I don't understand my insurance coverage for a doctors bill?

Question

I went to my doctor last month because I wasn't feeling well and I had some blood work done.. I just received my bill and out of the 784 it cost my insurance is only covering 240? I have never had a doctors bill this large and I don't understand. I have Blue Cross and I don't know what to ask them in terms of why this bill is so much. I have a ppo, pay 180 a month for my insurance, plus have a co pay for my doctor already... this doesn't seem right at all... hope someone can assist me.

Thank you!

Answer 1

Some lab tests ARE expensive. There's one for diabetics that costs $2100. BUT, what the insurance gets billed ($784)and what they pay ($240) are quite often vastly different. As long as the EOB doesn't say that YOU have to pay the difference, I wouldn't worry.

(BTW - providers often price their services as to cover their highest-paying insurer - it's legal, it just means they write down a bigger discount on some plans, smaller on others.)

Answer 2

~~You need to wait for your explanation of benefits from BX to have the exact amount you will be responsible for. You can call them and they can break it down over the phone too. However, BX will have a contractual rate for the services you had providing this doctor and lab was in-network. The doc and lab will write the rest off, except for your copay and sometimes a deductible has to be met first before anything is covered from the insurance co. on you-this is where you need to know your policy. However-no matter what, there is a contractual rate which will be far less than the amount your doc and lab charged, so you would only be responsible for that amount. I would call the insurance co, and have them explain the entire explanation of benefits to you for these charges. Don't trust the doc or lab's billing department they make mistakes all the time!~~

Answer 3

Did you receive an actual bill from your doctor, or the Explanation of Benefits from your insurance company?

(The Explanation of Benefits is not a bill - its just a document that shows a claim was processed on your behalf, and what you may be billed for from the doctor.)

Did the statement actually say that you're liable for the remaining balance?  $240 sounds in the right ballpark for what the doctor's office might receive for an office visit and some lab work.  However, its quite likely that a large chunk of the rest would be a contractual write off.

If the statement did actually say that you're liable for the remaining balance, there should be an explanation why its your liability.  (For example, was it applied to your deductible?  Was it non-covered lab work?  Was there a billing problem on your doctor's end? etc.)

Quite honestly, it sounds to me like most of the remaining balance will be a contractual write off...take a closer look at your statement.  Are you *sure* it says that its your responsibility?  (If not, let us know why it wasn't paid...the reason should be listed...and maybe we can offer more suggestions.)

Edit to add:

Okay, since you've provided some additional info...

There are a few questions I'd ask your insurer, to help you determine if the claim was processed correctly according to your benefits.

1)  Were any of the charges denied?  If so, why?  (Possible reasons include:  non-covered service for the diagnosis it was billed with, non-covered service under your benefit plan period, etc.)  Note - if you are told that a charge was denied, feel free to post the reason for the denial here.  Maybe we can suggest a way to help.

2)  What is the breakdown of your patient balance?  (For example...is it deductible?  Coinsurance?  Some combination of the two?)  After they tell you that, see if the answer makes sense to you.  (For example, if they tell you that $500 was deductible but you only have a $250 deductible, then you know something wasn't processed correctly.)

3)  Another scenario that could happen to a person...are there benefit limitations on your plan?  (For example, I see patients end up with large bills because their policy will only cover $X per service or day, and they get billed with the excess.)  Obviously I can't tell based on the info you posted whether you have a cap on your benefits for lab work...I'm just letting you know that it does happen to some people.

Um...that's all I can think of for now.  Without knowing the terms of your benefit plan and exactly what lab work you had done, its hard to say.  But certainly someone at your insurance company should be able to explain more clearly exactly where the breakdown of your patient balance came from...I'd push them for the information.  (I used to work in the customer service dept of a large health insurance company, and I'd frequently have to explain in detail how the patient's balance was calculated...its just part of the job.)

Hope that helps you figure out how to proceed from here, and good luck!

Answer 4

Call the number on the back of your card.

It's highly possible that the bill for $784 was "repriced", and that you don't have to pay anything else.

Answer 5

hi donkey, I have BC PPO as well. You need to read the insurance book that HR gave the company employees that lists what the plan covers, what it doesn't cover, and if any deductibles/copays apply.  Go to HR and ask them if blood work is covered at 100% via the plan they chose or if the employees have to cough up $$$.

I am fighting with BC right now b/c they won't cover anesthesia for surgery that was medically necessary. Their customer service stinks (at least in NJ) so go to the person in charge of benefits in HR to get your answers.

good luck to you.

Answer 6

Start with your EOB - what does it say about coverage and copay?  Did you go "out of network"?