Got a balance bill for in network doctor

[Dutch88 27]

In october our son was born and now the bills are coming in. We have a pretty good health insurance plan via the employer of my wife. After deductible, copay etc we have 100% coverage for the delivery. We got our EOB explanation of benefits that says our member responsibility is zero and the disallowed amount is 6000. Ive been googling and i understood that in network doctors negotiate a price with the insurance and that is a set fee and cant charge a penny more than that.

 

Friday we received a bill from the doctor asking to pay the remaining 6000 dollars within 30 days. But because he is in network that is not allowed right? Ive been worrying a lot this weekend, losing sleep over this. I cannot call until monday im looking for advice how to proceed. Im am very confused with the health care in this country its so much easier in Europe.

[SalishSea 18,040]

This is a question for your insurance company.  No one here will be able to address the details of your particular health care plan.

[geowrian 22,338]

If the service provided is disallowed, then it must be covered by the patient or otherwise worked out with the provider.

But yes, this is a question for your insurance company and/or provider.

[Dutch88 27]

Thanks i will definitely call tomorrow just wanted to see if someone had a similar experience. Google tells me this,

 

Quote

A disallowed amount is simply the difference between what has been billed by the health care provider and what the insurance company has paid. These amounts are not billed to the patient; instead, they are written off by the health care provider.

Edited December 22, 2019 by Dutch88

[geowrian 22,338]

46 minutes ago, Dutch88 said:

Thanks i will definitely call tomorrow just wanted to see if someone had a similar experience. Google tells me this,

Ah, I was reading it as there was a service not covered. You are referring to a charge in excess of the allowed amount. Gotcha.

Then yeah, that should not be charged to the patient.

[little immigrant 801]

Hi since it's your deductible you are responsible for it. Anything after your deductible is met, you have a zero out of pocket. 

 

I had two surgeries this year. I'm responsible for $5400 of that. I called them and asked to setup a payment plan. They allowed it. I'll be paying this bill for a year until paid off. It is what it is. But my second surgery was "free". 

Edited December 23, 2019 by little immigrant

[Dutch88 27]

1 hour ago, little immigrant said:

Hi since it's your deductible you are responsible for it. Anything after your deductible is met, you have a zero out of pocket. 

 

I had two surgeries this year. I'm responsible for $5400 of that. I called them and asked to setup a payment plan. They allowed it. I'll be paying this bill for a year until paid off. It is what it is. But my second surgery was "free". 

 

Our deductible is 1150 thats why im so surprised we got billed 6000 on top of that. It doesnt sound right. They did max out our sons deductible as well as soon as he was born.

[Neonred 3,600]

11 hours ago, little immigrant said:

Hi since it's your deductible you are responsible for it. Anything after your deductible is met, you have a zero out of pocket. 

 

I had two surgeries this year. I'm responsible for $5400 of that. I called them and asked to setup a payment plan. They allowed it. I'll be paying this bill for a year until paid off. It is what it is. But my second surgery was "free". 

That's not usually the case.  Most plans have a copay.  The insurance often pays 70% or 80% and the patient pays the remaining 20% or 30% depending on the plan.

 

In the OP's case it sounds like he won't owe the $6000.

[little immigrant 801]

Some hospitals are in network but not all services and doctors inside it are. They can still bill you. 

 

@Dutch88 did you call already? What did they tell you? 

Edited December 23, 2019 by little immigrant

[Wuozopo 4,293]

23 hours ago, Dutch88 said:

Friday we received a bill from the doctor asking to pay the remaining 6000 dollars within 30 days. But because he is in network that is not allowed right? Ive been worrying a lot this weekend, losing sleep over this. I cannot call until monday im looking for advice how to proceed. Im am very confused with the health care in this country its so much easier in Europe.

 

Don't pay it. They have to accept the negotiated rate. Tell them your insurance provider says you owe $0 and that's what you're going with. 

[Dutch88 27]

Thanks all for the replies i appreciate it. I called this morning and the doctors office is gonna resubmit the claim with the insurance. Insurance said they submitted the claim without chart notes. They also billed the wrong doctor at the hospital i found out this morning. The hospital put a different doctor than the one who delivered our baby in the bill. Doctors office said maybe thats where it went wrong they didnt know either. We will have to wait they said it can take a while. It kinda ruined my holidays the bills keep piling up it stresses me out and i lose sleep over it. Lets hope its a mistake they can fix

Edited December 23, 2019 by Dutch88

[Wuozopo 4,293]

3 hours ago, Dutch88 said:

Thanks all for the replies i appreciate it. I called this morning and the doctors office is gonna resubmit the claim with the insurance. Insurance said they submitted the claim without chart notes. They also billed the wrong doctor at the hospital i found out this morning. The hospital put a different doctor than the one who delivered our baby in the bill. Doctors office said maybe thats where it went wrong they didnt know either. We will have to wait they said it can take a while. It kinda ruined my holidays the bills keep piling up it stresses me out and i lose sleep over it. Lets hope its a mistake they can fix

It's their problem to fix if they want to collect more money from insurance. They are to accept whatever your insurance has negotiated. If they can send in more codes to get more approved by insurance, that's how they will get more.  Don't worry about it and don't pay. 

Edited December 24, 2019 by Wuozopo

[Dutch88 27]

11 hours ago, Wuozopo said:

It's their problem to fix if they want to collect more money from insurance. They are to accept whatever your insurance has negotiated. If they can send in more codes to get more approved by insurance, that's how they will get more.  Don't worry about it and don't pay. 

Can they let it go to collections worst case scenario?

[Wuozopo 4,293]

1 hour ago, Dutch88 said:

Can they let it go to collections worst case scenario?

 

The medical providers have not finished submitting paperwork. They made clerical errors in submitting their claims to insurance. They don't have a case to send to collections. Even if a bill auto-generates to you monthly, it is in error until they fix it. It's not yours to fix with insurance, or pay. You were correct in calling and saying "according to my insurance, I don't owe you this amount". Furthermore you should say "please take it off my account".

 

You understand insurance more than you think because your initial posts shows that.  An example of a medical bill: 

A doctor bills $20,000 for an appendectomy. The insurance company's agreement with the doctor is an appendectomy is worth $2000.  That means the surgeon has to take $18,000 off your bill. So all you ever have to deal with is who pays $2000. The $18k is gone and not negotiable.  So what happens to the $2000 bill?

• If you had a high deductible that hadn't been met, then you could owe all $2,000.
• If you had met deductible, you might still have a co-pay of 20% depending on the policy. Insurance pays the surgeon $1600 (80%) and you pay the surgeon $400 (20%).
• If you had already paid during the calendar year your family deductible and for other procedures like your broken leg and a CT scan and Emergency Room fees, then you may have reached your "Out of Pocket Maximum" (OOP). Once you've paid that much OOP, the insurance covers everything else until a new calendar year rolls around. They would pay the surgeon $2000 and you would pay $0. (Edit to add: Don't think they can get more from you in the new year. The appendectomy happened in 2019 and doesn't reset Jan 1, even if insurance hasn't paid yet.)  

It would seem that you either have no co-pay or have already met OOP because you insurance company says you owe $0. Believe them. If the doctor wants to come up with more codes and revise their appendectomy bill to "super complicated appendectomy" then perhaps insurance would say that procedure is worth $4000. That's how the doctor can collect more money from insurance, but not from you if you have no co-pay or have met your OOP. Let them sort it out. 

Edited December 24, 2019 by Wuozopo

[Dutch88 27]

4 hours ago, Wuozopo said:

 

The medical providers have not finished submitting paperwork. They made clerical errors in submitting their claims to insurance. They don't have a case to send to collections. Even if a bill auto-generates to you monthly, it is in error until they fix it. It's not yours to fix with insurance, or pay. You were correct in calling and saying "according to my insurance, I don't owe you this amount". Furthermore you should say "please take it off my account".

 

You understand insurance more than you think because your initial posts shows that.  An example of a medical bill: 

A doctor bills $20,000 for an appendectomy. The insurance company's agreement with the doctor is an appendectomy is worth $2000.  That means the surgeon has to take $18,000 off your bill. So all you ever have to deal with is who pays $2000. The $18k is gone and not negotiable.  So what happens to the $2000 bill?

• If you had a high deductible that hadn't been met, then you could owe all $2,000.
• If you had met deductible, you might still have a co-pay of 20% depending on the policy. Insurance pays the surgeon $1600 (80%) and you pay the surgeon $400 (20%).
• If you had already paid during the calendar year your family deductible and for other procedures like your broken leg and a CT scan and Emergency Room fees, then you may have reached your "Out of Pocket Maximum" (OOP). Once you've paid that much OOP, the insurance covers everything else until a new calendar year rolls around. They would pay the surgeon $2000 and you would pay $0. (Edit to add: Don't think they can get more from you in the new year. The appendectomy happened in 2019 and doesn't reset Jan 1, even if insurance hasn't paid yet.)  

It would seem that you either have no co-pay or have already met OOP because you insurance company says you owe $0. Believe them. If the doctor wants to come up with more codes and revise their appendectomy bill to "super complicated appendectomy" then perhaps insurance would say that procedure is worth $4000. That's how the doctor can collect more money from insurance, but not from you if you have no co-pay or have met your OOP. Let them sort it out. 

Thank you so much! I understand it more now