Insurance billing

[AGDLynn]

Okay so the other day I get a bill from the dr.'s office that I have been going to for 6 years. The items are from 08/03 and 12/04. I emailed Aetna asking why I was getting billed because looking at their statements, it looks like I or the ins. company paid for everything.

Today I get a response and here's something....please help me to understand, lol. I don't do well with insurance math.

1. Dr. is not a participating Aetna provider....my insurance hasn't changed in 6 years so why are they saying this?? When hubby was there a couple of weeks ago, they didn't say that the dr's office wasn't a participant.

2. I was questioning a $78 charge...."The allowable charges of $443 were reimbursd at 70%, after the 2003 $300 deductible, for a total payment of $100.10 (okay I get that). The allowable amount for the $78 was $64. The $64 was included in the $300 deductible. The balance of $14 was denied, as it exceeded the plan's allowable amount. Based on this information, the patient is responsible for the $78 charge.....((okay why not $14?))

3. I was questioning $68 for a metabolic panel of tests..."The $68 charge was not denied. That..had a contract rate of $14.05. The patient responsibiiity for this office visit is $15.00 (okay I paid that). We paid $160.52 on the claim and the rest is a write off for the provider (who apparrently is/isn't a participant). ((So why am I asked to pay the $68 to the dr's office??)

Thanks y'all!!!
Lynn

[tunatartare]

Did you get a bill or an Explanation of benefits? Sometimes the two look the same and people get confused and this causes problems. I swear it's all part of an evil plot by the insurance companies, I've gotten way too many of those. An Explanation of Benefits will have "This is Not a Bill" written on it somewhere. Good luck either way.

[cashmoney]

Originally posted by AGDLynn
Okay so the other day I get a bill from the dr.'s office that I have been going to for 6 years. The items are from 08/03 and 12/04. I emailed Aetna asking why I was getting billed because looking at their statements, it looks like I or the ins. company paid for everything.

Today I get a response and here's something....please help me to understand, lol. I don't do well with insurance math.

1. Dr. is not a participating Aetna provider....my insurance hasn't changed in 6 years so why are they saying this?? When hubby was there a couple of weeks ago, they didn't say that the dr's office wasn't a participant.

2. I was questioning a $78 charge...."The allowable charges of $443 were reimbursd at 70%, after the 2003 $300 deductible, for a total payment of $100.10 (okay I get that). The allowable amount for the $78 was $64. The $64 was included in the $300 deductible. The balance of $14 was denied, as it exceeded the plan's allowable amount. Based on this information, the patient is responsible for the $78 charge.....((okay why not $14?))

3. I was questioning $68 for a metabolic panel of tests..."The $68 charge was not denied. That..had a contract rate of $14.05. The patient responsibiiity for this office visit is $15.00 (okay I paid that). We paid $160.52 on the claim and the rest is a write off for the provider (who apparrently is/isn't a participant). ((So why am I asked to pay the $68 to the dr's office??)

Thanks y'all!!!
Lynn

Georgia law and Florida law work differently in health insurance. If I were you, I'd call up your agent have him put it in lamens terms for you and make him do his dam job. If you deal directly with Aetna (which is completely stupid because Aetna tends to have more moorons working for them than any other carrier I know of (thats why I stop sending a decent amount of business their way....because of stuff like this) then I would suggest looking up an Aetna agent, not a CSR-customer service rep, and talkign to him about why is it this is happening with the health insurance.

Also, if you dont have an agent and do decide to call up one.....act as though you're interested in swtiching from dealing directly with the company to having him/her as your agent so that they'll help you through this mess. Otherwise, you may just be shit out of luck.

If you lived in Florida I could answer all your questions. But seriously, if you don't have an agent, you really need to look one up and talk to him and not a secretary/CSR...ask for the health insurance agent.

Cashmoney

[PsychTau2]

So here's what little bit I know from working in the psych hospital and having to talk to insurance companies (joy I tell you...sheer joy):

When a doctor is a "participating provider" or "in network", they have a contract with that insurance company that specifies how much they charge for different services and how much payment they are willing to accept from that insurance company (same thing goes for hospitals and labs and such). That's why you'll see an Explanation of Benefits that has some astronomically high fee for an office visit (which is what the doctor would charge someone who isn't using insurance...we had a psychiatrist who would charge $300 for an initial visit), then it will have something that says "allowable charges" which is the maximum amount that doctor can charge those insurance customers (this number can be different between insurance carriers, btw), then it goes into the deductibles and % that your plan covers, and finally leaves you with the amount that you owe (which in theory should be the % of the allowable charges that your policy doesn't cover). Some doctor's offices get their payment from the insurance company, then turn around and bill the patient for the part of the original, cash office fee (the $300) that isn't an allowable charge. So they're still trying to get their $300 from someone.

I've found that insurance companies and doctors are resending bills and statements over and over again, hoping to catch someone who isn't paying close enough attention (or doesn't have the time or brain power to sit down and ask 10,000 questions to get it straightened out), and who will simply write a check and send it away. The more you get copies of bills and statements (from both companies) and ask questions, the less chance you have of actually paying.

I would also get a copy of your policy (the small print document that talks about exclusions, etc) and see what it says about allowable charges. Some insurance networks specifically state that the doctor CANNOT bill their patients/customers for more money in order to get more than the allowable amount. Meaning if the psychiatrist who charges a non-insurance person $300 has signed a contract with QCA Insurance to only bill QCA patients $150 for an office visit, they can't get more than $150 from ANYBODY for that office visit (they can't try to rebill the patient for the extra $150).

Ask lots and lots of questions, and ask them repeatedly. And don't let those CSRs on the phone back you down. Good luck!!!

PsychTau