r/HospitalBills • u/BrierPatch4 • Apr 28 '25
Hospital-Non Emergency In-network is more?
I feel like I'm going crazy here. Explaining is too long, let me sum up.
Husband went to two appointments with new provider. We checked before, was listed on our insurance portal as in-network. When I got EOB, processed as OON. Called insurance (three times) & finally got them to reprocess as in-network. Just got new EOB's & now we owe $650 more than the out-of-network cost.
I have spent an hour on the phone today between insurance & the clinic. Both are saying I need to speak with the other. Do I just escalate this or is there a specific department I need to ask for?
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u/Sweet_Livin Apr 28 '25
It’s possible. However, keep in mind that the provider does not have to accept the $238.77 as payment in full. They can subsequently balance bill you the remaining $391.23 so that they get the full $630. On the second, in-network claim, the provider must accept the $590.34 as payment in full.
Now the provider doesn’t have to balance bill the patient on the out-of-network claim, but that are allowed to.
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u/BrierPatch4 Apr 28 '25
That's not what is happening. Provider is saying I owe $650 more when it is billed in-network vs out-of-network.
We paid the OON bill from the provider while insurance reprocessed the claims. It is now in-network & we owe $650 above what we already paid.
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u/Sweet_Livin Apr 28 '25
The insurance doesn’t care what you paid to the provider. They will have no knowledge of that and it will not impact the EOB that they send. They are saying that the contract rate for the service is (630 - 39.66) = 590.34. That’s the total owed to the provider between both your payments and the insurer payments. If you haven’t hit your deductible, you probably owe the full 590.34.
If you already paid more than that, the provider will issue you a refund. If it had continued to process out-of-network, you would probably owe the full $630
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u/BrierPatch4 Apr 28 '25
Sort of. Insurance is saying the contracted OON allowed amount is $238.77. And insurance is also saying the contracted IN allowed amount is $590.34. The first EOB (OON processed) says the provider cannot charge more than $238.77. Newest EOB (IN processed) says the provider cannot charge more than $590.34.
I paid the OON allowed amount but since the claim was reprocessed to IN provider is now saying I owe $351.57 more.
Why would I choose an in-network provider when it costs me $350 more than an out-of-network one?
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u/Sweet_Livin Apr 28 '25
There is no “contracted” OON allowed amount. By nature of being OON, there isn’t a contract. The 238 is probably a UCR rate, which is in theory is supposed to be a market rate but they aren’t all that accurate. Either way, the provider doesn’t have to accept that amount if they are OON. And in your case, the provider would never take less than 590 even as OON. They probably would bill you for the full 630 if it was truly OON. The note stating that the provider can’t charge more than 238 would be applicable if there was a contract on place for 238. But since there is not, they can hold out for the full 630
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u/BrierPatch4 Apr 28 '25
But we do have an OON deductible (from insurance) does that matter?
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u/Sweet_Livin Apr 29 '25
The 238 would go to your deductible. I still think you would have ended up having to pay the full 630 if it was OON.
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u/BrierPatch4 Apr 29 '25
Nope. I paid insurance in full after it was processed as OON. I spoke with provider billing & they agreed this was completely bizarre & not normal to have to pay more as an in-network claim.
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u/Sweet_Livin Apr 29 '25
They don’t have to accept 238 as an OON provider. They can accept it if they want to, but they can also just bill you for the rest.
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u/BrierPatch4 Apr 29 '25
My EOB states they can't charge more than what it states though.
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u/elsisamples Apr 28 '25
Can you post the EOB with personal info redacted? It sounds like when it was processed out-of-network, you were charged a cash price, which can sometimes be lower than the insurance-negotiated in-network rate. When processed in-network, you are responsible for the full contracted rate until you meet your deductible. Cash prices don’t apply to your deductible or out-of-pocket max, but insurance charges do, even if they are higher initially.
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u/BrierPatch4 Apr 28 '25
I can't post image. Here's one of the charges though:
OON- billed $630, discount $391.23
IN- billed $630, discount $39.66
Does that help? There's 4 different charges & every one is the same. Billed amount is the same, discount is less for in-network.
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u/elsisamples Apr 28 '25 edited Apr 28 '25
This doesn’t make sense. Out-of-network, the provider could either offer you a cash price or bill you the full billed charge — but your responsibility should not be lower out-of-network than in-network. Something is definitely wrong here. Feel free to PM me with redacted screenshots of the EOBs — but I would also call your insurance and ask them to escalate the claim for review, because the way this was processed doesn’t add up. The insurance-negotiated discount for a given CPT code cannot be worse when switching from out-of-network to in-network.
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u/BrierPatch4 Apr 28 '25
That's exactly what I said to the insurance person & she said it all had to do with how procedure codes are assigned/billed & then told me to call provider about procedure codes. Provider gave me the codes but said I had to talk to insurance (possibly contract team?) about the negotiated discounts.
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u/Cultural-Ad1121 Apr 28 '25
Communicate only in writing. These phone calls will bite you in the a$$. Screen print Network status at the time of service.
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u/BrierPatch4 Apr 28 '25
Everyone (insurance & provider) agree that this Dr is in-network. That's not in question. What is in question is why insurance OON allowed amount is less than the insurance IN allowed amount.
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u/Tech_Rhetoric_X Apr 28 '25
Does the provider state that they are in network at the location you had your visit?
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u/Sweet_Livin Apr 29 '25
That’s fundamentally incorrect. It could be a wrap network but that is usually considered in-network. Maybe more of a handshake agreement for OON rates? But That’s still not contractually binding.
But it doesn’t matter anyway. You’re arguing a hypothetical situation. You went to an in network provider, it (eventually) processed at the contracted rate. You have the amount that you need to pay. There’s no way to change it, that’s the agreement.
There’s no one to talk to about changing the rates. Obviously they can’t share the contract with you (honestly it probably wouldn’t illuminate much anyway). You can get all of your insurers rates for all of their codes at all of their providers on their website. It’s massive and hard to download/work with, but it’s out there if you feel like digging more
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u/BrierPatch4 Apr 29 '25
I'm just telling you what four different people in four different departments at my insurance company told me. That they have contract rates for IN & OON providers. Maybe it's because not all providers at this location are IN but they have a contract with the location itself?
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u/BrierPatch4 Apr 28 '25 edited Apr 28 '25
Update: I've been on the phone another hour+ with insurance & provider. Everyone agrees this is crazy & they've never seen this happen before. No one knows what to do, just referring me to the other one.
I'm also currently researching how to file a grievance with my state.
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u/elsisamples Apr 28 '25
Something is going sideways with claims processing. Get a reference number for every call and detailed EOBs for both scenarios.
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u/BrierPatch4 Apr 28 '25
I have ref #s & names for every person I talk to. & All OON & IN EOB's are printed.
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u/elsisamples Apr 28 '25
If you wouldn’t mind sharing with personal info blacked out via PM. I’m curious now.
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u/MagentaSuziCute Apr 28 '25
The word "discount" is deceptive in this case. The 391.23 is the oon reduction. The provider can bill you for the full billed charge, but only the allowable amount would apply to your oon costshare. The innetwork provider has negotiated a higher rate for reimbursement, therefore the discount is lower.