I don't understand Insurance or Medical Processes

[Dahlia]

Hi everyone,
I'm going to admit that I don't understand how medical insurance works. I know there are many people in the industry here, please clarify for me:

Deductibles
I have a $5k deductible. I know I need to pay out of pocket $5k and the remaining medical costs are covered by insurance.

But I don't think my co-pays are going to the deductible?

I see a therapist 4x a month and pay $25/ copay ($1200/yr). I anticipated this would take care of a good portion of my deductible. She bills the insurance the remaining charges after copay. The therapy visits show on my insurance history- but my deductible is still untouched. As of today, my insurance says I've paid $28.99 of the $5k deductible. I still have a $4971.00 deductible left to go.

Recently (July 2017) my daughter went to the ER for face stitches and I had to pay $720 because the deductible had not been met. But why $720? Why didn't I need to pay the full amount? It seems like her ER visit was billed to the insurance as $3500.00, but the insurance negotiated their rate and paid $2185. My insurance website said I was responsible for the $250 copay, but the hospital billed us $720. The $720 check I sent the medical center is not credited anywhere on my insurance website account.

I have emailed the insurance company but received a response that didn't make sense and seemed generic, like no one had really analyzed my account.

Can anyone explain to me how the deductible gets met?

Thanks!

[msomnipotent]

First, if your explanation of benefits (EOB) states that you only owe $250 for the ER, call the hospital and get the rest of your money back. Also, you get more than one bill when you visit an ER. You will also get a bill from the doctor. I doubt your daughter had x-rays or an ambulance, but those would be separate, too.

Your insurance company is completely separate from your hospital and will never know what or if you pay your hospital bill. Your payments will never show on an EOB.

Co pays are not part of the deductible.

Depending on your coverage, you might have to pay a percentage of the approved amount of the bill until you meet your deductible. It sounds like it from what you have posted. Say you have a $7,000 bill. Your insurance is contracted to approve and pay $2,500 of it. The provider writes off $5,000. You pay your $25 copay, which leaves $2,475. Your plan calls for you to pay 80% of the contracted rate until you meet your $5,000 deductible, so you pay $1,980.

Are your therapist visits actually covered under your insurance plan? Non-covered bills do not go towards deductibles in most cases. Or, it sounds more to me that your therapist services are covered differently, which is usually the case. You have to read your insurance book to find out how they are covering it. Just like a lot of insurance companies do not charge deductibles for services like mammograms, or no copays for flu shots, etc. Therapist visits may fall under a category that doesn't go towards your deductible. That small amount that did go to your deductible may have been billed differently, like a consultation visit that is considered medical, but all other visits were billed as mental health or something. Billing can be extremely confusing. I have worked in hospital billing for over 10 years (but not recently), and even I will get a bill and think, "Wait, what's this now??".

[Dahlia]

Thank you for clearing that up- I did not realize that medical agencies just send bills without accounting for insurance plans. Next time I'll wait for the insurance to pay and update my account before determining what I owe.

[disneysteve]

Also, be aware of the fact that almost all hospital bills are wrong. Make sure you get an itemized bill, not just a bill with a total amount charged. Review that itemized bill line by line to be sure that you actually had whatever tests and treatments you have been charged for. If you don't know what something is, call and ask. If you think something was charged in error, contest it.

I've told this story before but the last time my wife had surgery, I found a $1,000 error on the bill. The insurance company had already paid their share so that $1,000 came straight off what we owed out of pocket.

Also, never pay a hospital bill without asking for a discount. The hospital offered me 30% off for paying in full. Simply for asking. I grabbed that deal in a flash.

[Thrif-t]

Also, never pay a hospital bill without asking for a discount. The hospital offered me 30% off for paying in full. Simply for asking. I grabbed that deal in a flash.

Dang Steve I never knew that! I always just send in my money owed. So would this work for any hospital bill say maybe for x-rays or lab work that is owed to a hospital? Or are you talking just big money owed for a surgery or more expensive procedure that they'll discount for paying in full?

[LivingAlmostLarge]

Fantastic deal. I've never had insurance where i've ever paid more than a co-pay personally for anything. I paid $250 to have a kid and that was it. If i had had her 3 weeks earlier she'd have been free with the insurance we had.

Even now we pay our premium and $20 copays. Sigh I recall 15 years ago we didn't even have co-pays. And even with our cadillac plan we were paying our $200/month premium share and then co-pays of $10 each visit for anything with BCBS.

I have no idea what this deductible and % business is until I started helping my friends with some of their bills. Medical care in the US is crazy expensive.

[disneysteve]

Dang Steve I never knew that! I always just send in my money owed. So would this work for any hospital bill say maybe for x-rays or lab work that is owed to a hospital? Or are you talking just big money owed for a surgery or more expensive procedure that they'll discount for paying in full?

I don't really know but it can never hurt to ask. One time, the hospital offered me a discount without me even asking. I had gone in to ask a question about the bill and after she answered that she said I could have a discount for paying in full.

Both times they were larger bills, though, in the thousands, not hundreds.