In-network is more?

[u/BrierPatch4]

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?

[u/BrierPatch4]

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.

[u/greeneyedgirl389 → u/BrierPatch4]

There is no such thing as a “contracted OON rate”. If they were contracted then they would be IN. If the provider you saw was OON, they are not obligated to accept or pass on to you any suggested discounts by the insurance company. As an OON provider, they can bill you up to their charge amount IF THEY CHOOSE TO.

[u/BrierPatch4 → u/greeneyedgirl389]

IDK what to tell everyone. This is exactly what is written on my EOB:

"The amount billed by your provider exceeds the reasonable allowance amount. If the provider bills you more than the Total you may owe, please contact Clear health at (redacted). Please refer to Claims and Appeal Procedures in your Benefit Booklet. Your claim was processed at the out-of-network level of benefits. This is a high deductible health plan"

[u/greeneyedgirl389 → u/BrierPatch4]

“Reasonable allowance” is also known as usual, reasonable and customary. That is an amount that your insurance has determined is “reasonable” for the cost of services in your area. It’s basically a suggestion on what the provider should accept. An out of network provider is NOT contractually bound to honor those suggested amounts. They may not agree that the reasonable allowance is enough to cover the services they provided to you. They are not the same as ”contracted allowances”. The OON provider can bill you for the total cost of services they submitted to your insurance or they can choose to honor the suggested discount. In network contracts are different. In network providers MUST accept the contracted rate as payment in full. For In Network, that means if the total charge is $1000, but the contracted rate is $800, the provider will write off $200 and collect the other $800 between you and your insurance carrier. For OON, say the insurance says $600 is reasonable. The provider can collect the $400 difference from you, the patient. No insurance company can force any out of network provider to accept the usual, reasonable and customary amount.

[u/BrierPatch4 → u/greeneyedgirl389]

Then why does it say "if the provider bills more than the Total amount you may owe" to contact the insurance company?

[u/greeneyedgirl389 → u/BrierPatch4]

My guess would be so that they can contact the provider and try to convince them to accept their suggested reasonable allowance. That happens a lot. All the provider would have to do is say no. Nothing the insurance company can do to make them accept it. I haven’t seen an actual copy of your EOB. If you can send it to me redacted (of course) through PM I would be happy to take a look at it. At the end of the day, if the provider is actually in network, you would owe the difference in what you have already paid and the amount applied to patient responsibility from the reprocessing of the claim as in network.