Source
r/HealthInsurance•
memory_fading

Insurance won’t pay after meeting out of pocket max

Plan Benefits

Hi, hoping someone here can help.

I had a hospital visit over 2 years ago (2021). At the time the insurance said about $1000 of the total should be adjusted to remove because the hospital was in network. Apparently the hospital doesn’t think so. So two years later(2023), after I moved on from that insurance company, they say I met $0 of my deductible that year. Their numbers were all deleted as well as the history with Explanation of benefits. I have all of them showing I met my out of pocket max and even my deductible before the hospital visit happened. I’ve appealed twice already and they just review it and say they are meeting the policy.

Is there any recourse here? Any advice what to do next.

Thank you all for the help.

Posted Aug 10, 2023, 2:06 PM UTC

11
AutoModeratorMOD•

Thank you for your submission, u/memory_fading.

If your question relates to COBRA under CARES and ARPA, please post here: COBRA & Covid-19

Please pick the most appropriate flair for your post. Include your age, zipcode, and income to help the community better serve you.

Reminder that solicitation/spamming is grounds for a permanent ban. Please report solicitation to the modteam and let us know if you receive solicitation via PM.

Be kind to one another!

I am a bot, and this action was performed automatically. Please contact the moderators of this subreddit if you have any questions or concerns.

1
your_longing_heart•

You have the right to request a Deductible and Out of Pocket Audit which would be able to prove if or not the DED/OOP was met at the time services were rendered. They normally send you that info through the mail after their quoted TAT. Keep in mind that due to claim adjustments it could be possible that it had reflected as met but if any adjustments occurred and impacted any other claim(s) then it would readjust the amounts accordingly. I make no assumptions, I’m just trying to give you another possible perspective for the possible discrepancies. Best of luck.

1
memory_fadingOP•

Thank you! They offered no explanation at all either time. Only that it was correct.

1
EuropeIn3YearsPlease•

Let us know how it goes OP once you talk to them and use the specific jargon the other redditor pointed out

1
UserNotFound-Error•

Another thing I would like to mention is that recent here has been a shift in using 3rd party customer service agents that really are not trained very well And the escalation process is slow and confusing so asking for someone above a manager is always a good idea.

Now as far as this “adjustment “ is concerned, if I’m understanding this correctly the insurance is saying they will pay 1,000 less bc the hospital is in-network but the hospital is saying no - so I am assuming they are billing you for it now - fast forwards to now, you are still getting billed and your insurance is saying “oh we are not paying that, it’s part of your deductible.” That sound about right?

If that is the case then that is something the hospital and the insurance need to negotiate

1
memory_fadingOP•

Hi, kind of. The original explanation of benefits in 2021 said, the provider billed $1000, the plan discounted $1000, myself and insurance owes the provider nothing. That explanation of benefits shows the deductible being met already for previous visits.

Fast forward to now, 2023, I get a new explanation of benefits, and a bill from the hospital for $1000. The new explanation of benefits says the provider billed $1000, the insurance owes nothing, and I owe the hospital $1000. That $1000 will be applied to my deductible which now has $1000 of the deductible net. (Even though I met that and my out of pocket max already in the previous 2021 EOB)

I can’t explain to them enough times to look at their EOBs and see that they have zeroed out all the money I paid in 2021 already prior to the hospital bill and adjusted EOB.

The hospital has basically said, you’ll be sent to collection if you don’t pay. If the insurance does pay us, you’ll get a refund.

Thanks so much for your input!

1