. There is no place on the forms to put claim codes. I asked where those came from and where they'd be documented. From the doctor and on a form that they'll only give to the doctor. But they wouldnt call my doctor or send him the form unless he filed the claim. It had only taken me three days to fill out all the forms for a couple of office visits and a couple of prescriptions.

After a multi-week fiasco of unreturned phone calls, escalations, billing departments shooting it out with each other and many other fine layers of ridiculousness, the doctors office billed blue cross, blue cross renegotiated the fee from its original $200 (which we paid $170 due to a cash discount) down to $100 and charged us a $20 copay. Then they paid the doctor. Then the doctor sent us a check for the $70 we 'overpaid'.

It became clear to me during this process why health care costs too much. Including my own time there was probably 20-25 hours of total attention spent on a $100 bill.

 

[jIMOh]

Yes- had this happen. Wife spent a patient hour on the phone and got bills cut in half.

More power to her. Issues like this is why the industry needs reform.

 

[W2R]

News story here says that emergency room docs at our local hospital will no longer accept Blue Cross, so I'll have to figure out what that means for us.

That is shocking to me. Did they give a reason?

 

[mn54]

Each ins. co. and the govt. negotiate their own fee schedule with the health care provider. That is why you need to see a provider that accepts your ins., otherwise you do not get the benefit of the discounted fee schedule.

 

[Peaceful_Warrior]

Each ins. co. and the govt. negotiate their own fee schedule with the health care provider. That is why you need to see a provider that accepts your ins., otherwise you do not get the benefit of the discounted fee schedule.

Even then you can often negotiate if the hospital is led to believe you can't/won't pay the bill.

For example, some hospitals will offer to let uninsured people pay half of their bill on the spot and then wipe out the other half. That's because the hospitals know that once an uninsured person walks out the door without paying, it's unlikely they ever will... so half is better than none, and half is usually more than they would charge a qualified provider anyway.

 

[TromboneAl]

Originally Posted by TromboneAl
News story here says that emergency room docs at our local hospital will no longer accept Blue Cross, so I'll have to figure out what that means for us.

That is shocking to me. Did they give a reason?

Yes:

"The emergency room physicians have gotten fed up with the low reimbursement rates from Blue Cross and no longer accept the insurance policies -- even though the hospital does."

----------------------

Go anywhere near a doctor's office or hospital and expect to get a bunch of bills and statements. Here's my "note to self" on understanding a Blue Cross statement:

How To Understand A Blue Cross Claim Statement
(AKA Explanation of Benefits)

​

The main reason these statements are hard to understand is that someone has chosen totally inaccurate and misleading terms to describe the items on the statement. Use this sheet to understand what the terms really mean.

Explanation Of Benefits

The statement is called an "Explanation of Benefits," but it is really a claim statement showing how much Blue Cross has paid, and how much you will need to pay when you receive a bill from the service provider. If you want an explanation of benefits, see the Service Agreement.

Total Billed

This is not the total billed. This value should be labeled "The amount you would have been billed if you did not belong to Blue Cross." This value is totally irrelevant, and can be ignored. The only reason to include it is to make you feel that Blue Cross is paying more.

The True "Total Billed"

The real "total billed" is not displayed anywhere on the statement. To calculate it, add the "It is your responsibility to pay" amount to the "Paid Amount." If you call Blue Cross, they will refer to this as the Negotiated Fee Rate, which is not a "rate" so this should be called the "Negotiated Fee."

It is not your responsibility to pay

This value is also totally irrelevant, because it is based on the Total Billed amount. Ignore it.

Applied To Deductible

This is the amount you pay because your charges have not yet exceeded your deductible. That is, until you pay $2500 [old plan], you pay 100% of the true total billed. True, this is an amount that is applied to the deductible, but for the purposes of the statement, it should be labeled "Amount you pay because you haven't yet met your deductible."

Coinsurance Copayment Amount

[for old plan] You pay 30% of all amounts once you meet the deductible. This represents 30% of the amount over the deductible.

Member's Medical Deductible Applied To Date

This should be: Amount of payments that you've made that apply to your deductible.

 

[lets-retire]

So far they either refile with insurance (using a different code) or wiped it off the bill.

I'm sure you know this, but make sure it is taken care of or it will come back to haunt you. I talk to all kinds of people often, ranging from poverty level up to directors of major corporate subdivision about credit issues. Many have hospital bills they thought were paid by insurance because they hadn't heard from anybody after filing a dispute.

 

[ziggy29]

I recently have incurred medical bills due to an accident. The insurance statements are starting to roll in. As usual some of the charges are "not covered" by the ins. co. and are put in my column to be paid.

My question is has anyone else had this problem? If so what tactic did you use to combat the ins. co.. What was the outcome?

Was this an out-of-network provider for insurance purposes? If so, you could be liable for overages. If this was a legitimate medical emergency and the out-of-network provider was the most logical place for immediate treatment, most insurance would treat it as in-network until you could be reasonably transferred to an in-network provider.

The next question is, will the hospital bill you for the difference? They don't always do that, and sometimes even when they do, they won't pursue payment. Several years ago we had a minor emergency and we went to an in-network hospital which directed us to an out-of-network imaging lab. Weeks later we received a bill (or at least it looked like a bill) from the imaging center for over $3000 (when insurance paid about $700). We never paid it -- and never heard from them again, so presumably they just wrote it off. But you know what happens when you assume.

 

[W2R]

Yes:

"The emergency room physicians have gotten fed up with the low reimbursement rates from Blue Cross and no longer accept the insurance policies -- even though the hospital does."

That's awful.

Go anywhere near a doctor's office or hospital and expect to get a bunch of bills and statements. Here's my "note to self" on understanding a Blue Cross statement:

How To Understand A Blue Cross Claim Statement
(AKA Explanation of Benefits)​

The main reason these statements are hard to understand is that someone has chosen totally inaccurate and misleading terms to describe the items on the statement. Use this sheet to understand what the terms really mean.

Explanation Of Benefits

The statement is called an "Explanation of Benefits," but it is really a claim statement showing how much Blue Cross has paid, and how much you will need to pay when you receive a bill from the service provider. If you want an explanation of benefits, see the Service Agreement.

Total Billed

This is not the total billed. This value should be labeled "The amount you would have been billed if you did not belong to Blue Cross." This value is totally irrelevant, and can be ignored. The only reason to include it is to make you feel that Blue Cross is paying more.

The True "Total Billed"

The real "total billed" is not displayed anywhere on the statement. To calculate it, add the "It is your responsibility to pay" amount to the "Paid Amount." If you call Blue Cross, they will refer to this as the Negotiated Fee Rate, which is not a "rate" so this should be called the "Negotiated Fee."

It is not your responsibility to pay

This value is also totally irrelevant, because it is based on the Total Billed amount. Ignore it.

Applied To Deductible

This is the amount you pay because your charges have not yet exceeded your deductible. That is, until you pay $2500 [old plan], you pay 100% of the true total billed. True, this is an amount that is applied to the deductible, but for the purposes of the statement, it should be labeled "Amount you pay because you haven't yet met your deductible."

Coinsurance Copayment Amount

[for old plan] You pay 30% of all amounts once you meet the deductible. This represents 30% of the amount over the deductible.

Member's Medical Deductible Applied To Date

This should be: Amount of payments that you've made that apply to your deductible.

WOW!!! THANK YOU!!! As another person with BC/BS who has always been a little befuddled by their statements, this will surely help.

 

[cute fuzzy bunny]

I'm thinking that after this last blue cross fiasco, that I'll make a list of all the members of congress and file a random blue cross claim for each of them, so they can see what a claim rejection looks like.

 

[Bikerdude]

Was this an out-of-network provider for insurance purposes? If so, you could be liable for overages. If this was a legitimate medical emergency and the out-of-network provider was the most logical place for immediate treatment, most insurance would treat it as in-network until you could be reasonably transferred to an in-network provider.

This was "in network". This was a Doctor bill. Other bills submitted by same Dr. were paid as normal. It's just this bill (so far) that BCBS says a certain amount of each procedure is "not covered" and that amount is moved to the "patient responsibility" column along with deductible and copay.

 

[artist59]

If it is "in network" and they have a negotiated rate that is what the insurance pays but you are not liable for the difference. When we had this happen, I called the insurance company and that is what they told me, I then contacted the doctor, hospital, etc., and told them what the insurance co. said. I told them we weren't responsible for the difference, they have a negotiated rate and that is what they received, and that we wouldn't be paying any of difference. It was never a problem.

I got the impression some doctors, hospitals, labs try to bill the patient because sometimes the patient will pay the difference and that's extra money for the them.

 

[starter82]

First we currently have a really comprehensive policy. When similar billing happened to us, we contacted the insurance company first and were told we were not liable for the charges outside co-pays for the covered items. We then contacted hospital / lab and told them what insurance company had said and followed up with letter stating that and we would not be paying that portion of the bill along with check for co-pay amount. A couple of times we got a bill back with same charges and we again sent copy of original letter with bill and a follow-up call. So far they either refile with insurance (using a different code) or wiped it off the bill.

Good Luck - insurance billing is such a scam. We get lab charges for blood work for $400 but then insurance says the amount they have negotiated is $100 and our co-pay is $5. The kicker is the lab accepts the $105 for $400 charge without a problem.

Doesn't that grant them a tax deduction of $295?

 

[Helena]

This was "in network". This was a Doctor bill. Other bills submitted by same Dr. were paid as normal. It's just this bill (so far) that BCBS says a certain amount of each procedure is "not covered" and that amount is moved to the "patient responsibility" column along with deductible and copay.

I worked for BCBS for 26 years... if the provider of services is
in your policy's BCBS network, the provider must write off any
allowable amount differences and you would owe any deductible,
coinsurance and anything not covered by your policy.

Some policies will pay network benefits for out-of-network providers
in a medical emergency situation... and even allow billed charges.

But based on the info given, I am unable to determine the reason
the charges were disallowed or why it would be your share. Have
you contacted the insurance company yet ?

 

[Bikerdude]

But based on the info given, I am unable to determine the reason
the charges were disallowed or why it would be your share. Have
you contacted the insurance company yet?

This is also my question. I have yet to ask BCBS why the charges were not allowed. I wanted to get feedback on how to approach them from someone who had a similar experience. I’ll let you know when I find out.

 

[Helena]

This is also my question. I have yet to ask BCBS why the charges were not allowed. I wanted to get feedback on how to approach them from someone who had a similar experience. I’ll let you know when I find out.

I just retired, so I haven't been out of the BCBS loop too long...
I was in Customer Service 26 years... and I always tried my best
to make the customer happy... and I have personally made additional
payments on hundreds of thousands of claims. Claim processing is
computerized... the claim is reduced to coding... and mistakes are
made... by the service provider and by the insurance company...
trash in = trash out.

BCBS prides itself for having excellent "Customer Advocates", so hopefully
you will be well treated... I can offer this extra bit of advice... the old
adage is true.. you will catch more files with honey... if you know what
I mean... but don't hesitate to ask to speak to the supervisor, if necessary...
and call during the day... from 9am to 3pm is best.

Let us know how it goes.

 

[Bikerdude]

I can offer this extra bit of advice... the old
adage is true.. you will catch more files with honey... if you know what
I mean... but don't hesitate to ask to speak to the supervisor, if necessary...
and call during the day... from 9am to 3pm is best.

Let us know how it goes.

Thanks. I hear ya. I'll let you know.

 

[Jonathan Pletzke]

Procedures for Getting Your Proper Benefit

Here are a few thoughts that come to mind about getting what is due to you. There is great variance in the types of policies, what is covered, and how they pay. These steps should work in most cases. There is a book out there called Making Them Pay: How to Get the Most From Health Insurance and Managed Care that has plenty more information in it.

First off, there are plenty of mistakes that are made in billing. Coding things wrong or submitting them improperly can deny payment to either the provider or you. Check with the provider and insurer to see if this is the case. This is a first, simple step that can resolve a number of issues.

Second, if you can't get satisfaction in this way, the next step is a two-level appeal with the health insurance company. They have certain time frames that they respond to these two appeals, and the insurer uses this approach to find problems within their organization or with the providers, and to try to satisfy their customers (you!).

Third, if you don't get anywhere with the insurer, or are getting the "run-around", contact your state department of insurance. I've got contact information for each department of insurance on my website. Most states have a formal complaint process in addition to a hotline for advice before you have to go with a formal complaint. I've never had to do this, but according to my sources, this step will really get the attention of the insurer, and they will try to resolve the issue. Results of these complaints are compiled and statistics are published about each insurer. The statistics are known as the "complaint ratio" and tell the state and the world how well an insurer is doing. You can get an idea of the types of complaints and how they are resolved from the consumer information section of the website for the National Association of Insurance Commissioners (National Association of Insurance Commissioners).

Best of luck resolving your issues. Let me know if you need further resources.

 

[Bikerdude]

Best of luck resolving your issues. Let me know if you need further resources.

Thanks for the information!

 

[LIPhotoMan]

If it is "in network" and they have a negotiated rate that is what the insurance pays but you are not liable for the difference. When we had this happen, I called the insurance company and that is what they told me, I then contacted the doctor, hospital, etc., and told them what the insurance co. said. I told them we weren't responsible for the difference, they have a negotiated rate and that is what they received, and that we wouldn't be paying any of difference. It was never a problem.

I got the impression some doctors, hospitals, labs try to bill the patient because sometimes the patient will pay the difference and that's extra money for the them.

That is exactly what happened to me - paid the Co-pay to the In-Network doctors (There were THREE that did this). Docs get paid by BCBS according to their negotiated contractual rate, then Docs bill me for diff btwn the BCBS rate & their "normal" rate. I told them I wouldn't pay as they were paid their contract rate. They tell me that in this region the negoiated rate in unreasonable so I am responsible for the difference. I say "a contract is a contract" - they told me they'll be putting it out for collection if I don't pay.

 

[travelover]

That is exactly what happened to me - paid the Co-pay to the In-Network doctors (There were THREE that did this). Docs get paid by BCBS according to their negotiated contractual rate, then Docs bill me for diff btwn the BCBS rate & their "normal" rate. I told them I wouldn't pay as they were paid their contract rate. They tell me that in this region the negotiated rate in unreasonable so I am responsible for the difference. I say "a contract is a contract" - they told me they'll be putting it out for collection if I don't pay.

Take the complaint back to BCBS. Docs can't do this.