I need insurance help! - What does this really mean for me?

[k2bdeutmeyer]

I just called my insurance company about my surgery next week. This is what they told me:

 

We are responsible for the first $3000 that they allow (my individual deductible). They will pick up at 80% after that, but we are still responsible for our 20% co-insurance up to our $5000 out of pocket max. After that, it will be covered at 100%.

 

So....this whole "they allow" thing - apparently they will require the dr/hospital to give discounts, because they won't allow the whole thing? I'm not sure I understand that.

 

Anyway....being as though I've never had surgery before - what am I looking at for actual costs out of MY pocket for this thing. I seriously want to throw up right now. $3000?? How in the world are we going to pull that off?

[*********]

Kristin, I'm so sorry. :grouphug:

 

Since your individual deductible is $3000, that's what you have to pay before your ins. kicks in and starts paying 80%.

 

Any chance you've pain anything at all this benefit year towards your dedictible already?

 

When I was in the hospital last year for a kidney stone, my bill had some info on the back about patients recieving discounts. It was a different % off your bill depending on how much you make and how many dependents you have. And the income levels were quite high; by which I mean, you could make a very decent living and still get a discount off your bill. Please talk with your hospital and see what programs they have like that. Also, I know our hospital would let us make payments on the balance. They would spread it out over up to 12 months, with no interest and no penalties. So ask about that, too.

 

The 'allowed amount' just means that yes, you get a lower rate for things because you have insurance. For example, maybe they only allow the anesthesia to be charged at $1200 instead of $4000 or whatever. But you still will have to cover the first $3000 worth.

 

Talking to the hospital is your best bet. I'd imagine it's very likely they can work with you.

 

:grouphug:

[Lara in Colo]

Well, the allowable is the x factor.

 

Depending on the contract with the hospital, the non-allowable could be written off by the hospital, but it sounds like you will get the non allowable--WHATEVER that may be-- anyone's guess.

 

Lets say the surgery is 12 grand.

 

They allow 10

They pay nothing of the first 3 grand

they pay 80percent of the next 2 grand and

100 percent of the last 5 grand.

 

You will owe 2 grand for the Non-allowable

You will owe 3 grand for first 3 grand

You will owe the 20 percent of the next 2 grand

You will owe nothing for the last 5 grand.

 

 

Allowable is hinky and up to the company. They will review the case a decide the allowable based on their factors.

Example:

They won't pay for 2 treatments per day for 1 illness, but will for another illness.

They won't pay for 3 drs in the operating room, just 2---Dr 3 is YOUR cost.

 

They COuld allow 100 percent or 50 percent.

 

They best way to know is to call the insurance person at the hospital and ask them. They will know how the company operates better than anyone else. Be sure to ask for the person who does the insurance claims and works with your company ( I used to be the medicare"expert" when I did insurance billing-- but I couldn't help you with other companies).

 

Lara

Edited March 20, 2012 by Lara in Colo

[k2bdeutmeyer]

Okay....I just called the hospital. I have to wait for "Connie" to call me back. I also saw something on their website about payment help for those who may not be able to afford their procedures. Hoping we qualify for that.

[melissad2]

My mom applied for help with her bill for hip and knee replacement surgery and the hospital picked up ALL cost after her insurance paid.

[Element]

Okay....I just called the hospital. I have to wait for "Connie" to call me back. I also saw something on their website about payment help for those who may not be able to afford their procedures. Hoping we qualify for that.

 

I don't have any advice or insurance knowledge, but I wanted to say I really hope they can help you out. It's so nerve wracking when you aren't sure what your final cost for something like that will be.

[k2bdeutmeyer]

I don't have any advice or insurance knowledge, but I wanted to say I really hope they can help you out. It's so nerve wracking when you aren't sure what your final cost for something like that will be.

 

Isn't that the truth! I feel sick right now.

[KatieJ]

:grouphug:

Surgery is frightening enough without insurance worries.

 

I think the "allow" thing you are talking about is this:

Say the Dr. charges you $500.00 to the do the surgery. Your insurance will only allow him to charge $350.00, so that is what they will allow. The Dr. must write off the remaining $150.00 because he agreed to accept what the insurance will pay. So, No, you should not be responsible for the $150.00 difference, as along as you use Dr.'s that are using your insurance group.

AFter that, the insurance will start accumulating you bills and will not pay for the first $3,000.00 of that amount that insurance company has allowed.

 

I will add that my daughter had very poor insurance when she had her first child. They called the hospital and asked what the bill would be with her insurance. Then they asked what the bill would be if she was not insured and it was cheaper to be a self pay. Very interesting, so that is what they did.

 

Yes, contact your hospital and see if they have some kind of assistance. According to the numbers you listed, you will be responsible for $3,000 for sure..and then up to $2,000 more depending on what you bills run.

Remember, it isn't just the hospital bill factoring into your totals. DH just went thru surgery and there were 3 bills. The hospital, the Surgeon and the anethesiolgy bill. You might want to call your Dr. and see what his bill is going to be. I wouldn't have a clue how to figure out the anesthesia bill.

Edited March 20, 2012 by KatieinMich

[LadyMSews]

It is very likely the hospital will work with you to resolve whatever your insurance doesn't pay. I had an operation last year to remove a uterine fibroid. The surgery procedure used a robot! It was a much less invasive and allowed my ob to do a better removal of the fibroid without excessive damage to my uterus. The thing was, that robotic machine is billed *by the minute*, to the tune of $121...yes, $121 A MINUTE. And my surgery took 4 hours, instead of the 2 1/2 my insurance had pre-approved. Just the bill for the surgery (not my room or meds or anesthesia, or anything else) was over $30K.

 

First, the hospital worked hard with my insurance to get as much covered as possible, then we paid what we could and they wrote off the rest (because of our income/family size).

 

I hope you hear back soon and the hospital can put your mind at ease.

[Lara in Colo]

:grouphug:

Surgery is frightening enough without insurance worries.

 

I think the "allow" thing you are talking about is this:

Say the Dr. charges you $500.00 to the do the surgery. Your insurance will only allow him to charge $350.00, so that is what they will allow. The Dr. must write off the remaining $150.00 because he agreed to accept what the insurance will pay. So, No, you should not be responsible for the $150.00 difference, as along as you use Dr.'s that are using your insurance group.

AFter that, the insurance will start accumulating you bills and will not pay for the first $3,000.00 of that amount that insurance company has allowed.

 

This is not always true: This depends on the contract the hospital/dr has with the insurance company. Some tell the Dr to write it off, some forward it to the patient. You must check with the providers (hosp/drs).

 

 

 

 

I will add that my daughter had very poor insurance when she had her first child. They called the hospital and asked what the bill would be with her insurance. Then they asked what the bill would be if she was not insured and it was cheaper to be a self pay. Very interesting, so that is what they did.

 

this is very true!!! However, this will not help with your co-pay issue and if you need stuff later in the year, you will be in the same position.

 

Yes, contact your hospital and see if they have some kind of assistance. According to the numbers you listed, you will be responsible for $3,000 for sure..and then up to $2,000 more depending on what you bills run.

Remember, it isn't just the hospital bill factoring into your totals. DH just went thru surgery and there were 3 bills. The hospital, the Surgeon and the anethesiolgy bill. You might want to call your Dr. and see what his bill is going to be. I wouldn't have a clue how to figure out the anesthesia bill.

 

this is also true and you could get really hurt if the other doctors are not in your plan. This happens often when the only dr available at that time, isn't in your plan.

The best advice is to call, call, call.

[k2bdeutmeyer]

I know for sure my doctor and hospital are in-network. I assumed the anesthesiologist would be too?!? I don't even know how to find out who that is.

[G5052]

Ask about each doctor and the hospital "just to confirm." Been there, done that, although it is always a bit unpredicable.

 

We just had one that could have been over $5000 total (we thought the doctor was out-of-network), and it ended up being $800. I went around and around with the insurance company, and we finally just did it because DH absolutely had to have it done and only with that doctor. The insurance company couldn't figure out if he was in-network or not because he wasn't in the database, but his group was. In the end an office staff member somehow straightened it out, and we got network coverage.

 

We've played these games for ages now, and I hate how unpredictable it is.

 

And yes, every doctor and hospital we've ever dealt with has had a payment plan, but you need to ask and let them know if you are having trouble keeping up with the payments. They'd much rather be paid than turn it over to collections.

[FairProspects]

I have had 2 surgeries within the last year, and both hit my maximum co-payments (and one was only 45 minutes long total, including recovery room). My hospital bill for the operating room only each time was over $12,000 before I was even billed for the surgeon, anesthesia, and anesthesiologist. Even after discounts and co-insurance the charges will be well over your max out-of-pocket.

 

I think you should expect to be charged your $5000 max and work with the hospital from there if you can't afford the payments.

[k2bdeutmeyer]

I have had 2 surgeries within the last year, and both hit my maximum co-payments (and one was only 45 minutes long total, including recovery room). My hospital bill for the operating room only each time was over $12,000 before I was even billed for the surgeon, anesthesia, and anesthesiologist. Even after discounts and co-insurance the charges will be well over your max out-of-pocket.

 

I think you should expect to be charged your $5000 max and work with the hospital from there if you can't afford the payments.

 

I was afraid of that. Sigh.

[MeghanL]

Try not to worry about the financial part of it. We also have an outrageously high deductible for our medical insurance. We submitted to insurance, and then worked with the hospital to get our costs lower. My husband makes pretty good money, but we still qualified for 50% off our total bill. And we got to pay for it in monthly installments interest-free. However, the insurance company never knew about the discounted cost, so the whole amount still gets credited toward our deductible.

[KatieJ]

Say the Dr. charges you $500.00 to the do the surgery. Your insurance will only allow him to charge $350.00, so that is what they will allow. The Dr. must write off the remaining $150.00 because he agreed to accept what the insurance will pay. So, No, you should not be responsible for the $150.00 difference, as along as you use Dr.'s that are using your insurance group.

This is not always true: This depends on the contract the hospital/dr has with the insurance company. Some tell the Dr to write it off, some forward it to the patient. You must check with the providers (hosp/drs).

 

 

I guess I should have said, this is what is true in our area. My information is from a friend who works for an insurance broker and is a liason between clients at times.

[WeeBeaks]

You already got good info.

 

My only caveat is that if you do hit max out of pocket of $5000 (likely with surgery), have anything and everything else you need done this year while you are already at max out of pocket for the year. We have BTDT. :grouphug:

 

And ours is like some amount individual deductible but only another small amount for family deductible. I think ours is like $500 individual but $700 family deductible. So if we meet it with one family member and others need something elective done ... that is the year we do it.

[k2bdeutmeyer]

You already got good info.

 

My only caveat is that if you do hit max out of pocket of $5000 (likely with surgery), have anything and everything else you need done this year while you are already at max out of pocket for the year. We have BTDT. :grouphug:

 

And ours is like some amount individual deductible but only another small amount for family deductible. I think ours is like $500 individual but $700 family deductible. So if we meet it with one family member and others need something elective done ... that is the year we do it.

 

I was just telling DH the same thing. Unfortunately (or maybe fortunately?), we don't really need anything else done.

[Mommyof4ks]

I would ask about financial assistance. We applied when dh made good money but not enough to pay our medical bills, and the hospital packed up whatever we could not pay for a year. It was wonderful.

[kroe1]

I would also get a second opinion before you have the surgery. Does the risk of keeping a golf ball size cyst, i.e. Pain, torsion, and rupture outweigh the risk of the surgery, i.e. infection, bleeding, lifelong pain from adhesions, debt from surgery, etc. I would also want to know the chances the cyst will resolve on its own.

 

You may have already done all of this and posted about it. I am behind. Whatever you do, I pray for a speedy recovery. Remember many times an outpatient surgery suite is cheaper than a hospital. Lastly, get the infection rate from both the surgeon and the place you are having the surgery done.

[FairProspects]

Remember many times an outpatient surgery suite is cheaper than a hospital.

 

 

Well, not in my experience or my MIL's. In our cases the outpatient surgery suites were more expensive than the hospital ORs. I joked that it must be because they try to make it feel like a "spa" with all the armchairs and plants, but they can buy a heck of a lot of plants and armchairs for what they charged me. I hope for OP's sake that this is true, but I wouldn't count on it.

[JFSinIL]

:grouphug:

Surgery is frightening enough without insurance worries.

 

I think the "allow" thing you are talking about is this:

Say the Dr. charges you $500.00 to the do the surgery. Your insurance will only allow him to charge $350.00, so that is what they will allow. The Dr. must write off the remaining $150.00 because he agreed to accept what the insurance will pay. So, No, you should not be responsible for the $150.00 difference, as along as you use Dr.'s that are using your insurance group.

.

 

Yup - this is true.

[k2bdeutmeyer]

I would also get a second opinion before you have the surgery. Does the risk of keeping a golf ball size cyst, i.e. Pain, torsion, and rupture outweigh the risk of the surgery, i.e. infection, bleeding, lifelong pain from adhesions, debt from surgery, etc. I would also want to know the chances the cyst will resolve on its own.

 

You may have already done all of this and posted about it. I am behind. Whatever you do, I pray for a speedy recovery. Remember many times an outpatient surgery suite is cheaper than a hospital. Lastly, get the infection rate from both the surgeon and the place you are having the surgery done.

 

This has been causing me debilitating pain for 6 months or so....combined with my endometriosis symptoms, I think the surgery is the right thing to do. I will have a definitive diagnosis on the endo (which will help in the future) and be rid of this horrible pain every month.

 

The doctor would've been willing to wait and watch if that's what I had preferred, but I really feel like this is the best course of action right now.

[MistyMountain]

I would be interested to see what happens. My husband got a new job and the insurance is similar to that. It has a deductible then you pay half up until a max OOP of $4000. We have no insurance right now so it is better than that but we still could have $4000 dollars in expenses. I didn't know that you could get finacial help if you did have insurance so that is good to know.

[asta]

Double check that the "cash rate" isn't obscenely higher than the insurance rate. It doesn't make sense, but often, the rate offered to cash customers is double, triple, quadruple that offered to insured patients.

 

Lesson? Everything is negotiable.

 

 

A

[Dana]

My only caveat is that if you do hit max out of pocket of $5000 (likely with surgery), have anything and everything else you need done this year while you are already at max out of pocket for the year. We have BTDT. :grouphug:

 

Also, keep an eye on stuff for taxes. We had two years where we were able to itemize and count medical as a deduction. :glare:

[MrsBear]

 

Lets say the surgery is 12 grand.

 

They allow 10

They pay nothing of the first 3 grand

they pay 80percent of the next 2 grand and

100 percent of the last 5 grand.

 

You will owe 2 grand for the Non-allowable [incorrect]

You will owe 3 grand for first 3 grand

You will owe the 20 percent of the next 2 grand

You will owe nothing for the last 5 grand.

 

Lara

 

If the surgery is billed at $12,000 and the insurance contract rate for reimbursement is $10,000, that's the allowable and the other $2,000 is adjusted by the hospital as they've agreed to accept $10,000 on the billable $12,000, that patient is not subject to balanced billing or the additional $2,000 that was not allowed/reimbursed by the insurance company.

 

The first $3,000 is the patient responsibility (deductible)

 

The remaining $7,000 is subject to an 80/20 coinsurance, with the patient having a maximum $5000 total out of pocket, that includes the $3,000 above. 80% of $7,000 is $5,600 to insurance, $1,400 to patient responsibility.

 

In total, for a hypothetical $12,000 surgery:

 

$3,000 patient deductible paid by patient

$1,400 patient coinsurance payment

$4,400 paid by patient with $600 remaining in year of total $5,000 max

$5,600 paid by insurance company (80% of the amount over $3,000)

 

$10,000 total amount hospital accepts for payment by both the insurance company and patient....they write off the $2,000 because they've contracted to accept the $10,000 in their insurance contract with that carrier.

[Happy]

Double check that the "cash rate" isn't obscenely higher than the insurance rate. It doesn't make sense, but often, the rate offered to cash customers is double, triple, quadruple that offered to insured patients.

 

Lesson? Everything is negotiable.

 

 

A

 

We've found this to be true, as well.

[Kipling]

I agree with KatieinMich and Mrs. bear. That has been our experience, too. We have a really high deductible, and my son had surgery last year. The hospital, the surgeon, and the anesthesiologist all submitted separate bills. The insurance company processed them at the "allowed" or "contracted" rate, meaning that the surgeon charged $3600, but the allowed amount was $1080 for that procedure. We had to pay 1080, and the doctor had to write off the difference. My brother is a doctor and says this is completely normal. The other two bills were handled the same way - hospital and anesth. submitted their bills, had the rates adjusted, and we paid the allowed amount.

 

So, my interpretation is if the allowed amount of everything is $5000, you would pay $3,400 ($3000 ded, 400 for the 20%coinsurance.) This becomes the new bill for the hospital, and you can work out a payment plan with them to pay it off. Most medical facilities are very good about this type of thing.

 

What I did find frustrating was that no one could tell me in advance what the allowed amount would be because the hospital has different contracts with different ins. companies, so different allowed amounts. And the insurance company needed to know the specific medical code to know the allowed amount. I tried to find out what our cost would be ahead of time, but ended up just having to wait and see. Very frustrating and nerve wracking.

[magnificent_baby]

High deductibles are no fun, we have one too.

 

Just in my own opinion, I would not pay cash to avoid the deductible, even with a discount. What if something else comes up this year? Your out of pocket will likely be met with this surgery, and it is still early in the year.

 

Around here, hospitals seem to be very cooperative with payments, even if it's a little bit here and there. And many forgive some of the amounts too, depending on need.

 

:grouphug:

[KatieJ]

What I did find frustrating was that no one could tell me in advance what the allowed amount would be because the hospital has different contracts with different ins. companies, so different allowed amounts.

 

To make it even more confusing, our Dr. has a son who is also a surgeon. The first bills we got had the wrong Dr. name on them. The insurance company adjusted the bills and applied it to our deductible. Someone figured out they had the wrong Dr. and when the corrected bill came, the original charge was the same, but the adjustment was completely different! My friend in insurance says this is very normal. Each Dr. works out his contract with the insurance companies.

[*********]

Kristin, I just wanted to add that I know it's overwhelming. I know it seems like that's just too much money to spend. But first of all, the hospital will likely be able to work with you on lowering your amount owed and making payments.

 

Also remember, you've posted about the horrible pain you have each month. Let's imagine for a second that it was one of your precious children that was going through that pain every month. You would not blink at incurring medical bills to help them be rid of such pain. Well, you are the Lord's precious daughter. And he has gifted the world with the ability to relieve you of this pain. I realize money worries are real, and that bills have to be paid. But it's worth it in the long run. Look at it that way.

 

:grouphug: to you dear. Let go of the guilt or whatever you're struggling with. You need this surgery to have a good quality of life. And the Lord will be with you, and help you work out the money side of it. Blessings to you dear. :001_smile:

[*********]

High deductibles are no fun, we have one too.

 

Just in my own opinion, I would not pay cash to avoid the deductible, even with a discount. What if something else comes up this year? Your out of pocket will likely be met with this surgery, and it is still early in the year.

 

Around here, hospitals seem to be very cooperative with payments, even if it's a little bit here and there. And many forgive some of the amounts too, depending on need.

 

:grouphug:

 

This is definitely the gamble one takes.

 

My dh uses a cpap. We have a $1000 individual/$2000 family deductible. The price to get his mask replaced (which he needs each month) is $10 if we don't have insurance. It's close to $50 if we do use the insurance. :001_huh: That's absurd. So basically, so long as we're not maxed out on our deductible for our coverage year, we pay the cash rate and don't go through insurance. It's all quite a sad game they play, and one has to learn the rules and use them to your advantage. I don't understand why it's ok to have different rates depending on how the item is paid for. It just seems dishonest to me.

[TexasRachel]

I hope things go well, but I just wanted to mention you are under no obligation to pay $x/month that the hospital says. My oldest DS had multiple health issues and the drs/hospitals all wanted their bills paid immediately. We would just say we can't. We can pay $25 because we had so many bills. It didn't make them happy and it took years for some of them, but we paid every month until they were paid off. We did it again last year for youngest DS. They wanted $100/month. I said we could do $50 and we set it up for automatic withdrawal. They were happy and never called again.

[EKS]

That's the problem with high deductible insurance. It is cheaper month to month, but you need to have (in this case) $8000 in the bank for situations like this.

 

As for the allow thing, it means that if you use a hospital that has a contract with the insurance company, the hospital will charge the contracted rate and what you owe will be based on that rate. So say that without a contract, the hospital charges $10,000 for your procedure. The insurance company has a contract where the hospital charges less, say $6000. The percentage that you owe will be based on the $6000 and not the $10000. So you would owe $3000 + $600 (20% of the other $3000). Now if your insurance company does not have a contract with the hospital, you will pay your deductible of $3000, $600, *and* the $4000 that the insurance company doesn't cover.

 

I absolutely *hate* everything to do with health insurance.

[magnificent_baby]

This is definitely the gamble one takes.

 

My dh uses a cpap. We have a $1000 individual/$2000 family deductible. The price to get his mask replaced (which he needs each month) is $10 if we don't have insurance. It's close to $50 if we do use the insurance. :001_huh: That's absurd. So basically, so long as we're not maxed out on our deductible for our coverage year, we pay the cash rate and don't go through insurance. It's all quite a sad game they play, and one has to learn the rules and use them to your advantage. I don't understand why it's ok to have different rates depending on how the item is paid for. It just seems dishonest to me.

 

In your situation, yes that makes way more sense to not turn it into insurance! In her case, if you are going to pay a few thousand either way, it would seem to be more sensible to have it count toward deductible.

 

The pricing differences are absurd, but it has to be made up for somewhere for those who have medical treatment then disappear and never pay, as well as Medicare reimbursement, which is very, very low (in surgery anyway).

[k2bdeutmeyer]

Thanks so much for all the input!

 

The hospital just called and left me a message. Thankfully, this hospital DOES provide estimates. What I don't know (I called her right back, but she didn't answer) is if the total she gave me includes my doctor and the anesthesiologist, or if it's the just the hospital's portion. With the numbers she gave me, I'd be responsible for about $4500 of my bill. (The contracted amount was just over $10,000)

 

She also didn't address my questions of financial assistance. So, when she calls me back again, I'm going to ask if that will be my total bill, or just the hospital's portion as well as ask about financial assistance.

 

I know this has to be done. It just does. But, oy. I just want it over.

[zimom]

Kristen,

I don't mean to add to your stress, but the estimate from the hospital was likely JUST the hospital fees. Your surgeon and the anesthesiologist will likely bill separately.

 

Oops, edited to add: I see you asked that above and I did not notice.

[k2bdeutmeyer]

Okay....I talked to the hospital yesterday afternoon.

 

That number is JUST for the hospital (I figured it would be). We still have to add on my dr's fees, the anesthesiologist's fees, and pathology. Obviously, even just the hospital's portion is only $500 shy of our out of pocket max, so we'll hit that $5000 mark for sure.

 

I did get to ask about financial assistance. It is based on income. She is sending the packet out to me to fill out and turn in. Help is offered anywhere from 0% to 100% depending on where your income falls. I won't know where we fall for 3ish weeks until they process my application.

 

Now, that will only help with the hospital's portion of the bill. However, since their portion technically will have brought us within $500 of our out of pocket max, will we only be responsible for $500 of the rest of the bills (dr, anesthesiologist, pathology)?

[KatieJ]

Okay....I talked to the hospital yesterday afternoon.

 

That number is JUST for the hospital (I figured it would be). We still have to add on my dr's fees, the anesthesiologist's fees, and pathology. Obviously, even just the hospital's portion is only $500 shy of our out of pocket max, so we'll hit that $5000 mark for sure.

 

I did get to ask about financial assistance. It is based on income. She is sending the packet out to me to fill out and turn in. Help is offered anywhere from 0% to 100% depending on where your income falls. I won't know where we fall for 3ish weeks until they process my application.

 

Now, that will only help with the hospital's portion of the bill. However, since their portion technically will have brought us within $500 of our out of pocket max, will we only be responsible for $500 of the rest of the bills (dr, anesthesiologist, pathology)?

 

 

Kristin,

 

Insurance pays or applies to your deductible the bills as they recieve them, or so I think. So if the hospital bill is the first one they get, that one will have the deductible applied to it. If the Dr. or one of the others get there first, that will have the deductible applied to it. Maybe someone else will have a thought here, but I don't know how you get the hospital bill there first so that the deductible can be applied and then the insurance would begin paying the other bills. I think when my hubby had his surgery in December, the Dr. bill and the hospital bill were both sent within a few days. But of course each Dr. office and hospital has their own way of billing. I think you should call your Insurance company back and ask them how you could get them to apply the deductible to the hospital bill so the others would get paid then.

[*********]

Now, that will only help with the hospital's portion of the bill. However, since their portion technically will have brought us within $500 of our out of pocket max, will we only be responsible for $500 of the rest of the bills (dr, anesthesiologist, pathology)?

 

Kristin, unfortunately I think this is totally luck-based. I *think* the insurance company just goes by whoever submits the bill first. So if your anesthesiologist submits his bill first, and say his 'approved amount' is $800, then you will owe him that $800. I wonder if there's any way for you to speak to both your dr. and the ansethesiologist before hand and explain the situation, and ask if it's possible for them to delay billing just a bit so that the hospital bills your insurance first? It'd be worth a try. You could just call their offices and speak to someone in billing.

 

Be optomistic about the hospital financial aid. Let me go see if I can find an old hospital bill...

 

Ok. There's a chart on the back of my bill. For a family size of 5, they have these discounts. (Note that it doesn't say if the income they list is gross or net.) This would be for just the hospital charges, not the physicians:

 

Income less than $52,340 would get you a 100% discount.

Income between $52,341 and $65,425 would be a 75% discount.

And income between $65,426 and $78,510 would be a 50% discount.

 

It's really crazy generous when you consider that for a family of 5 in our state, the average income (per a quick google search) is around $47,000.

 

I hope your hospital has something like this, and that you can benefit from it. Remember too that your dr. and anesthesiologist will likely let you make payments.

[k2bdeutmeyer]

Ugh! I never even thought about the billing order. I bet you are right!!! Darn! More phonecalls I guess.....not optimistic they will want to delay billing though. I feel like so often, the hospital is great, but outside offices are not. I don't know though....hoping to be surprised.

 

According to your numbers Bethany, we would EASILY qualify (even if it's gross) for 100% coverage! I hope that's the case!

[*********]

I just thought of something else that may be useful to you.

 

Moose had to have his circ. done when he was one year old, so it was surgery under anesthesia (yeah, I didn't do enough research, but he needed something 'extra' done than a regular circ; long story). Anway, since it was not an emergency surgery but rather scheduled ahead of time, the hospital where we were going did some sort of pre-billing thing, and called us to ask how we were going to pay our co-pay the day of the surgery, and would we like to go ahead and pay it now. I was all :001_huh:, because I'd never had that happen before. But maybe it's something you can discuss with the lady at the hospital, so that she knows you're hoping to have the hospital bill received by your insurance first.

 

I don't think (I could be wrong) that your insurance will be able to help you. THEY don't care whose bill gets processed first, and I *think* I've been told that in order for them to remain impartial in situations like this, that there is some sort of industry standard where they process the claims in the order that they're received. That way, it's not the insurance company's 'fault' who gets paid and who doesn't, if that makes sense.

[k2bdeutmeyer]

I just thought of something else that may be useful to you.

 

Moose had to have his circ. done when he was one year old, so it was surgery under anesthesia (yeah, I didn't do enough research, but he needed something 'extra' done than a regular circ; long story). Anway, since it was not an emergency surgery but rather scheduled ahead of time, the hospital where we were going did some sort of pre-billing thing, and called us to ask how we were going to pay our co-pay the day of the surgery, and would we like to go ahead and pay it now. I was all :001_huh:, because I'd never had that happen before. But maybe it's something you can discuss with the lady at the hospital, so that she knows you're hoping to have the hospital bill received by your insurance first.

 

I don't think (I could be wrong) that your insurance will be able to help you. THEY don't care whose bill gets processed first, and I *think* I've been told that in order for them to remain impartial in situations like this, that there is some sort of industry standard where they process the claims in the order that they're received. That way, it's not the insurance company's 'fault' who gets paid and who doesn't, if that makes sense.

 

Interesting......because when I was in for my pre-op bloodwork and registration on Tuesday the lady did say "I see you have a $3000 deductible, can you pay anything on that today?". Hmm.....

[MrsBear]

Kristin,

 

Insurance pays or applies to your deductible the bills as they recieve them, or so I think. So if the hospital bill is the first one they get, that one will have the deductible applied to it. If the Dr. or one of the others get there first, that will have the deductible applied to it. Maybe someone else will have a thought here, but I don't know how you get the hospital bill there first so that the deductible can be applied and then the insurance would begin paying the other bills. I think when my hubby had his surgery in December, the Dr. bill and the hospital bill were both sent within a few days. But of course each Dr. office and hospital has their own way of billing. I think you should call your Insurance company back and ask them how you could get them to apply the deductible to the hospital bill so the others would get paid then.

 

Reimbursements are paid as received by the insurance companies. When I had DS last year, the OB's office wanted me to pay before I had him because we have a high deductible policy (it was going to be $6000 out of pocket since the total of hospital, OB, anesthesia and whatever else was going to be more than that). I had to firmly tell the finance manager that no, I'd pay if I was billed after DS was born because she couldn't know, nor could I, if the hospital would bill before they did as neither could bill before DS was born!

 

Sure enough, the hospital submitted first and it was the hospital I had to pay to, then the lab, they submitted second, and then anesthesia we owed some but not all since we'd met deductible - my OB's office was paid by the insurance company since we'd met the deductible with the above. I'm glad I didn't pay it, otherwise I'd be having to chase my money to get it back!

 

I recently had the same thing happen with some oral surgery DS needed - the dentist office insisted, was adamant, that his anesthesia and facility charges at the hospital would not be covered, the insurance company had declined it. So I paid it in advance. Guess what? He was fully, 100% covered for both - I knew it, but what do you say when they insist the insurance company already declined and you're heading into the surgery? UGH - now I'm having to go to the dentist office to get a check cut back to me so I can put it back into our HSA!

[MrsBear]

Interesting......because when I was in for my pre-op bloodwork and registration on Tuesday the lady did say "I see you have a $3000 deductible, can you pay anything on that today?". Hmm.....

 

I've learned....."I'll pay what I owe after you submit my insurance and we both receive the EOB.".....you'll owe only the reimbursement contract rate, not their billing rate. After experiencing this with DS's oral surgery, I will not ever, pre-pay something until it's been submitted to the insurance first, then I can review the EOB, see if I need to appeal for some reason and/or pay my portion when the office bills me for their contracted portion the insurance company has said I owe!

[k2bdeutmeyer]

I didn't pay it! I couldn't.....I have nothing to give them anyway.

 

I'm just hoping that maybe that means that the hospital will bill to insurance FIRST.

[QueenCat]

UGH - now I'm having to go to the dentist office to get a check cut back to me so I can put it back into our HSA!

 

They should mail that to you with one simple phone call, which may not even be necessary. We almost always overpay the dentist. They just send us a check when they get the insurance $ in, and it was more than they were expecting.

[MrsBear]

They should mail that to you with one simple phone call, which may not even be necessary. We almost always overpay the dentist. They just send us a check when they get the insurance $ in, and it was more than they were expecting.

 

That is true if the check were mine to keep and deposit in my bank account, or back into the HSA account without penalties. Because it is an HSA account that I paid through, and because we have already funded the account with the max for this year, the doctor's office has to cut the check back to our account and provide me a letter that it is for an overpayment reimbursement so I can deposit it back into the HSA without triggering a penalty for exceeding the maximum contribution to the account for the calendar year. So, in my case, I do need to go pick up the check and the letter since that's easier for me so I can review the letter and then just swing by the bank on the way home once I know it's all done correctly.

[LMA]

I've learned....."I'll pay what I owe after you submit my insurance and we both receive the EOB.".....you'll owe only the reimbursement contract rate, not their billing rate. After experiencing this with DS's oral surgery, I will not ever, pre-pay something until it's been submitted to the insurance first, then I can review the EOB, see if I need to appeal for some reason and/or pay my portion when the office bills me for their contracted portion the insurance company has said I owe!

 

:iagree: You need to see how much really goes toward your deductible first.