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/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.

5

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.

3

u/IrisFinch Apr 28 '25

Agreed, the numbers don’t add up to me either.

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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.

1

u/kirpants Apr 28 '25

What are the procedure codes?

2

u/BrierPatch4 Apr 28 '25

90792

Q3014

90833

99214