Who is responsible for ineligible amount listed on explanation of benefits?

Question

I just had some labwork done and the explanantion of benefits came today in the mail.

The hospital lab billed a total of $2,423.
The approved amount is only $1,113.
This leaves an ineligible amount of $1,309.

Out of the approved amount of $1,113, my plan paid $653. It says I am responsible for paying $460.

So, what happens to the rest of the ineligible amount of $1,309? Am I going to receive a bill for this from the hospital?

My deductible is $500, so I don't think that can happen, can it? Can someone please explain how this process works? Thank you so much.

P.S. I do plan to contact the insurance company Monday to ask about this, but I wanted to get some advice from you guys first so I don't end up looking *completely* clueless when I call them.

Answer 1

The answer depends on the network provision of your policy. If you went to a network provider (one with contractual agreements with your insurer) then you are not responsible for the excess charge. This is probably the case.

If your policy is not network-based, you would be responsible for the excess amounts. This would prevent a lab from making an outrageous charge... if the cost were really $50, and the lab billed $500, would it be reasonable to stick the insurance for $500??

Answer 2

It sounds like the $460 amount is what is remaining of your $500 deductible. The approved amount is likely what the provider and the health insurer have agreed upon for the procedure. The ineligibible amount should not be your responsibility. It's a good idea to call your insurance company this week to confirm the charges. Good luck.

Answer 3

All insurance companies play this game at one time or another. They figure if they can get you to pay the bill, why should they? Payment for charges takes up to 8 weeks or longer, but a denial comes immediately if not sooner! As long as you notified the insurance about the hospitalization the next business day ( or at least called your PCP if they're not the attending doc in the hospital) to get "authorization" , the insurance doesn't have a leg to stand on. If you didn't call your PCP, call them tomorrow and ask them to call the insurance and give them "prior authorization" - which really isn't prior, but as long as they call, most of the time the insurance backs down. The other alternative is to call member services at your plan and explain WHY your wife is in the hospital and ask them to reconsider the charges. Sometimes, the idiot who gets the claim (here in NY, they hire college kids to process claims, which BUGS me but that's a whole other story!) looks at the provider wrong - some providers fall under more than one heading, and it effects the way the claim is processed. If they refuse to reconsider the charges, ask them for the appeals process and appeal it formally. Whatever you decide to do, make sure you notfiy the billing department at the hospital so they don't harass you about paying it. Tell them you're fighting with your insurance and will keep them informed. (Otherwise, you could end up in collection, which is a headache!) I know this is all a pain the *ss, especially now, but DO NOT back down! Insurance companies count on p*ssing you off so you give up and pay the bill. As long as you do what you're supposed to and stand your ground, they'll lose! If the person you get initally isn't helpful, ask for their supervisior. If that doesn't work, wait ten minutes and call back. Good luck! I hope your wife feels better.

Answer 4

What I *think* it is, is that the lab work has an "agreed amount" under the contract, that the hospital discounts the insurance company. That means, that the hospital won't bill you OR the insurance company, that's the pre-negotiated discount amount.

Then your copay/deductible part would be $460.

Answer 5

The $1309 "ineligible" amount is the provider discount or the difference between what's been billed and the contracted rate. In theory, providers can bill whatever dollar amount they want, they are just only going to get paid what the contracted or approved rate is.