Copays, Deductibles, OOPs and WTF is Happening Here?

[jordanmarli]

Our health insurance plan is killing me. Like I’m dropping them for the other plan my husbands company offers when open enrollment comes killing me. THIS IS ONLY HAPPENING ON OUR KIDS VISITS TO THEIR PRIMARY CARE DOCTOR. I know yelling I’m so frustrated.

One of us takes a kid to their PCP, Pays the $35 copay. The office sends the stuff in for the claim. The insurance company kicks it back and charges us their cost for the entire office visit. So say their cost is $73 for the office visit. I’m paying $35 for the copay and then $73 for the office visit a total of $108. Our health insurance is paying $0 and applying routine medical care for our children to the family deductible. I could just pay out of pocket and save $38 when I take them to the doctor. Cash payments are $70 if you pay out of pocket at the window.

If I go to the doctor I pay my copay. The end it doesn’t go towards the deductible. Same for my husband so why is it different for the kids?

Edit: this is a PPO and here's a link to a redacted EOB on a Google drive https://drive.google.com/file/d/1SSSmxJkY048rISN-ofw2WhgXgxZ5LUco/view?usp=drivesdk

Edit #2 here's the 1st page of our Summary of PPO Blue Benefits I took the company name off. https://drive.google.com/file/d/1eZof55wf7eg_lImZoIhQ_rXV34R12isr/view?usp=drivesdk

 

[buildfaith777]

@jordanmarli Without a Summary of Benefits or some kind of plan documents it's impossible for anyone here to help you understand your benefits.

 

[jordanmarli]

@buildfaith777 I edited and added a drive Link to a redacted EOB sometimes I forget people can't just see into my brain.

 

[jordanmarli]

@buildfaith777 Link to benefits summary: https://drive.google.com/file/d/1eZof55wf7eg_lImZoIhQ_rXV34R12isr/view?usp=drivesdk

 

[thenewblack]

@jordanmarli What does that EOB say?

If you have an office visit copay than the deductible usually doesn’t apply. If you have a deductible for office visits than you shouldn’t be paying anything at the time of the visit, you should only be paying when you receive your EOB and the bill from the doctors office.

 

[inspiredwalk]

@thenewblack Also what type of visit? Routine or sick? If it is a well child visit those should be billed under preventative and not cost you. Need to see EOBs as said above to be clear though.

 

[jordanmarli]

@inspiredwalk The EOB I copied above is a routine med check for ADHD meds

 

[inspiredwalk]

@jordanmarli Med checks don’t fall under preventative. They billed a regular office visit. It appears you have a $200 deductible and did not need to pay your copay at the time service. You should call and confirm benefits with the insurance company. Once you meet the deductible then they still only cover a certain percent (80/20, 90/10, etc).

 

[jordanmarli]

@inspiredwalk I'm guessing I'm reading our benefits information/explanation for office visits incorrectly? We have a PPO this is directly from our plan site.

PHYSICIAN OFFICE-OUTPATIENT VISIT AND CONSULTATION

A primary care Pediatrician for plans such as PPOs, EPOs, and HDHPs, where you don't have to select one at the start of your plan

You can expect

In Network 0%

Copay: 35 Dollars

Apply Only 1 Copayment, per Date of Service, per Provider

Covered from plan start date

Out of Network 20% Coinsurance

 

[inspiredwalk]

@jordanmarli If that is what your plan states then I would call insurance and ask why claims where processed with a deductible. It could be that you have the $200 ded and then copay. So you would basically pay the first $200 and than copay beyond that. Since it appears ded was not met and charges where $146 you pay that (copay amount you paid at time of service goes towards this) and $55 still remains of ded, so next visit expect to pay that plus copay.

 

[josh_ats]

@jordanmarli HSA? HCA? PPO? What kind of plan is it? We dont have any info to help...

 

[jordanmarli]

@josh_ats Oh PPO!

 

[resjudicata]

@jordanmarli For the record, the insurance company isn't "charging" you anything.

Sounds like the PCP is out of network?

 

[jordanmarli]

@resjudicata No they're listed in network and are selected as the preferred provider for the kids. It's so odd. We just switched to this PPO plan from his employer from another PPO plan with the same company just a slightly different rate structure on the copays and deductible and it's been crazy the amount of trouble I've had with billing. I'm aware that these are the charges from the doctors office but the insurance company is causing a billing problem somewhere in their line and they're telling the doctor's office that we owe $73. It's not some arbitrary number the doctor made up it's what they're being told by our insurance company. It's on our EOB and our claims forms as well.

 

[resjudicata]

@jordanmarli You'll have to wipe the PHI from the EOB and upload it so we can take a look, or call your insurance to find out why this is happened. There's a way the provider is billing that isn't jiving with how your benefits set up. It's possible they're billing a second code that now applies to your deductible in addition to the office visit (biopsies, lab work, etc)

 

[jordanmarli]

@resjudicata I have an email out to them with all the claims that are messed up. I tried resolving it on the phone but I like an electronic paper
trail to follow. We have lab work on one of them we owe a whopping $3 on that.

EOB linkage https://drive.google.com/file/d/1SSSmxJkY048rISN-ofw2WhgXgxZ5LUco/view?usp=drivesdk

 

[catalystsocial]

@jordanmarli My first intuition is that it’s not processing under the office-based benefit. The code 99213 is a normal seeing-a-doctor code, but it can be administered in non-office based settings as well. In particular outpatient hospital centers. Your benefit for outpatient _hospital_services is 100% after the deductible.

The other possibility is that the PPO Summary you’re looking at is not the one you’re enrolled in. The EOB says you have a $200 in network, individual deductible. The plan document says you have a $500 in network, individual deductible. That’s not right. It’s one or the other. Is it $200 or $500, you know? If your HR enrolled you in the wrong plan, for instance, and you haven’t found out yet, that might explain why the insurance company seems to think everything is hunky dory: because they’re following the plan your HR told them to.

 

[jordanmarli]

@catalystsocial AFAIK it's a $500 deductible for the 2019 benefit year. I have to call HR but someone died yesterday that works there so I'm going to wait until the end of the week.

It's not like the health insurance shenanigans can't wait a few more days

 

[charmaine93]

@jordanmarli That 35 dollars should probably be applied to the 73 and the doctor might owe you a refund

 

[jordanmarli]

@charmaine93 I don't know. I'm in uncharted territory here having a routine office visit at the primary, in network, care provider be charged above the copay. I have a PPO from the same company my copays are less and my OOP is lower and all I ever pay is my copay. My husband sees the same PCP I do all he ever pays is his copay. The insurance company kicks the kids stuff back. It's so weird.