downtherabbithole
New member
(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—
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?