Why only a fraction of what i paid an out-of-network provider counted towards my deductible?

[jacquelinedeane55]

Went to see a out-of-network psychologist which charged me $400 for a session (I paid already. And yes I know it's pricey but lets keep that out of the discussion). My insurance has a $1000 for out-of-network, after reaching deductible it will be a 30% co-pay.

Submitted a claim it came back with a "Discount amount" of $302.47, and "Covered by Plan" and "Deductible amount" is $97.53 (i.e. $400-$302.47). And when I check my deductible account it only increased by $97.53

So I guess for out-of-network services, maybe what count towards deductible will only be what insurance deems a reasonable price for the service, instead of what I have actually paid/charged? This is the first time I use out-of-network so it came as a surprise to me, and obviously that really sucks... Just trying to understand. Attached a link for screen cap of the claim:

https://imgur.com/a/Dyd9OpB

 

[sanctified112]

@jacquelinedeane55 Its based on usual and customary what the the insurance company thinks that rate should be.

 

[jacquelinedeane55]

@sanctified112 ok i guess same thing happen with in-network, although difference is the insurance co works with the provider, they only pay the provider full price minus the discount.
but in the case of out-of-network provider, the patient shoulder the difference between full price and what insurance think price should be? can i potentially use this a basis to negotiate with the out-of-network provider for a lower rate?

 

[sanctified112]

@jacquelinedeane55 For in network providers its a contracted price. Each in network provider has different pricing for the same service but they are average.

For an example.

Doctor A's contracted rate for a office visit may be $45.00, while doctor B's rate could be $75.00.

For out of network, they can charge what ever they want and the insurance will only reimburse usual and customary what they think it is.

While the doctors rate could be $400.00 the insurance company will only reimburse for $80.00.

 

[jacquelinedeane55]

@sanctified112 so, when i get to the deductible and start the 30% co-pay, sticking with your example, i'll be only reimbursed 70%$80 instead of 70%$400?

 

[cachep0013]

@jacquelinedeane55 Yes. The percentage is based on the amount allowed by the plan (contracted rate for in network, usual and customary for out of network) and not the total charged amount.

 

[resjudicata]

@jacquelinedeane55 Yep. Once the deductible is met, you get 70 percent of the usual and customary rate back, not 70 percent of what you paid

 

[resjudicata]

@jacquelinedeane55

So I guess for out-of-network services, maybe what count towards deductible will only be what insurance deems a reasonable price for the service, instead of what I have actually paid/charged?

Yep. That's exactly how it works.

 

[kimmiediscovery]

@jacquelinedeane55 I think you might get a check for the $302.47 from them. Therefore the insurance paid those $302.47 and you only paid $97.53

 

[jacquelinedeane55]

@kimmiediscovery certainly not getting check because i haven't reach my deductible.
and seems like deductible only changed by $97.53.

 

[vladimirsurguy]

@kimmiediscovery Nope. The excess would ordinarily be written off by a contracted provider. Since the provider is not contracted, that means OP eats it instead.

 

[vladimirsurguy]

@jacquelinedeane55 Yes, it’s common for you to only receive credit for the allowable charge rather than the amount you paid. One of many reasons why it’s better to stay in network whenever possible.

 

[jacquelinedeane55]

@vladimirsurguy ok didn't realize this and this sucks... i thought it is like car insurance i can go whichever body shop i want and insurance will still pay (i mean, i expected the deductible and 30% copay but didn't expect it would be based on "allowable charge" not what i paid / what service provider charges)

 

[holipuli]

@jacquelinedeane55 Do you have employer insurance? The "Multiplan" discount is something to get your hr to ask about. I had multiple OON EOBs for the same provider come back with different "discounts" from month to month, and there's no way the reasonable and customary varies from week to week like the price of gas. These were being incorrectly calculated, but the only way I could get help was to get my HR to contact their liason to the insurance company. The insurance still can't do it correctly from month to month, so I submit directly to my employers account manager at the insurance company.

Don't even bother with the phone reps or email. Go to your HR.

 

[resjudicata]

@jacquelinedeane55 what you have stated is correct. Your insurance deemed that their allowed amount for the service is $97.53 (these amounts are based on what code was billed and for the region you are in). Only that 97.53 would be applied to the deductible, and since you are seeing an out of network therapist (elective service) you would be balance billed for the entire charge ($400). Once you reach your deductible, you will have a 30% coinsurance. HOWEVER, this would only be based on the amount being allowed (insurance would cover $68.27, you would have to then pay the remaining balance).