Really need help understanding why my doctor is charging me more than my EOB says I should owe (+ other questions).

[downtherabbithole]

(Crosspost from r/Insurance)

I have Empire BCBS PPO 250 through my job.

Ok. So. I’m in a confusing situation here and could really use help figuring out whether my Doctor is secretly overcharging me, why insurance hasn’t reimbursed me after hitting my deductible seemingly months ago, etc. This might be a long post; I’m sorry…I’d be forever grateful if someone could help me out! (Disclaimer: I didn’t check on these claims for months because I’ve been grieving a loss and mindlessly paying my out of pocket costs without bothering to check why I haven’t been reimbursed yet…until now.)

—The situation—

My doctor is out of network. My insurance has out of network coverage. My out of network deductible is $750. Once I hit that deductible, my insurance pays me back 70% (due to coinsurance). My doctor charges me $200 out of pocket every single month for my monthly appointment with her. I went through all of my claims with her, and none of this makes sense (to me). Her office files the claims for me every month.

Noteworthy: I only see her face-to-face for a 2 minute long consultation every single month in order to get my pain medication refilled. I have never received any “medical services” from her. Literally- every month is identical: show up, talk to her for 2 minutes, she refills my script, and I leave. And yet, you’ll see below that for 2 out of the 7 dates I list, she randomly charged my insurance company an additional $160 on top of her “usual fee” for…”medical care”.

• 3/2: I paid her fee of $200. She billed my insurance $110. My plan paid $0 and the claim was approved for out of network care. “What I pay” aka owe (shown in app as well) = $110.

• 4/1: I paid her fee of $200. She billed my insurance $110. My plan paid $0 and the claim was approved for out of network care. “What I pay” aka owe (shown in app as well) = $110

• 4/29: I paid her fee of $200. She billed my insurance $270 (her fee of $110 + an unknown mystery $160 “medical care” fee. I did not receive any special medical care. Refer to my italicized paragraph above). My plan paid $0 and the claim was approved for out of network care. “What I pay” aka owe (shown in app as well) = $270.

• 5/27: I paid her fee of $200. She billed my insurance, again, $270 (same comment as above). My plan paid $161 (for some reason…). “What I pay” aka owe (shown in app as well) = $109.

• June: (My doctor never filed this claim for me. It’s missing, even though I paid her $200 for this visit…)

• 7/27: I paid her fee of $200. She billed my insurance $110. My plain paid $0 and the claim was approved for out of network care. “What I pay” aka owe (shown in app as well) = $110.

• August: (I missed my August appointment because I wasn’t in the state).

• 9/16: I paid her fee of $200. She billed my insurance $110. My plain paid $0 and the claim was approved for out of network care. “What I pay” aka owe (shown in app as well) = $110.

• 10/14: I paid her fee of $200. She billed my insurance $110. My plan paid $77 (for some reason…). “What I pay” aka owe (shown in app as well) = $33.

—My questions—

• Based on what I’ve physically paid with her full price fees, I technically hit my $750 deductible back on 5/27. If we do the math based off of what I’ve actually paid her, my insurance owes me 70% of $50 from the 5/27 visit, and 70% of $200 from the missing June visit they never filed a claim for, the 7/27 visit, the 9/16 visit, and the 10/14 visit. Why haven’t I been reimbursed for these visits yet? I was told by my insurance company months ago that I would be reimbursed 70% of my cost every month- in my bank account- after I paid $750 out of pocket for this doctor.
• Why is my doctor charging me $200, but only billing my insurance company $110?
• In the same vein as #2..why did she randomly charge an additional $160 on top of her “$110” office visit fee that she keeps charging my insurance, when I only have an office visit with her every single month- and all visits are identical? (I’ve never received “medical care” from her. Never. Every month is the same.)
• Is my doctor doing something sketchy here, or do doctors like to bill their patients more than they bill their insurance for our of network claims so they can pocket the difference? I was under the impression that if I pay $200 every month, that $200 goes towards my deductible. Is this normal?
• Why did my insurance randomly “pay” $161 and $77 on those 2 dates?

If anyone could help with these questions, I’d appreciate it so much. I want to come armed with (accurate) knowledge before I call my insurance company tomorrow and talk to my doctor next week. Thank you so much!

 

[tikhonofsc]

@downtherabbithole Sounds like a balance billing issue

For out of network care, providers can bill whatever they want. Your insurance plan isn't going encourage them inflating their prices, so they have schedules to determine what's "usual and customary" or "reasonable and customary".

Simple example - provider charges $200 for a visit. The reasonable and customary cost for that office visit in your area is $200, so insurance will pay up to the $200.

But let's say the provider decided to charge $1,000 for that same visit. Your insurance company isn't going to just pay the provider an extra $800, that will just be welcoming fraud and abuse. The reasonable and customary cost for that visit is still only $200, so that's what they pay and THAT'S what is counted towards your deductible/out of pocket maximum. So in your situation, your EOB would only reflect $200 being applied towards your deductible, the remaining $800 is considered a balance bill between you and the provider.

As to why you provider is changing their bills randomly, that's something you'd have to ask them.

 

[downtherabbithole]

@tikhonofsc Thank you so much for your in depth response.

I’ve gathered from these replies that 1) the random extra charges should be investigated (those two times they billed my insurance for services I never received), 2) that the insurance company likely deems $110 as their acceptable amount to pay, whether or not my doctor is actually billing them the full $200, and 3) that I need to call my insurance company/doctor to try to understand the specifics of how they go about things, here.

I’m a bit lost with some of the other information (very new to understanding health insurance, but I’m trying SO hard, here…spent 4 hours doing research until 4am the night that I posted this, attempting to grasp the complexities of out of network billing), but I’m getting there.

My doctor’s receptionist/nurse actually ended up texting me (she has my phone number in her cell) last night telling me “Hello (name). I just seen your email il call you tomorrow to clear this up. I have to be on my computer to go over everything with you.”…but she never called me.

I would have such an easier time figuring this out if A) my doctor’s office actually had a full blown billing department (all they have is a single person who “works in billing”, who is essentially never in the office at all; aside from her, there’s the nurse/receptionist, another receptionist, and the doctor. Tiniest practice ever, and I could go into depth about how generally shady/shitty of a practice they are, but I’ll spare you the long story), B) I understood enough about this to know how to stand my ground/speak my mind whenever I call my insurance company, and C) I knew what next steps to take to make sure this is all being worked on properly.

I definitely don’t feel comfortable that they billed me for two random “medical care” services I never received…and I’m also still puzzled about why my health insurance has not reimbursed me what I’m owed yet (since I hit my deductible already…I think?? Their numbers and math are incredibly confusing to me).

Yet another (of the millions of things I’m puzzled about) thing that I don’t quite understand fully yet: from what I’m gathering from these comments, my out of network doctor is completely allowed to charge me $200 per appointment despite my insurance only allowing $110, and that extra money ($90) doesn’t get reimbursed back to me? I just want to be clear on whether I’m understanding this correctly.

I apologize for my n00b behavior…man, insurance is complicated in ways that I really wish it wasn’t.

Thank you again.

 

[tikhonofsc]

@downtherabbithole

Yet another (of the millions of things I’m puzzled about) thing that I don’t quite understand fully yet: from what I’m gathering from these comments, my out of network doctor is completely allowed to charge me $200 per appointment despite my insurance only allowing $110, and that extra money ($90) doesn’t get reimbursed back to me? I just want to be clear on whether I’m understanding this correctly.

When a provider is in-network, they're contractually obligated and can't charge any more than the allowed amount.

When a provider is out-of-network, there's no contract. Your doctor can LITERALLY charge WHATEVER they want. 10 minute office visit? They could charge you $5,000 if they wanted.

 

[downtherabbithole]

@tikhonofsc Fuck. That blows. I’d see a different in-network doctor, but I’ve been forced to stick with her (long story short: she prescribes me a pain medication- the only medication that works for my various chronic pain conditions- that not a SINGLE other pain management doctor within a 50 mile radius is willing to give me, so when my insurance changed in March and she ended up being out of network, I was forced to stick with her).

I’m assuming that this essentially ends up meaning that she can just keep the extra money I pay her- despite the smaller amount she bills my insurance company- and I have no say in it. Yes?

I thought I had a decent grasp on how insurance works, but out of network insurance is such a confusing shitshow to me. Drives me nuts…

Although, if there is one thing my doctor’s office is doing wrong- it’s charging my insurance company (those 2 random charges I explained in my post) for services she never actually provided. That’s the one part that truly bugs me and feels…fishy?

I’ve been seeing her once monthly since September 2019. That’s 2 year and 3 months of once monthly appointments.

Each appointment consists of- I shit you not- me walking into her overly crowded office (she schedules 5 appointments at a time for the exact same time slot…yeah, fun), waiting for 1-3 hours to be seen, walking into my exam room, speaking to her for 1-2 minutes at most (“what’s your pain score? Show me your prescription bottle. Okay, I refilled it. Bye!), and leaving. Every month for 2 years and 3 months, this is what happens. That’s it. A disgustingly quick “office consult”. No physical, no treatments, no weighing…nothing.

i’ve never received “medical care”, or anything that would cause her to randomly bill my insurance twice for ADDITIONAL charges (the regular office visit- as always- plus that extra “medical care” fee).

I’m unsure if this constitutes as fraud, but it doesn’t feel right. Based on how this office is run, including the 3-4 total people who work in her private office, I’m suspicious about those charges for sure and will have to bring it up with my insurance company…somehow.

Once I sent an email to my clinic detailing everything in this post + asking for clarification about my claims/etc, the one receptionist in the office immediately texted me privately (she has my number and texts me occasionally if my refill hasn’t come in yet since the doctor is incredibly absent-minded and 0% reliable) telling me she’s going to call me “tomorrow” (Friday) to talk about this. She never called me, which is very typical of their office. But her immediate response/etc sounded a lot like “……fuck, she’s onto us and we need to fix this ASAP”.

I dunno, man. I do now understand how out of network providers can bill whatever they want and that it’s allowed, but those extra charges for services I never received are definitely ringing alarm bells in my head, unfortunately…:l

(Another part that still confuses me is why my insurance company’s EOB’s for 2 of the visits show that my insurance paid out $161 and $77- why did this happen when the numbers don’t add up properly and make no sense in regards to my $750 out of network deductible? I also haven’t received any refunds. Months ago, whilst on the phone with my insurance, they told me as soon as I hit that deductible, I’ll still have to pay out of pocket for each visit but they’ll then end up refunding me 70%. I’ve yet to see any refunds, and am just baffled about the process, here. Even though my $200/mo isn’t counting towards the deductible- based on what I’ve heard here, the amount my doctor bills my insurance is what counts towards my deductible- I should still have hit my $750 out of network deductible by 5/27. The amounts she billed my insurance between 3/2 and 5/27 = $760. My insurance app even shows my $750 deductible has been met, and yet…my insurance still hasn’t refunded me the 70% per visit since then that I’m owed. It might be obvious to people experienced with how out of network insurance works, but I’m stumped. I’ve done hours of googling about this, but it’s so rare to find a post or story explaining out of network coverage/refunds so I feel completely alone and lost, here.)

 

[mountaintrip98]

@downtherabbithole

Based on what I’ve physically paid with her full price fees, I technically hit my $750 deductible back on 5/27.

No, you didn't. Except for a couple of specific scenarios that don't apply to elective care, for out-of-network services the amount that gets applied to cost sharing is the insurance company allowed amount, and the amount you owe is the full billed amount. For example, on 3/02 $110 is applied to your deductible, and you owe the provider $200. This concept is called "balance billing".

Why is my doctor charging me $200, but only billing my insurance company $110?

If this is what is going on, it could be she knows $110 is the insurance usual and customary amount, so they won't allow more anyway, although normally out-of-network providers will bill the full amount.

In the same vein as #2..why did she randomly charge an additional $160 on top of her “$110” office visit fee that she keeps charging my insurance, when I only have an office visit with her every single month- and all visits are identical? (I’ve never received “medical care” from her. Never. Every month is the same.)

Might be fraud, waste, or abuse. Might not be. I don't know enough about the situation to speculate. You could raise the issue with the insurance company but with an out-of-network provider they'll have less inclination and ability to investigate.

Is my doctor doing something sketchy here, or do doctors like to bill their patients more than they bill their insurance for our of network claims so they can pocket the difference? I was under the impression that if I pay $200 every month, that $200 goes towards my deductible. Is this normal?

No, that's normal. As stated above, no matter what the fee is, the rules of the game are that for out-of-network elective care, the accumulation to your cost sharing is what the insurance company allows, and what you owe is what the provider bills. The real problem for you is that if we're assuming she's just trying to bill the allowed amount and it's wrong, say it's really $130, then you're leaving $20 on the table each visit since it's money that could be counted towards your cost sharing that is not. Since she's out-of-network you can request a "superbill" and file claims yourself for the full billed amount to make sure that's not a possibility.

Why did my insurance randomly “pay” $161 and $77 on those 2 dates?

5/27 I don't know, I'd guess 10/14 is when you met your deductible, although the above numbers only add up to $692, so maybe one of the above numbers is wrong of there's some in-network dollars cross applying to out-of-network, or the accumulations are wrong at the insurance company or something.

 

[downtherabbithole]

@mountaintrip98 Yeah, it’s such a weird situation. I emailed all of this info to my provider last night (they’re…not the greatest. They only sometimes have a “billing department” consisting of one single person who we can’t even contact) and they immediately replied saying they’re going to give me a call tomorrow (Friday). Definitely want to be armed with good information, because some of it sounds sketchy, while like you said, other parts don’t. Had a helluva terrible day today with work and stress so I can’t reply as much as I’d like to, but I’ll keep everyone updated after tomorrow’s call + with any new information I obtain from my insurance company themselves. Thanks so much for your reply.

 

[kittin]

@downtherabbithole

1. Is my doctor doing something sketchy here, or do doctors like to bill their patients more than they bill their insurance for our of network claims so they can pocket the difference? I was under the impression that if I pay $200 every month, that $200 goes towards my deductible. Is this normal?

It doesn't make sense for an out of network to charge you more then what they bill insurance. Cause as out of network they can bill the insurance the 200.00 and still pocket the differnt ause of balance billing

If the doctor billed insurance 200.00 a month , 200.00 may not go towards your deductible. What happens for out of network, is your doctor bills 200.00 your insurance says okay but we only think 150.00 is fair for this service so that is all we recognize so we are applying 150.00 to your deductible. The doctor is allowed to bill you the other 50.00 cause as they are out of network they don't have to agree to that 150.00. This you pay 200.00 Also once your deductible is meet your coinsurance is going to be based on the 150.00 so if you have a 30% coinsurance 45.00 is applied to your coinsurance so you pay 45 plus the 50.00 over the allowed amount.

Are you sure she is not billing your insurance $200.00 and their allowed amount is 110.00?

10/14: I paid her fee of $200. She billed my insurance $110. My plan paid $77 (for some reason…). “What I pay” aka owe (shown in app as well) = $33.

77 would be their portion of your coinsurance of the 110.00 ( they pay 70 % you pay 30%

 

[downtherabbithole]

@kittin Yeah, at least from what I saw in my EOB- it’ll say “doctor billed amount” or something along those lines, which matches up with what I’d written in the post (the $110, plus the random $160 additional fees they threw in for services I never even had provided to me. Kind of odd.

I’m confused about as well how even after paying the $161 on 5/27, they still proceeded to not cover (in the EOB) services afterwards, which makes no sense to me- but I’m very new to this.

Had a rough and stressful day today so I’d like to reply more soon. Thank you!

 

[victorinus]

@downtherabbithole I know this is old but it’s not your docs billing dept job to explain everything to everyone. That’s why they seem like they’re never in office. They’d be giving one on one coaching to everyone when those people have the internet, their policy and member services who can help with that.

It’s not that one persons fault they have to do the job of an entire billing department.