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?

1

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/Sweet_Livin Apr 29 '25

But why can’t they? Under what logic? There is no agreement. Under that theory they could just allow $1 and say that the provider can’t bill anything more to the patient. Unless there is a contracted rate in place, they can bill you the whole thing.

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u/BrierPatch4 Apr 29 '25

The OON is also a contracted rate. I spoke with multiple people at my insurance company & they all said they have IN & OON contracted rates with the provider & none of them have ever seen the OON contracted rate be lower than than the IN like it is here & they don't know why & can't explain it. That's the issue I'm having. Who do I talk to about why the OON contracted rate is cheaper? Talked to someone in the insurance contract department, she had no idea & had never seen something like this & said she can't provide me details about the actual contract because she can't disclose that information to members.

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