Insurance Claims Question

[TravelingChris]

I have Tricare but I think this question would pertain to any insurance.  I have some 50K worth of bills waiting to be processed.  But because the hospital I was in in March neglected to send my third party liability form I had filled in, these claims were reported in the monthly claims reports I get.  I will be faxing my third party liability form-- those things are so very annoying- since my accidents (and previously the kids) were never anyone else\s fault.  My fall in February was due to my neuropathy and the reason I didn't heal was due to my autoimmune.

Anyway, I have been going weekly to the wound clinic associated with the hospital.  While I am there, I get my bp measured, my bandages come off, they take photos, maybe put lidocaine on the wounds, wait for the doctor, and then re-bandage the wound.  The doctor occasionally takes a curette and cuts a little off- that has happened maybe 2 or 3 times.  Now the doctor charges 93.00 each week and Tricare pays 65.61.  Seems normal enough.   But now I see that the hospital which runs the clinic charges some weeks 1842.26   and some weeks 5647.53 .  So because I couldn't see what this all was about since it just says the hospital name and I thought with these type of charges, it was just put in the wrong date, I called the billing company yesterday.  They told me not to worry about it but even though I asked what the bills were for, exactly, they wouldn't tell me.  There is absolutely nothing that has been done at the clinic that is worth those kind of prices---and I know since I am a very high user of medicine and see what all types of services and doctor visits cost.

My question then is, should I call Tricare and find out what the bills are for and tell them what is actually happening or should I just wait until they process since they reduce amounts most of the time by a lot?  (My hospital stay was reduced so extremely much).  I just don't want taxpayer money wasted.

[Soror]

I'd call the provider and ask for an itemized bill. Even though there will be a lower negotiated rate with those charges being so much higher the final bill is undoubtedly going to be that much higher too. I've never gotten itemized info from the insurance company, if they do that I wasn't aware of it but the charging facility has to give you that. We had an issue with a hospital before too and asked for the itemized bill and it had every detail of the charges.

Edited June 25, 2021 by Soror

[Katy]

Yes, call Tricare & notify them. It may be fraud, it may not, but someone should look into it.

[TravelingChris]

17 minutes ago, Soror said:

I'd call the provider and ask for an itemized bill. Even though there will be a lower negotiated rate with those charges being so much higher the final bill is undoubtedly going to be that much higher too. I've never gotten itemized info from the insurance company, if they do that I wasn't aware of it but the charging facility has to give you that. We had an issue with a hospital before too and asked for the itemized bill and it had every detail of the charges.

Well that is what I did and they blew me off.

[RootAnn]

I'd call back and politely request them to send you an itemized list for x # of weeks. If they blow you off, politely ask to speak with their supervisor. Rinse, wash, repeat.

At the end person, you can use the words "insurance fraud" if they will not send the report to you. I can't remember the state title of who investigates insurance fraud that another poster always says to mention, but that would be good to mention if you need it.

I assume they are charging "going rate." It is amazing how much something costs when it is billed to insurance. 

[TravelingChris]

Okay, I figured it out.  I don't have to call because I just saw a previous claim that was for 4789.91 and they ended up paying 657.06.  So they are discounting a lot.  Even more discounting was made on my 135,793 hospital bill for 7 days in the hospital.  Tricare said it was worth 8076.