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Old 10-31-2018, 02:55 PM   #1
RiverRat1
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Default Health insurance question

For those who deal with health insurance deductibles etc.

My sister has BCBS Her plan is 80/20 with a max out of pocket of $4,000
She had to be hospitalized and basically paid $3,980 out of pocket (total up until Sep 1st) Then she had to have emergency surgery. Now BCBS claims she owes 20% on everything that was billed up until she hit the $4,000

So instead of her owing $20 (to hit the max out of pocket) they claim she owes like $1,500.

Has anyone ever heard of this? What should she do? She talked with BCBS and they said twice that's the way it works.

It may be more than $1,500 BTW - It's supposedly ALL invoices that came in prior to her hitting the $4k mark. So it's coming from lots of doctors etc.
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Old 10-31-2018, 03:00 PM   #2
captainsling
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She should only be out another $20. It is max out of pocket, not max out of pocket per incident.

I would get my employer involved if that is whom she purchases her insurance from. They should be able to clear it up for her.
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Old 10-31-2018, 03:10 PM   #3
gingib
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Absurd!!! But following. Healthcare is a crap shoot because of all the scums who don't pay for anything in this country

How convenient her previous amount was exactly $3980, $20 short of her out of pocket max. what a joke

$20 is all she should owe
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Old 10-31-2018, 03:18 PM   #4
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Quote:
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Absurd!!! But following. Healthcare is a crap shoot because of all the scums who don't pay for anything in this country

How convenient her previous amount was exactly $3980, $20 short of her out of pocket max. what a joke

$20 is all she should owe
She added up the $3980 so that number was correct. I'm just seeing if anyone who deals with insurance has ever heard of this.

It obviously should be just $20 she owes...But I can't see the fine print (not today) so who knows what the scam insurance writers have in there.

I'll have her get with her HR department ASAP
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Old 10-31-2018, 03:23 PM   #5
BrianL
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SHe will owe the $20 dollars, but their statement is still correct.

"Now BCBS claims she owes 20% on everything that was billed up until she hit the $4,000"
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Old 10-31-2018, 03:23 PM   #6
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Deductibles and Out of Pocket Max are different. She may have a deductible to meet and then a 80/20 with a max out of pocket of $4,000.
So, if she had a $2,000 deductible and a 80/20 after that up to $4,000 max then she would be responsible for the total amount of the first $2,000 and then 20% of all bills past that point until she was out of pocket another $2,000 equaling her total out of pocket $4,000.
She should have an EOB (explanation of benefits) sheet around from her last claim that BCBS sent her. In that EOB it would show what her responsibility was to pay on that claim, what BCBS responsibility was to pay on that claim and what amount of benefit she has on her policy.

This is just a shot in the dark since I don't know exactly which policy she has but usually someone doesn't start off with just an 80/20 with a $4,000 max out of pocket without a deductible or co-pays.
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Old 10-31-2018, 03:26 PM   #7
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I have BCBS and they have been ripping us off really bad this year. They changed from an individual max out of pocket to a family max out of pocket. They also don't cover the surgeon assistant, the critical items the surgeon needs, etc. I went several thousand over my max out of pocket this year.

Make sure they are running them in network. They try to run some out of network so you pay.
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Old 10-31-2018, 03:29 PM   #8
TexasBob
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Bills may need to be submitted again as well either by her or the doc... might have come in before the max out of pocket was met.
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Old 10-31-2018, 03:44 PM   #9
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Without knowing what the plan benefits look like it is hard to tell.

Could be she had some things done that she paid for that were not covered by the plan and therefore would not go toward meeting her OOP Max.

Could be she had some care that was out of network and some plans have separate deductibles & OOP Max for in/out of network claims. Most ER docs & anesthesiologist do not join networks.

Could be the claim is just not processed correctly - Some claims handlers are very good and some are not.

Very difficult to know why this is like you say without seeing a plan doc & EOB's
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Old 10-31-2018, 04:23 PM   #10
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I have been through this before, call the insurance and they typically handle it all. Their agents will know exactly what is owed. I have united healthcare and their agents did all the weight lifting when we met our out of pocket max but the bills kept coming in.

They notified the doctors for us and kept us from overpaying. because once you overpay then its hard to recover and theres a long waiting period.
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Old 10-31-2018, 04:27 PM   #11
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Quote:
Originally Posted by BrianL View Post
SHe will owe the $20 dollars, but their statement is still correct.

"Now BCBS claims she owes 20% on everything that was billed up until she hit the $4,000"
In other words the bills or invoices coming in were piling up. So BCBS is saying she owes 20% on all those bills since she didn't hit the max yet.

It's obvious she should be "out of pocket" 4k total. I told her to not pay. She is going to talk to her HR lady at work tomorrow.

What ticks me off the most is I was with her on the freaking phone with BCBS asking very specific questions. Specifically which invoices should she pay first as LOTS of them were coming in. And who was keeping track of how much she has paid out of pocket...We were assured it was all taken care of.. Jackwagons!
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Old 10-31-2018, 04:28 PM   #12
RiverRat1
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Quote:
Originally Posted by daniel044 View Post
I have been through this before, call the insurance and they typically handle it all. Their agents will know exactly what is owed. I have united healthcare and their agents did all the weight lifting when we met our out of pocket max but the bills kept coming in.

They notified the doctors for us and kept us from overpaying. because once you overpay then its hard to recover and theres a long waiting period.
This is what I thought. So she called the insurance..Hence this thread
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Old 10-31-2018, 04:47 PM   #13
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The impossible part when you have two different occurrences, that will total the 20% out of pocket. BCBS will pick one of the medical bills that will satisfy the remaining deductible, she or providers just won't know which one it is, so all billing assumes that they will be the bill that is short. I had that happen to me and had to pay my remaining deductible to the doctor, surgery center, and MRI place. I was $600 short of my deductible, but I had to write $1800.00 before my knee got scoped. I got $1200 back from two of the three about two months later when BCBS paid them.

Last edited by BrianL; 10-31-2018 at 04:52 PM.
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Old 10-31-2018, 04:51 PM   #14
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Tim,
Does your sisters company use a "go between" company that will interface with employees and insurance co. That is what my wife does.
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Old 10-31-2018, 04:56 PM   #15
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If she has not met deductible the 80/20 has not kicked in yet.

Also same thing happened to us as BrianL said. Wife had a procedure and I knew we had overpaid. The surgery center sent as a check about a month later when BCBS paid them.
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Old 10-31-2018, 05:01 PM   #16
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Quote:
Originally Posted by TexasBob View Post
Bills may need to be submitted again as well either by her or the doc... might have come in before the max out of pocket was met.
try this

We had to do this when my wife gave birth and then our daughter was in the NICU. even though the delivery put us at our deductible because both bills were submitted within days of each other they didn't reflect on the account. Once we resubmitted everything came out how it should
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Old 10-31-2018, 07:23 PM   #17
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The issue I run into is when I set up a procedure, the docs office looks at my coverage and tries to charge me like I have not paid anything yet. They come up with a number and try to collect. We shut them down and stand in front of them when they call the insurance company, only to find out I have met my max out of pocket and will owe them nothing. I never pay any medical bills for 2 to 3 months so the ins. co. and billing offices get it cleared up. I pay my deductible usually to my oncologist in early January, and had my moop by april. You can sometimes negotiate some of your out of pocket costs, especially if you have had massive bills.
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Old 10-31-2018, 08:50 PM   #18
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Quote:
Originally Posted by double bogey View Post
The issue I run into is when I set up a procedure, the docs office looks at my coverage and tries to charge me like I have not paid anything yet. They come up with a number and try to collect. We shut them down and stand in front of them when they call the insurance company, only to find out I have met my max out of pocket and will owe them nothing. I never pay any medical bills for 2 to 3 months so the ins. co. and billing offices get it cleared up. I pay my deductible usually to my oncologist in early January, and had my moop by april. You can sometimes negotiate some of your out of pocket costs, especially if you have had massive bills.
Same with me.
BCBS has become a rip off.
Always ask if it is an amended bill.
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Old 10-31-2018, 09:15 PM   #19
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I cannot gripe to much about the insurance. Ours is a 90-10 policy with $600 deductible (in network) $4200 max out of pocket. PPO to see docs, and great prescription coverage. We set up a procedure, the day before the dr office calls and says we have not gotten authorization. We call the insurance co, they give us the auth #, and tell us they got it to the drs office 2 days ago. Not sure where the incompetence is, the drs staff, or the insurance co. Very frustrating.
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Old 10-31-2018, 09:21 PM   #20
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The plans are not BCBS’s fault necessarily. They are defined by the Obamacare act.
The deductibles are high. The premiums are high. The coverage is less.

My old grandfathered BCBS plan was much better and cheaper.
The grandfather period is over and it’s much more with less coverage.

My guess is they are saying after you met your high deductible then she has to pay 20% until the max out of pocket is reached.
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Old 10-31-2018, 09:29 PM   #21
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Ttt
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