Insurance Allowed Amount question

[xixstar]

Does anyone have a health insurance that often lists an allowed amount that is greater than the billed amount??

 

Mine keeps doing this and it's so strange and annoying. My doctor bills $50 but insurance says the allowed amount is $80 and that I owe $80. $80 goes toward my deductible amount.

 

This plays out in two ways:

 

One doctor doesn't bill me $80, he takes the $50 he billed.

 

Another doctor bills is the increased amount - but it is on bills where there are multiple billing codes for one appointment. Example:

 

For my son - one appointment had two billing codes for $100 and $20 for $120 bill. Insurance says it should be $50 and $30 and that we owe $80. That medical office adjusts the bill and says we owe $80 which I feel should be $70, not $80.

 

Am I the only one here dealing with this kind of crazy?

 

*all these amounts are made up for example purposes*

Edited March 4, 2017 by xixstar

[Jaybee]

I don't have an answer, but I have begun to think that the billing/insurance way of dealing with things is so confusing and nonsensical just so that no one can make sense of it--on purpose. That way, you never really know what you owe or what they owe, and when you call to ask about a bill, they can provide an answer that is in their favor.  :crying:  Depending on what your question is, they can figure out some answer. Every time I think I have an issue figured out, it's something like, "Oh, no, you have to pay that because it isn't included" or "That will go toward your deductible" and so on. It is maddening. I can't budget for the bills, because no one can tell me how much they will be, how much will be covered, or when I might receive un unexpected bill from something done months earlier.

[Katy]

This just means that under the agreement to be a preferred provider for your insurance, the doctor is allowed to charge you more than (s)he does charge you.  The allowable amount is the amount that applies to your deductible, not the actual charge, if it is less.

 

If it is more, they are not allowed to charge you more and you should only pay the allowable amount.

 

 

Clear as mud?

[xixstar]

This just means that under the agreement to be a preferred provider for your insurance, the doctor is allowed to charge you more than (s)he does charge you. The allowable amount is the amount that applies to your deductible, not the actual charge, if it is less.

 

If it is more, they are not allowed to charge you more and you should only pay the allowable amount.

 

 

Clear as mud?

I had simply never seen situations where the allowed amount was more than the billed amount.

 

Still find it annoying that a doctor will then charge me more based on the allowed amount.

[ILiveInFlipFlops]

I work in insurance and I've never seen this. Has it happened multiple times? Have you called your insurance company to ask about it? 

 

ETA: It's not strictly legal for your doctor to charge you less than the amount insurance is allowing toward your deductible, which is probably why the second doctor is increasing the amount you have to pay. However, I've never seen an insurance company bump up to the allowed amount like that. Are these in-network providers or out-of-network providers? 

 

Edited March 6, 2017 by ILiveInFlipFlops

[xixstar]

I work in insurance and I've never seen this. Has it happened multiple times? Have you called your insurance company to ask about it?

 

ETA: It's not strictly legal for your doctor to charge you less than the amount insurance is allowing toward your deductible, which is probably why the second doctor is increasing the amount you have to pay. However, I've never seen an insurance company bump up to the allowed amount like that. Are these in-network providers or out-of-network providers?

These are in network providers. One time the allowed amount was only a couple dollars more. Another time it was about 30% more.

 

And I have not called them.

Edited March 6, 2017 by xixstar

[ILiveInFlipFlops]

These are in network providers. One time the allowed amount was only a couple dollars more. Another time it was about 30% more.

 

And I have not called them.

 

 

Well, in that case Katy's right that there's a negotiated rate for in-network providers that they have to stick to, but I've never come across a provider that didn't know what that rate was and either charge well above it or hit it on the nose because they knew what the allowable or negotiated rate would be. Most of our providers don't even give you a bill until they've submitted to insurance so they know what you'll owe. 

 

I'd still call insurance about it, honestly, just to see what they have to say about it. But in this case, I might be a bit more annoyed with your doctors, since they're in-network providers. Then again, every insurance has different negotiated/allowable amounts, so they may just be billing you upfront to make sure they get paid something and neglecting to make sure you understand that there may be an additional bill to come once insurance processes your claims. 

 

My standard response to stuff like this is that insurance is all smoke and mirrors. You will never understand it. I've been working in insurance billing for six years now, and I still can't understand it sometimes. It's a hot mess, and what insurance companies can get away with is absolutely shocking.

Edited March 6, 2017 by ILiveInFlipFlops