Please Explain This Health Insurance Statement

[TromboneAl]

Perhaps you can save me the time of calling Blue Cross on Monday. Can someone explain why, since DW has met the $5,000 deductible for 2008, the "It is your responsibility to pay" is $43.41 and not zero?

 

[KB]

It looks like the allowed amount for the service was 76.59. She paid a $40 copay and BC paid 36.59 to the provider. The difference is the 3.41.

Blue Cross is supposed to write off the difference between billed and allowed if the services were done by a preferred provider of BC. If it is not a preferred provider, the difference is the your/her responsibility.

If you know you went to a preferred provider, I'd call tomorrow and see why they are balance billing you.

 

[Gotadimple]

Al:
You have a co-pay of $40 for each service, regardless of the deductible amount. There is, however, in your contract a provision for no further payment if you exceed a total out of pocket amount. I'm guessing it's more than $5000.

The provider billed $80 but the plan will only pay for $36.59.

Billed: $80.00
Allowed: $36.59
You Owe:$43.51 $40 is your co-pay, $3.41 the amount over the allowed amount.

Now before you write the check, wait for the provider's invoice. I'd be asking them to waive $3.41 for being a good customer (or less politely for billing more than they knew would be allowed by the insurer, according to their fee schedule with them).

-- Rita

 

[Gotadimple]

It looks like the allowed amount for the service was 76.59. She paid a $40 copay and BC paid 36.59 to the provider. The difference is the 3.41.

Blue Cross is supposed to write off the difference between billed and allowed if the services were done by a preferred provider of BC. If it is not a preferred provider, the difference is the your/her responsibility.

If you know you went to a preferred provider, I'd call tomorrow and see why they are balance billing you.

BC isn't balance billing, just showing what is owed to the provider of service. Their contract may allow balance billing, so they are showing you what you owe the provider.

I still think -- whether the doctor is a preferred provider or not -- it's worth asking them to reduce to allowed amount.

-- Rita

 

[KB]

What kind of service was the office visit for, because apparently it has a $40 copay.

Also, separate from the copay, she had a $5000 deductible for the year which she has met.

You should call BC and ask for an overview of your benefits so you can understand how the copay and deductible are counted for a calendar year. If they count the copay paid as part of the deductible, she might have met the deductible with that claim.

 

[TromboneAl]

In the past, I believe that things over the allowed expense have not been billed.

DW paid the copay at the time of the visit -- are you saying that we might expect a bill for $3.41 from the provider?

 

[Gotadimple]

According to the BC statement you can expect a bill for $3.41, based on the fee schedule they negotiated with the doctor. It's been my experience that it's just better to wait for the provider's invoice, as they usually will write off that small amount.

Rita

 

[FIRE'd@51]

Where I live, the doctor submits the bill to the insurance company months before he bills me. My guess is (if he is part of the BCBS network) the bill he sends you will have the $3.41 deducted. As others have said, I would wait until you receive the doctor's bill before doing anything.

 

[TromboneAl]

For that plan, it says

Doctors' (sic) Office Visits $40 copay, deductible waived

Which I guess means you pay $40 and...I give up, I just can't understand this health insurance speak. I know what waive means but "deductible waived" could mean any of several things. It probably means that it is totally independent of the deductible.

Also, I thought that $40 copay meant that that was all you paid for a visit, so why is there even a bill? I believe the provider is "in network."

I guess I'll have to call BC tomorrow.

 

[FIRE'd@51]

For that plan, it says

Doctors' (sic) Office Visits $40 copay, deductible waived

Which I guess means you pay $40 and...I give up, I just can't understand this health insurance speak. I know what waive means but "deductible waived" could mean any of several things. It probably means that it is totally independent of the deductible.

Yes, it means she has a fixed $40 copay whether or not she has satisfied the deductible. However, the insurance company still has a limit on what they will pay for the services rendered, hence the additional $3.41 charge, which will be subtracted from the doctor's bill if he is part of the BCBS network.

 

[ziggy29]

Perhaps you can save me the time of calling Blue Cross on Monday. Can someone explain why, since DW has met the $5,000 deductible for 2008, the "It is your responsibility to pay" is $43.41 and not zero?

The deductible and the out of pocket maximum are two different things -- meeting a deductible doesn't typically mean the patient pays nothing more out of pocket. Before the $5,000 deductible is met the patient pays the entire negotiated (in-network) bill. After the deductible is met, insurance kicks in and pays everything above the copayment. Those copayments are still paid by the patient until the plan's out of pocket maximum is reached.

So there are three "tiers" in this:

(1) Before the patient has paid $5,000 out of pocket (the deductible), insurance pays nothing and the patient pays the full balance due;

(2) After the patient has paid the full deductible and before the annual out of pocket maximum is paid, the patient still has a copay but insurance pays the rest;

(3) After the total out of pocket maximum has been paid by the patient, insurance gets the rest without a copayment.

If this provider was in the BC/BS network, that disallowed $3.41 shouldn't even be your responsibility.

 

[FIRE'd@51]

The deductible and the out of pocket maximum are two different things -- meeting a deductible doesn't typically mean the patient pays nothing more out of pocket. Before the $5,000 deductible is met the patient pays the entire negotiated (in-network) bill. After the deductible is met, insurance kicks in and pays everything above the copayment. Those copayments are still paid by the patient until the plan's out of pocket maximum is reached.

So there are three "tiers" in this:

(1) Before the patient has paid $5,000 out of pocket (the deductible), insurance pays nothing and the patient pays the full balance due;

(2) After the patient has paid the full deductible and before the annual out of pocket maximum is paid, the patient still has a copay but insurance pays the rest;

(3) After the total out of pocket maximum has been paid by the patient, insurance gets the rest without a copayment.

If this provider was in the BC/BS network, that disallowed $3.41 shouldn't even be your responsibility.

DW once had a policy with a rider to pay for office visits (she had a $10 or $20 copay). The rider went into effect even before the deductible was met. So if she went to the doctor for an office visit three times a year, she would pay the three copays (which BTW didn't count toward the deductible). Even after she met the policy deductible, she still had to make the copay for office visits. This coupled with the rider's premium increases made the rider not worth having, so she dropped it, and just kept the main policy which worked exactly the way you described.

From what T-Al has described, either there is a rider involved for office visits, or the office visit part has been incoprorated into the main policy and is not subject to the deductible.

In my state BCBS had a plan with a $2500 deductible which covered 3 free office visits per year without having to meet the deductible. Insurance companies have all kinds of variations of policies, and they each work a bit differently.

 

[Rich_by_the_Bay]

If this provider was in the BC/BS network, that disallowed $3.41 shouldn't even be your responsibility.

Not necessarily. There are different levels of "participation" that a provider can claim depending on the contract with the carrier. Your assumption may or may not be true depending on the provider's participation category.

Private carriers and Medicare arbitrary assign what they consider "usual and customary" and call the spill-over amount the "allowed" amount. Many times this leads patients to thing the doctor is "over charging" and this leads to friction. While it is possible that the provider may be charging much more than typical, it si also true that the "allowed amount" is so low that it is break-even.

 

[Bestwifeever]

Our insurance tells us that the provider cannot bill us for more than the amount insurance company's contract with the provider allows. For example, we have to pay a copay plus a certain percentage of the cost of the services; if the cost of the services is more than the provider has contracted for with the insurance company, the provider cannot bill us for the difference.

So I would double check with the insurance company. If nothing else, make them take the time to explain this to you as it may happen again.

 

[fisherman]

I have got to ask a question due to my on paranoia. We also have a individual health Ins policy and a $5000 deductible. Last year it went up 11% and we had a total applied to the deductible of under $400. This year we may have a total of about $1000 applied to the deductible. My fear is the more they have to pay the more the increase will be. Is this at all logical or based in fact? I realize if it is applied to the deductible they are not paying but the closer you get to the full amount the better their chances are of having to. This will be our second year on the plan and I have not seen the increase yet and will not for a few months. I realize age is a big factor also and next year we will not hit what I understand to be the marker years.

Al have you had that policy long and can you put this fear out to pasture?

I have to admit that I find so many ways to worry about this that at my last doctors visit my BP was a little high for the first time ever since I was very scared it would be. Does the Ins. company check your records at that level?

Our current rate is not bad and I have budgeted for a 12% increase each year but then fear takes over and I worry that they will find a reason to go much higher than that.

I quess nothing really new hear just one more person complaining about our current mess.

Thank you,

 

[Gotadimple]

Your premiums went up not because of your claims, but because the insurance company filed a new rate change. You can always call the company and ask if they have filed a rate change for the coming year and the average change -- to help you with budgeting.

12% is not a bad amount to budget.

-- Rita

 

[TromboneAl]

My fear is the more they have to pay the more the increase will be.

No. It is only based on age and which policy you have (pretty sure).

The deductible and the out of pocket maximum are two different things

Yes, that's right. My HSA policy has a 3,500 deductible, and BCBS pays everything above that (apart from copays, etc). I had forgotten that DW's PPO pays 70% of everything above the deductible. But that doesn't seem relevant to the above bill.

Sure would be easier to just pay all the bills that come in the mail, but I've found that does not work well.

 

[youbet]

There seems to be some confusion as to what document TA posted. This is the EOB from his health insurance company, not the bill from the medical provider.

When the bill comes, it will either show zero balance due or $3.41 balance due depending on whether TA's insurance company and TA's wife's medical provider have a contractual agreement that the office visit charge is capped at $80.00 or not.

Also, I thought that $40 copay meant that that was all you paid for a visit, so why is there even a bill?

When you receive the bill from the medical provider, I'm thinking it will show zero balance due. (Or $3.41 depending on the contract between your insurance co and the provider.)

I agree, I also hate the effort of understanding, tracking and following up on all this stuff.

 

[FIRE'd@51]

When the bill comes, it will either show zero balance due or $3.41 balance due depending on whether TA's insurance company and TA's wife's medical provider have a contractual agreement that the office visit charge is capped at $80.00 or not.

Not to nitpick, but I think you meant to say "capped at $76.59". I know what you meant, though.

 

[FIRE'd@51]

I have got to ask a question due to my on paranoia. We also have a individual health Ins policy and a $5000 deductible. Last year it went up 11% and we had a total applied to the deductible of under $400. This year we may have a total of about $1000 applied to the deductible. My fear is the more they have to pay the more the increase will be. Is this at all logical or based in fact?last doctors visit my BP was a little high for the first time ever since I was very scared it would be. Does the Ins. company check your records at that level?

You cannot be singled out for a rate increase because of your individual claims. The rate increase will depend upon the claims from all the policyholders in your risk pool, and what the insurance company has to payout vs the premiums it has taken in.

 

[fisherman]

You cannot be singled out for a rate increase because of your individual claims. The rate increase will depend upon the claims from all the policyholders in your risk pool, and what the insurance company has to payout vs the premiums it has taken in.

Thank you and Al. For me, Health Ins. is a bigger worry than the market. Probably because it was so hard to get.

 

[TromboneAl]

I figured it out from talking to the provider.

Yes, you guys got it right. The provider charges $80, and BC allows only $76.59. We paid a $40 copay, BC paid $36.59. The provider is a participating provider, and is not charging us the $3.41.

The "It is your responsibility to pay" line was totally incorrect. It should have read

"You have already paid $40 -- you do not have to pay anything else."

Footnote 01 should have read "This is the amount in excess of the allowed expense for a participating provider. The member, therefore, is not responsible for this amount."

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

With reasonable terminology and a clear statement, there would have been no confusion. Any point in being a curmudgeon and calling BC to tell them the statements are wrong and confusing?

 

[Gotadimple]

With reasonable terminology and a clear statement, there would have been no confusion. Any point in being a curmudgeon and calling BC to tell them the statements are wrong and confusing?

Al,
One can always express that the EOB is hard to read, and as a customer, you hope they will listen. I worked for a health plan for 16 years and constantly pointed out that our customers wouldn't understand -- the result is the same today as it was then.

As to them knowing you were seeing a preferred provider and therefore, any amount over the allowed would be waived? Well all it takes is programming (or a completely different type of plan, OR the provider's software that doesn't submit a bill for more than the allowed amount).

One can always hope!

-- Rita

 

[KB]

Glad you got it figured out.

 

[Alan]

Interesting thread. I am with BCBS of Louisiana and my EOB's are very similar to Al's except it does have a footnote saying "Your provider is a preferred provider, you do not owe this amount".

One of my pet peeves with the EOB's is that they do not detail what the service is for, so it is impossible for me to tell if we (the insurance company and I) are being charged for the correct services. Last year I had a crown fitted at the dentist and I was shocked to see how much I had to pay compared to the last crown I had a few years back. When I inquired of BCBS I was told that the BCBS clerk and transposed 2 digits on the code and it appeared as something totally different than a new crown with a MUCH higher co-pay.