Need Advice: Paid $4,500 Out-of-Network, Insurance Authorized but Only Covered $1,199 - How to Get Reimbursed?

[peruss]

I live in Colorado. I have health insurance through my NC-based employer. I had a procedure done by an out-of-network doctor.

Before procedure was done, provider asked for authorization to my insurance for 4,500.

They got an authorization letter for 4,500 from my insurance.

Since it is out of network, I had to prepay the 4,500.

At submission, I got the following:

Your Provider Billed

$4,500.00

Allowed Amount

$1,199.27

[Insurance company] Paid

$1,199.27

Member Savings

$3,300.73

You May Owe

$0.00

Copayment

$0.00

Applied to Deductible

$0.00

Applied to Coinsurance

$0.00

Obviously, the 3,300.27 came out of my pocket. Is there anything I can do to get the difference back ?

 

[womanofgod123]

@peruss Since you went out of network, there is nothing further your insurance can do. That is the cost the insurance would’ve paid an in network provider for that service. The OON provider can charge what they want, which they did. You are unlikely to get the remaining money as they feel $4500 is appropriate.

 

[practicingchristianity]

@womanofgod123 This is the correct answer. The OON provider is under no obligation to accept the amount that the insurance company reimburses under the “allowed amount”. Since there’s no contract. You’re on the hook for the difference between the billed and the allowed amount. That’s the cost you pay for going to an OON provider

 

[trustinggod]

@peruss You don't. A pre authorization doesn't guarantee payment. You went out of network so you have no leverage here.

 

[foreverthankful]

@peruss If you paid $4500 and insurance covered 1199.27, you can seek reimbursement for the 1199.27 from your provider.

 

[peruss]

@foreverthankful Thanks for the reply. I should clarify that the 1199.27 reimbursement was sent in a check issued directly to me. My concern is about the remaining $3300

 

[foreverthankful]

@peruss Ahhh, well...

I'm trying to rack my brain as to why insurance would send a Prior Auth stating they'd cover $4500... as that's not typically how things work--- they don't say "this is approved and we'll cover $4500". They either approve the procedure or deny it--- and it's paid in accordance to your policy.

There are some situations like a network gap exception (if you needed to see a certain specialist and there was not one in network where you are) or continuity of care (you have existing treatment plan with a provider and when you move to a new policy and they are out of network, you might get approved to continue care at the in-network level).

But typically, out of network care has coverage limitations and if you don't have an agreement with insurance like one listed above--- then your check from insurance is all you're due back. It is odd that the EOB says you owe $0 though- it stead of saying that you may owe the remainder of the $4500 minus the 1200 that was paid by insurance. Typically, with out of network, the doctor who is out of network is not obligated to stick to in-network pricing or allowable amounts (your 1200 is the allowable amount here) and can balance bill you for whatever insurance doesn't cover.

Did you actually get sent a letter from your insurance saying they'll cover $4500 or did your provider just say they got a prior auth--- because again, a prior auth doesn't typically discuss pricing, it' just states that your case notes show the procedure is medically necessary and the procedure is covered by your plan--- to be paid in accordance to the payment details from your plan.

 

[mountaintrip98]

@foreverthankful Did they specifically state "We will pay the entire amount to charge" or "We will cover the procedure at this provider". I'm guessing the latter, and OP will need to eat the amount above the allowed amount because they made the choice to go to an out-of-network provider.

Unless it's a result of a continuity of care or network adequacy appeal, the company I work for would never pay a prior authorized procedure at a non-network provider to charge.

 

[foreverthankful]

@mountaintrip98 See, that's what I'm thinking too--- a lot of people assume that "covered" means paid at 100%... it just means the member meets eligibility for the procedure based on their medical condition "medically necessary" and the plan pays in accordance to the payment details-- and for out of network, that offers no protection from whatever the provider chooses to bill and they can balance bill for whatever insurance doesn't cover.

 

[aletia]

@peruss Was the procedure done in an in-network hospital or surgery center? Also, did you just get the EOB recently?

 

[peruss]

@aletia A major surgery happened in the day of service. Surgeon, hospital, anesthesiologists, etc were all in network. A 2nd surgeon was required and preauthorization was arranged and paid in advance. 2nd surgeon was out of network.

 

[tigggertat]

@peruss The plan discount is between your insurance and contracted, and network providers. Your provider probably does not recognize the contractual adjustment because they are not in network with your insurance company, and therefore have no obligation to honor the contractual adjustment.