Question about responsibility to pay for medical coverage following insurances coverage?

Question

I'm having problems with getting my insurance company to pay for services, and I need help figuring out what I will be responsible for, after insurance has paid all that they are going to pay. It's a PPO plan.

Basically, recent maternity bills cost around $5300, but my plan is only paying $3500. Per their own words about the denial:

"This self funded health plan provides benefits for obstetrical care at 100% of eligible charges for participating providers. The member was approved for a waiver, to allow in-network benefits for a non-participating provider. The claim was processed in-network. The payment explanation indicates that the covered amount of $3594.05 was reimbursed to the provider. The provider is not a participating provider, therefore; can bill the amount not covered to the member."

My question: Am I obligated to pay any balance beyond what insurance covers? I've tried appealing which did nothing. So am I legally responsible to pay the balance?

Thanks.

Hi Kraftee, thanks for the info. Actually, there was no certified nurse/midwife in a 30 mile radius, so insurance covered the exemption letter for an out of network doc, since there was no one in network close.

Answer 1

This is an excellent question, and hope others can learn from your question. I have been in the health insurance business since 1990, working for the largest health insurance co's in the country. First off terminology is important to understand:
PPO (Preferred Provider Organization) this means that you "MUST" go to a physician within this organization to receive the best negotiated benefits.

You say:
"The claim was processed in-network. The payment explanation indicates that the covered amount of $3594.05 was reimbursed to the provider. The provider is not a participating provider, therefore; can bill the amount not covered to the member."
Problem:
"non-participating provider" The insurance company did you a big favor allowing payment of $3594.05, under most contracts they do not have to pay participating rates for a "NON Participating Provider", all and any amount of the $3594.05 is completely your responsiblity. This is what they are telling you in the above statement- except in insurance speak.

This is a growing problem throughout America, Doctors are leaving the PPO Network of providers, and here is the problem the general public thinks that PPO means you can "Go anywhere" this is completely false, and in most cases I have found that when you go outside of the network providers (PPO) most plans turn into "Fee Schedule Plans". Tonight I had a client who called me up and wanted to go see a Dr. who was "out of network" for a big surgery that was anticipated (approx. $60,000) with the current PPO plan they have it says specifically that in the case of outpatient care -"out of network doctors" receive a max. of $600.00 per day Meaning that if the charges were over 600. bucks my client would be left paying.
Consumers need to understand that more and more doctors are leaving Participating Networks to make more money "which is understandable" but on the other hand patients "Like you" are left holding the bag.

Look if I go shopping at Saks 5th Ave., I expect to pay $100 bucks for a shirt or more. If I go to Sears I can expect to pay $20 bucks for a shirt. When you go see a Doctor out of network - think of it like going to Saks, it is going to cost you big time.

Congrats on having a baby, God Bless- Happy Holidays

Answer 2

If your insurance company is paying for a non-par provider at in-network rates, and the providers agreed to accept payment from the insurance company, then you are not liable for the balance unless your insurance company specifies it on the Explanation of Benefits. It's called "contracted rate" - meaning medical providers can, in theory, bill whatever price they want - it doesn't mean that the insurance is going to pay that amount.

Now, if the out of network provider chooses not to accept the insurance's payment as payment in full for services, you can be billed for the difference. What I would do though is - if you can pay a chunk of it (like if the bill is $2000 and you can pay $1000) immediately, see if they'll negotiate with you and take it as payment in full. Sometimes - because they don't have to chase you for it, which gets time-consuming and therefore expensive, they'll take it. If they don't negotiate, set up a payment plan and pay them small amounts over time. (Like $25 a month or something....)

However - IMO - they got paid pretty darn well - most plans pay like fifty cents on the dollar of what's billed.

My advice - don't ignore the bills, you can get sued for the amount, or at the very least, put into collection and completely screw up your credit!

Answer 3

Apparently your PPO covers 100% if you use a participating provider. You were approved to use a non-participating provider in return for in-network benefits (which are obviously less than the provider's bill). So, it seems clear that you are obligated to pay that provider the amount that your PPO didn't cover when that provider bills you. Don't pay anything to anybody until they bill you. Was there some special reason that you didn't use an in-network provider? I ask because these PPOs make agreements with their in-network providers that they will provide care for the fees that the PPO negotiates with them and these fees may be lower than those charged by out-of-network providers. That's the whole point.

Seems pretty straightforward to me.

Answer 4

Wow, something I need to look into before *I* hire a midwife.

Yes, you are obligated to pay the balance, HOWEVER. I'd call the hospital, or the non-participating provider in question, and ask them to waive the balance. They are receiving EXACTLY what they'd get if they WERE a participating provider, so it's not like they're LOSING anything on this.

Next time, I'd see if I could get them to agree to accept the insurance payment up front, without billing the difference. They're billing you like a cash patient, which isn't fair - and I'm thinking the business manager at the providers office could waive this for you.

Answer 5

Heck yes you have to pay that! Your'e lucky they paid what they did, you should try to negotiate with the provider though. Your insurance company only pays allowed amounts, and beside your getting off pretty well with only paying the difference. Next time check the provider before you let them touch you, plan ahead and you'll save a ton of money.

Answer 6

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Answer 7

YES YOU ARE RESPONSIBLE IT SUCKS BUT YOU ARE