Hospital billed 12k, insurance says it should be 4k. I’m left with the difference. How is this allowed?

[kbirchtree]

My billing situation is a nightmare. For a $12,000 out of network charge the insurance company is claiming the Medicaid rate is $4,400 and that is all they will pay. That would be fine with me if they negotiate that with the hospital but they didn’t. The line in the sand was drawn with me and I have to pay the difference. What good is insurance if they arbitrarily decide what should’ve been billed.

Of that $4,400 they claimed billable I’m paying $3,000 for the deductible and $722 in coinsurance. They are paying $722 total. I didn’t realize they could just decide what they want to pay. They just conveniently omitted $8,000 from the equation because they didn’t want to count it. Is this legal???

 

[pdg90601]

@kbirchtree Yes. This is why going to out-of-network providers is bad. Your insurance does not have to negotiate with the hospital, and the hospital does not have to negotiate with the insurance.

 

[shopteach]

@kbirchtree Out of network charges are the patient responsibility. Your insurance will not negotiate this for you, at least IME

 

[boseven]

@shopteach But the individual can and ALWAYS SHOULD.

It usually yields results.

 

[shopteach]

@boseven Absolutely

 

[wendyr]

@kbirchtree Call the hospital and negotiate the rate yourself, ask what the cash rate is for someone paying out of pocket. You’ll be surprised at the difference. Worst case scenario wait until December, call the hospital and they may accept a lower rate to get the charges off their books before the new year.