Copays, Deductibles, OOPs and WTF is Happening Here?

[jane_]

@jordanmarli Looking at the EOB:

You need to dig up your plan documentation. For instance, this insurance specifically states deductible does not apply to primary care visits but does not say that for specialists. This one says the first two visits you pay the $40 copay, after that it's all deductible and coinsurance.

It may be that your plan actually says "$35 copay After Deductible" for the office visits. The doctor doesn't know how much deductible you've used so they collect the $35 copay then bill you the rest once they receive this EOB.

It may be that your insurance is processing the claim using the wrong plan. If your plan documents say that deductibles don't apply to office visits, then you need to call BCBS and tell them to fix the problem and reprocess these claims.

 

[jordanmarli]

@jane_ Oi well nothing like a little light reading in the evening. Our benefits book is sitting next to me I had a feeling I was going to need to read it again. Thank you!

 

[jane_]

@jordanmarli It used to be way more straightforward, but companies have been trying to do everything they can to charge more for less.

In general: if you use in network doctors, the discounted rate always applies, so you never pay more than that in any situation. If deductible applies, it is almost always applied first, until you have used up the deductible for the year. After deductible, if coinsurance applies, then your percentage applies and you pay that % of the discounted rate. Finally if there's a copay you pay that every time. Except in unusual circumstances it's not "in addition" to coinsurance/deductible, they usually don't apply at the same time except in corner cases where you have $10 deductible left for the year and a $20 copay after you meet the deductible.

The trick is knowing when they apply. When I started working back in the '00s, deductible was usually for hospitals and xrays and expensive things like that. My plan that I have now is a HDHP which basically applies almost everything to deductible until I hit it then covers everything else.

Your out of pocket is calculated by the insurance based on what is billed to them and they've marked as copay/coinsurance/deductible. Once you hit that out of pocket maximum then all three stop and the insurance covers the remaining bills for the year.

As for cash, if you pay the cash price that won't go towards your deductible or OOP amount for the year. Some offices do this cash price thing because they don't like insurance either and getting $70 now is better than spending weeks trying to get the insurance company to pay them $76.

 

[jordanmarli]

@jane_ We have a couple that they've been trying to get paid for since March. Insurance and billing are definitely a sunk cost business. Even at federal minimum wage (7.25/hr) you can only work on a $73 claim for 10.06 hours (completely ignoring employment taxes and employee healthcare and the fact that the billing department of a medical office doesn't make minimum wage) before you make no money. I've spent more time than that on the phone and sending messages trying to get it fixed.

 

[jordanmarli]

@jane_ If this is what my plan says:

PHYSICIAN OFFICE-OUTPATIENT VISIT AND CONSULTATION
A primary care doctor 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

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

Does that mean we pay 0% and just the co-pay or am I reading this summary incorrectly?

 

[jane_]

@jordanmarli It does kind of sound like this is processing wrong, though the summaries I linked specifically say "deductible does not apply". Check in the policy if there's a section there about the deductible and whether you're required to meet the deductible before the plan pays for anything.

If not I'd say get HR (if this is a company plan) and the insurance company on a 3 way call, read that line about pediatricians, and ask them why you've had two EOBs now with a $73 deductible.

 

[jordanmarli]

@jane_ Oh I have like 6 of varying expense there's a spreadsheet. The charges aren't even consistent. Oi.

I didn't even think to call HR. I did email her yesterday and let her know that we're having some billing problems related to the kids and asked for a scan of our our original enrollment form.

I'll put call the 7th circle of hell AKA the insurance company on my list for Tuesday. Mondays are terrible for calling places like that.

 

[jamesgonebatty]

@jordanmarli The summary of benefits you are looking at is not matching the plan you are actually on. Summary says 500 individual deductible, EOB says 200. Did you have more than one plan option? And how sure are your office visits are applying copays and not going toward the deductible as well?