Should I pay these bills ? Or dispute ?

[leafbyniggle]

Hi,
I’m confused with bills I received and any comment will be appreciated.

I had anthem PPO with $1k deductible remaining.
I was pregnant and saw a in-network provider.
Just regular in office covered visit.
They were all paid by the plan. Example below. All the bills last year were paid by the plan.

Copay $ 30

Billed by provider $180.00

Plan discount - $106.03

Allowed by plan $73.97

Plan paid -$73.97

What you pay $0.00

Remaining ind. deductible $1,000 out of $1,000

Have a new pregnancy and saw the same doctor for same matter at same site. Standard covered pregnancy service.
This year I have Empire PPO with $1.5k ind deductible. (In-network and same benefit)

Now this time I got many bills to pay - example like below

Total

Copay $ 0

Billed by provider $195.00

Plan discount -$92.18

Allowed by plan $102.82

Plan paid $0.00

What you pay $102.82

Remaining ind. deductible $1,500 out of $1,500
This time the plan didn’t pay.

Additional context is that I switched anthem PPO to empire PPO in the middle of the year so it’s been a lot of issue on insurance’s side that it’s not properly recorded (termination not reported, out of network billing mark for in network billing etc) and I had to call like 10x times to figure it out for them. so I’m wondering if it’s also part of such error.

I’m confused what’s the difference in these two cases as benefits for the standard pregnancy doctor visit is the same under these two insurance and both times I had remaining deductibles. But earlier ones (anthem PPO ) is paid and the other(empire PPO) isn’t paid.

Could anyone guess what the reasons are?
I called empire and they said whether it’s covered service or not I have to pay until deductible is met.
Was I just lucky with earlier Anthem bills that they paid even though the deductible wasn’t met?

Any comment or idea would be helpful for me to better understand this and plan my doctors visit accordingly.

 

[vladimirsurguy]

@leafbyniggle Some plans carve certain services out of the deductible. For instance, my deductible only applies to services that have a percentage cost share. Anything with a flat copay is covered from day 1 regardless of where I am in the deductible.

 

[leafbyniggle]

@vladimirsurguy I think you’re right and it might be co-pay. I had $30 copay for the anthem which covered the rest of charges and had 0 copay with empire which billed the rest to me.
I just assumed 0 copay would be better but I guess I was wrong

 

[cassiabr]

@leafbyniggle New plan, new deductible most likely. They don't typically transfer deductible mets when you have a new plan. Call your insurance and find out your benefits with empire ppo.

 

[yesnice]

@leafbyniggle What's concerning is that the Empire visit didn't reduce your deductible, indicating to me that it processed as out of network. Call Empire again and ask them if the amount you're responsible for is coming out of your deductible.

Also this doesn't make sense: "whether it’s covered service or not I have to pay until deductible is met."

Typically noncovered services won't apply to the deductible.

 

[john861]

@leafbyniggle Full disclosure: I do not work in billing or for insurance, I’m just a hospital admin.

This is unfortunately very common, especially with PPO plans. It’s hard to know the reason without access to the Summary of Benefits for either plan.

Some plans have deductibles for any services or medications, some plans have deductibles for certain services or providers, etc. Usually the higher monthly cost, the less you pay for a deductible, and vice versa. Same goes for the perks, the cheaper the plan is monthly, the more rules to abide by. So if this is a more cost effective plan monthly for you, there’s a chance that is why the deductible is pricier and trickier to deal with.

I have an HMO plan without a deductible, but if I see providers out of network or at a high tier, then I do have one. There’s always a lot of stipulations in the fine print of insurance plans.

If you still have them, I would try to take a look at the summary of benefits for both plans to try to figure out what the exact change is, or call your insurance again. It sounds like you’ll probably be paying everything out of pocket until your deductible is met, but it’s good info for the future - especially with pregnancy/birth costs and a new family member on the way!!

Best of luck!

ETA: If someone thinks the info I provided is inaccurate I think it would be much more beneficial to comment than blindly downvote…