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?

0 Upvotes

40% Upvoted

40 comments sorted by

View all comments

4

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.

1

u/BrierPatch4 Apr 28 '25

But I'm not being billed the full amount. EOB states:

OON- billed 630, discount 391.23, owed $238.77

IN- billed 630, discount 39.66, owed $590.34

The amount owed is what the provider billed me for. I paid the $238.77 & now that it's been reprocessed as IN I owe $351.57 more to the provider.

2

u/MagentaSuziCute Apr 28 '25

It sounds like the provider is/was giving you the cash rate and the claim was reprocessed as innet. The provider may or may not come back and bill you the difference. They do have to tread lightly here due to their contract with your insurance company.

0

u/BrierPatch4 Apr 28 '25

Provider was not giving cash rate. Total amount billed for visits was exactly the same for OON & IN.

2

u/MagentaSuziCute Apr 28 '25

I don't mean that they have multiple fee schedules for insurance vs self pay, they just take OON "discounts" as an adjustment. I have worked with medical providers that did have multiple rates and it created so many problems.

2

u/Environmental-Top-60 Apr 30 '25

It's worse when they go by their mood.