Is this trickery or am I stupid?

[u/hello-7224]

I hate insurance and can never understand how it works. I have been going back and forth with my insurance because I feel like they are lying to me about how this works but I may just be stupid. I thought any payments I made out of pocket were applied to my deductible, but they are telling me that it is just co-insurance. Can someone decode the bullshit babble?

Relevant info: Deductible: $1500

I had a pre-approved covered medically-necessary surgery in April. In March, I went in for my pre-op blood work. I paid the hospital up front $1100 based on the info they got from my insurance and I was super pumped that the rest of my surgery would be covered because that payment would surely get us to the $1500 with previous care throughout the year.

Well surgery is complete and a month later low and behold I get a bill for $1700 to my surgeon, my deductible plus $200 of coinsurance to the surgeon.

Insurance is saying that the $1100 didn't go to my deductible because the claim wasn't processed until after the surgeon's claim (they processed it in May), so that $1100 went towards my co-insurance instead.

Does that make sense to people who know insurance? Please be nice. They make this shit so confusing on purpose but

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[u/Leading-Reference-31]

After you meet your deductible you still often have a cost share. So no matter the order of the claims, you owe $1500 and then whatever your coinsurance % is for everything remaining after that.

Sounds like the $1100 was paid to the facility not the surgeon.

[u/Foreign_Afternoon_49]

The total you owe will still be the same in the end. That's your deductible plus 20% of the allowed amount above that, until you meet your OOPM. 

The $1100 you prepaid was an estimate to the facility. But since the surgeon's claim processed first, your insurance is applying your deductible to that (they can't know what you prepaid to the facility). By the time the facility's claim hits, you'll have already met your deductible so you'll only owe your coinsurance. That means they'll have to refund you the overpayment that you prepaid.

It all squares away in the end. 

[u/megan8086]

Three key points in the process you need to know: deductible, coinsurance, out of pocket maximum. Your insurance company receives claims and applies the allowed amount of the claim (how much money in total your dr or facility is allowed to be paid per their contract with the insurance company for each claim) and processes them in the order they receive them. So at the beginning you pay your drs or hospital (facility) the total allowed amount on each claim until you hit $1,500. At that point is usually when coinsurance kicks in. Let’s say you have 20% coinsurance - if your dr bills a claim and the total allowed amount for the claim is $100, insurance will pay the dr $80 and you will pay the remaining $20. It keeps going in this manner until you hit your out of pocket maximum. Once you’ve paid that amount of money, then for the rest of the benefit term, insurance will cover all allowed amounts of claims at 100%. You can usually track how much you’ve paid into your plan through the insurance company’s website. Keep in mind that a lot of insurance plans have different rules about what’s counted towards deductible and/or coinsurance (usually applies mostly to prescriptions), but if it’s a covered medical procedure or supply or prescription, it should count towards your out of pocket maximum. Monthly premiums do not count towards any of these accruals (yuck). Hopefully that helps!

ETA: It sounds like between the two claims, you’ve met $2,800 towards your OOP max no matter how they applied the benefits, so that’s a good thing.

[u/Old_Draft_5288]

The answer is that it might make sense, sometimes hospitals, ask for pre-pay and the end up having to refund it after the fact because it didn’t get factored incorrectly to the payment and insurance.

What you need is your explanation of benefit from the insurance company, and presumably a receipt from what you prepaid.

Then you should call the hospital provider and discuss the existing claim and procedure and prepayment and ask for reimbursement if that’s the way it needs to go.

[u/Old_Draft_5288 → u/Old_Draft_5288]

But if you want more accurate answer, you need to put the total cost of the procedure that the insurance was willing to cover from the ex explanation of benefits, what you prepaid, and what the EOB says that you still owe. And also what your coinsurance and deductible are.

[u/CPandaClimb]

I manage my elderly parents medical - everything: appointments, medicines, and financials. They both regularly have specialist appointments and both end up in the hospital once or twice a year. Dad has had biopsies, other procedures, and now regular cancer treatments. We have NEVER had to pay prior to any visit or procedure - we get bills after the co-insurance is applied - and the insurance outlines how much deductible and copays are left. I compare the insurance EOB to the provider bills. 95% of the time the bills are accurate - the others I call and question and eventually I receive a new adjusted bill. I think it’s odd someone would have to pay anything prior to a surgery if they insurance - I suppose each provider checks that the insurance is valid before proceeding (except maybe the hospital).

[u/Leading-Reference-31 → u/CPandaClimb]

It's becoming much more common to ask for payment prior to surgery but typically you can just say "I'll pay when I get the bill". But collecting copays for visits has been very common for a long time.

[u/HOSTfromaGhost → u/Leading-Reference-31]

Agree… Never pay beforehand if you can absolutely avoid it. Wait for your EOB to come out.

[u/Radiant-Ad-9753 → u/CPandaClimb]

It's pretty common in my experience to have the outpatient facility try to strong arm me in paying the deductible before my surgery. That includes my elderly father before his procedures.

They don't want to be on the short stick of getting on $20 payments for a decade which I understand, but people also don't have a extra couple grand to front providers because someone stuck their hand out first.

[u/AnniesMom13]

They need to repay you their portion of the co-pay amount for the 1100$ or, yes, you've double paid your deductible.

[u/Radiant-Ad-9753]

There's three numbers

Max out of pocket- that's the most you will pay, total

Deductible- that's the total you have to pay, before your insurance starts chipping in and helping out with some of the costs.

Co insurance - once you meet your deductible, insurance starts paying a percentage of your medical bills, and you pay the rest that they don't.

Here's the fun math, you have to get every EOB, and compare where it says "patient responsibility" to what the provider is billing you, to make sure it matches. If it doesn't, you have to get on the phone with their billing department and find out why they haven't reduced the bill.

If you paid one provider too much, you have to get a refund and use that money to pay another provider.

But the max out of pocket is the magic number to focus on for big ticket items like surgery, hospital stays or even E.R visits if they do a bunch of stuff. Be prepared to pay that, and be pleasantly surprised if it's less.

[u/zeph816]

You are confusing the terms deductible and out of pocket max.

You should try to get a firm understanding of these terms:

Deductible Coinsurance Copay Out of Pocket Max

[u/Emotional_Beautiful8]

Ugh. Insurance works by first claim in first claim out, generally. So this is really on the lab provider for not filing faster than the other provider. You’ll have to have them pay you back but they probably won’t do it until after their own claims process. You may be able to give them the explanation of benefits (EOB) from the other claim to expedite your reimbursement. I was able to do this with one of my providers recently.

People will say that you shouldn’t pay up front but it depends on the provider if they will provide service without payment. Mine would not (it was for an orthotic appliance).