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One time I called my insurance to check if they would cover something that I could only find an out-of-network provider for. They said that I had out-of-networ
by ihumanable 5y ago
One time I called my insurance to check if they would cover something that I could only find an out-of-network provider for.
They said that I had out-of-network coverage after a $750 deductible they would pick up 80% and I would be responsible for 20%.
The out-of-network provider had quoted me $6700 for the service, so my responsibility should be $750 + (20% * ($6700 - $750)) = $750 + $1,190 = $1,940.
I wasn't happy about having to shell out nearly two grand while having the best possible employer provided healthcare, Anthem PPO where we paid the most per month to have low deductibles and high coverage.
At the end of the call, I tell the insurance company my understanding of what my responsibility is and what their responsibility is. Then they drop this on me, "Well we will pay 80% of the allowable price for the billing code the out-of-network provider submits."
Good thing I asked, this was the first time they said anything about an "allowable price" so I describe the service and ask "what's the allowable price for that?"
"Depends on how they code it"
So I go back to the out-of-network provider and ask them for the billing code, which being a doctor that doesn't do their own billing, they have no idea. So I wait a few weeks to get back the billing code, and I'm back on the phone with my insurance company.
"Hey, I have this billing code someone out-of-network will be doing, what's the allowable price on this?"
"We can't tell you that, you'll have to submit a claim."
"But when I submit the claim you will have this billing code and my member id and you will know the allowable price so you can figure out how much you are going to pay, you have that information now. What's the allowable price for this billing code, performed by someone out-of-network, with my plan?"
It took them 2 weeks to come back and say that their "allowable price" was $1,658.
So to summarize, it took me nearly two months of phone calls between myself, the insurance company, and the provider to find out what this service would actually cost. I only avoided accidentally getting hit by a massive surprise bill because of a combination of persistence and luck.
It is nearly impossible to have any reasonable idea how much anything will cost, much less to comparison shop, when it takes months to get answers to basic questions.
- cwkoss 5y agoInsurance billing practices should be criminal theft.