Anyone wrested with insurance over "usual & customary"?

So my son was born 3 weeks ago and already Blue Cross Blue Shield of Georgia has sent out bill. I know our coverage and I know that labor and delivery are all covered, yet I still get a statement stating they will only pay X dollars when the hospital bill cost 2X dollars. Let the fun begin.

Anyone out there in the health insurance world got any tips on how to strongarm BC/BS into paying for what I pay them for? I have a statement of benefits and coverage and nothing we had done was off that list. It's just what BC/BS says they are willing to pay, versus what the hospital actually charges. I'll be damned if I'm paying anything other than my co-pay.

Have you gotten a bill from the hospital yet? Did your BC statement show any patient responsibility left?

For my two kids they ended up accepting the BCBS (VA) amounts, because that's what they knew they were going to get.

You probably won't actually be on the hook for the rest, that's just what you'd have to pay if you didn't have insurance (but that's for another thread...)

Two years ago I had a cancerous kidney removed at Cleveland Clinic Weston. Fantastic, absolutly first class place. The bill that I got was over 40 large. My insurance paid them 8,000.00 and that was it. I would say that the insurance companies have some power. Since that, I lost the job that provided the insurance and sweat bullets every time I sneeze. Just hoping I can stay vertical until Medicare kicks in for me. Eight more months.

Slefain, you probably won't get billed for the difference. If you do, let me know. My wife does medical billing for the area hospital and knows all about this stuff should you get in a bind.

I have BC/BS of NC and could not be any happier.

First of all BC/BS does not send out a bill. BC/BS will send out an EOB that states what they pay and what you will be responsible for to the provider. The provider will then send the "Bill", which should agree with what BC/BS says. For the life of me I cannot figure out my bills and EOBs etc. The way the provider codes everything makes it darn near impossible.

A 15 minute surgery to remove a tumor from my bladder originally was going to cost several thousand at the hospital fantasy fee. That's what you would pay if you had no insurance. BC/BS paid less than two thou and i paid a few hundred $. The MRI was going to cost $2000 and only cost a couple hundred. Sure the machine cost a few million, but that mother runs 24/7.

I've got BCBS and I too can never get the EOB statements to match my bill that I get from the doc/hospital. I'd wait and see what the hospital wants to charge you before I start fighting it. You've got time. My hospital tried to charge BCBS the full amount for a neonatologist to be on hand at the birth of my son (5 weeks early). BCBS paid most of it, but I ended up getting charged for the difference ($200) almost 5 months later. I called them up and they explained it. I will say that I love my BCBS, but it's a special version only certain people can get. The entire bill for my son from conception until now has been $207 ($200 for neonatologist and $7 for the extra meal we ordered in our room after he was born). No copays, no nothing. And he was a Preemie so we stayed an extra day at the hospital. When I had my elective shoulder surgery it ended up costing me about $1000 out of pocket when you count in all the PT, MRI, and such (out of a total of $11,000 billed).

Tanner cost us about $650.00 out of pocket between birth and 6mo. Trevor got us for about $1350.00 for the same period. Tanner had zero issues except for his ears (he's a little deaf, but you can't tell him that) Trevor was in and out of the NICU and PICU for the first 6 months.

BCBS on both kids.

Insurance companies have contracts with networks, doctors, and hospitals for rates that they actually pay for procedures. What hospials bill, what the insurance company has negotiated to pay, and what they are actually paid are three entirely different amounts.

Last procedure I had, a colonscopy, I had to go by the hospital and pre-pay my portion. This time, and the first time ever, they actually showed me up front what BCBS would pay. I used to have to pay a percent of the hospital's orignal estimate, then get re-imbursed their BS overcharge months later. But to get the cash discount you had to do it that way. Problem is, the way they screw up the bill, there was no way of knowing if you got the discount. It's much better now.

My wife has a different BCBS plan with the state of SC that costs a lot less than mine, but seems to cover little. its fine for someone that is healthy. She was healthy, but recently had a trip to the ER that resulted in several days in the heart unit. That cost us quite a bit and there is no way to decipher those bills or EOBs.

And I just got back from a trip to England. With everything in the new recentlyI decided to ask a few locals about the NHS. Every one loved it and can't understand why the US is panicking about a similar system. Our cab driver pays about $40 a month for NHS coverage and has never waited more than a couple of days for treatment. I am paying $300 a month and I have to wait until September to get my MRI read (which was done a month ago).

Yeah the American system works

Alright, I guess I'll wait to see if I get a proper bill from the hospital. I just remember that after my car wreck I spent almost two years going back and forth with BC/BS over the bills. They'd agree to pay, then they wouldn't, rinse & repeat. I had to get the Georgia Insurance Commissioner's office involved at one point to threaten legal action.

I already filled out a form from BC/BS that was a full page of questions designed to find a way that BC/BS is not responsible for the bills. I hate having to prove to my insurance company that I do indeed qualify for their coverage AFTER they have been taking my money for years.

Datsun1500 wrote:

gimpstang wrote: And I just got back from a trip to England. With everything in the new recentlyI decided to ask a few locals about the NHS. Every one loved it

My Father is English, as in born in England, lives in England. He hates it, so do my other relatives, so everyone does not love it. Did you ask how high the taxes were to get that $40 healthcare? Dads is 50%.......

We already have a thread for this. Feel free to join in.

Medical billing is done using ICD9 coding. Decipher using this: http://icd9cm.chrisendres.com/

still not a key to everything that was done but at least get you some clue of what's being billed.

I work in the insurance industry, though not in medical insurance. I sell Life, Long Term Disability, and Dental Insurance.

Dental and Medical plans both fall under health, and operate in the same manner.

If you are hearing the words Usual and Customary, you must be enrolled in a PPO (Preferred Provider Organization), and used a hospital that wasn't in the network. If you used a hospital in the network, you need only look at your EOB (Explanation of Benefits) and track down the "Member Responsibility (or some phraseology like that)" and pay that amount.

The way a PPO works is that your carrier contracts with a number of providers who agree to discount their rates in order to have more patients driven to them. In this arrangement, the carrier saves money by having you go in-network, as the cost per procedure is lower. The carrier will generally incent you to go in-network by offering higher levels of coinsurance, or lower deductibles in-network.

When you go out of the network, the provider you see is entitled to charge you whatever they want, and you are willing to pay. Your insurance company is indemnifying you, but you are selecting your provider and agreeing to pay their prices, as they're not contracted to abide by any provisions implemented by your insurance carrier. Because there is a possibility of a wild swing in pricing, insurance carriers use Usual and Customary as a way to benchmark reimbursements. (You'll also see this referred to as Reasonable and Customary).

U&C is calculated along percentiles, not percentages. Common U&C levels are 80th and 90th, though a wide swing is available and has a significant impact on your premium rates.

If you have a 90th percentile U&C out of network reimbursement, your claims will be paid at the lower of what 9 out of 10 providers in your area will charge for a service, or actual charges.

So, if you've got 10 doctors, and their charge for a given procedure is as follows: $150 $99 $99 $98 $98 $97 $97 $94 $93 $85, you're going to be reimbursed based on a cost for that procedure being $99. If you go to the doctor who charges $150, you will be responsible for the extra charges. If you see any of the other doctors in the sample, your only charges will be your deductible or coinsurance that you're responsible for when going out of network.

So, looping back around. If you were in-network, go off of your EOB. Pay only the member responsibility total. If the hospital continues to harrass you for further payment, call BC/BS and inform them that the hospital is trying to balance bill you for in-network services that are not in accordance with what your EOB states.

If you were out of network, the balance above U&C falls squarely on your shoulders. As the judge would say, ignorance of the (contractual provision) is no excuse. The only way I could see you getting around this would be if you were far from home and the birth came at an unexpected time, and you had to get to the nearest hospital with no option to seek out an in-network hospital, or the hospital you planned to deliver the baby at.

If you planned the whole time to deliver the baby at the out-of-network hospital, and didn't look at your benefits, or call your provider during the 9 months you had to prepare for this, it's really nobody's fault but your own.

I hope that helps.

Thanks Panzer, that should be printed out and sent out with the statements.

We are in network, checked and double checked before she was even pregnant. We've played by the rules so we'll just see if the hospital sends us a bill.

Funny, I almost got thrown out of a health insurance "information" session at a previous employer. The spokesperson explained how we can only go to the doctors that they approve. She then went on to say they only pay the "U&C" prices and anything over that was our responsibility. So I asked if we can only go to their doctors, why don't they choose doctors who charge what they are willing to pay? Silence. I asked again and she said she'd talk to me afterwards. I then asked if anyone else in the room wanted to know the answer. After everyone raised their hand she said she'd get back to us. I then pointed out the "total benefit limit" of $1m that she glossed over. Once again she put me off and once again I asked everyone if they wanted to know the answer. Once again she moved on. My boss was glaring at me the whole time. When she asked if anyone had questions she never looked at my half of the room and then dismissed us. Fun stuff.

Sounds like the person running the meeting didn't have a good grasp on how to communicate the benefits.

One thing to keep in mind, the person presenting your benefits to you didn't design your plan, or select your benefits. Your employer, in partnership with your company's insurance broker designed the plan to fit into a given budget.

We have a cultural issue in this country where people generally don't understand, or even make an effort to understand their benefits. They simply think "everything is" or "should" be covered. Insurance is a contract to indemnify against specific losses, and you should be aware of what those specific losses are.

If you total your own car in a single car accident, and don't have collision and comprehensive insurance on your car, are you going to be irate when your auto insurance company tells you to pound sand over the value of the car? (Not directed at you, or anyone in particular, just an analogy that represents the dilemma.)