Omg! Anyone understand insurance?

I had a sonogram in January then again this month to make sure all the tissue was gone. Well I just got something from empire. The first appt says they charged $1583.60 and the plan pays $649.60 and patient pays $934 Then they charged the same amount for the second one and plan pays $876 and patient pays $219. Ok, first of all what the heck and secondly they sent the one payment of $649.60 to me in my name! Can someone please explain this. Am I going to owe my doctor $1100 for this m/c?

Re: Omg! Anyone understand insurance?

you probably have a deductible so thats why the first was so high. ANd if the check was sent to you most Drs will just let you sign the check over to them so you don't have to deposit it and then pay the Dr

Re: Omg! Anyone understand insurance?

Re: Omg! Anyone understand insurance?

I would just call the insurance company and have them explain why the 2 are different and explain the deductible part etc.

Re: Omg! Anyone understand insurance?

When the check gets mailed to you, that means that you are not participating with the facility or doctor who performed the test/service. Did you have it done at your doctors office or did you go to a facility?

If you had it at your doctors office, I would call the doctor's billing department to confirm that they are not in your network. If they just dropped your insurance, I would hope they would inform you. Things can get much more expensive, KWIM?

If there was a mistake with the way your insurance processed the charge (which is also a possibility) and you are sure that your doctor or the facility you went to was in your network, I would call the insurance company and have them reprocess the charge.

I wouldn't pay anyone or send in any check until you confirm with your doctor that this was processed correctly.

HTH

Re: Omg! Anyone understand insurance?

I have the same insurance and they covered everything. I also had a second sonogram, but my bill said waiting for more information on that sonogram. I don't think you will have to pay just call and speak to them. Maybe they did not get the information they needed. As a teacher. your insurance will cover this i am sure.

Re: Omg! Anyone understand insurance?

It maybe that a different company is doing your sono and they may be out of network. My OB has a person that does sono's in the office. But the person works for madonna prenatal and I always get a seperate bill from them whenever I get a sono. However for me they are also in network so I only pay a $20. Co pay. Do you have empire blue cross blue shield or the empire plan for NYS employees?

Re: Omg! Anyone understand insurance?

Re: Omg! Anyone understand insurance?

I would call the insurance and ask them why it's coming up as out of network. Something doesn't Seem right.

Editted to add.

I have the empire plan. After my first D&C, I had lab work done and I got my statement from united healthcarre stating that they paid a certain amount and I was responable for the rest (I think it was over $2000). The amount that they paid, they sent to me in a check. When I got the bill from the lab it was only for the amount of the check that the insurance company sent me. I called the lab and they told me to endrose the check and send it to them and that would cover what was owed. That was it, I never had to pay the other amount. It was really weird.

Message edited 2/26/2011 8:24:52 PM.

Re: Omg! Anyone understand insurance?

Crashing, this happens to me a lot with out of network doctors but most of the time the doctor does not "balance bill."

Balance billing would mean the doctor would hold you responsible for the $934 BUT he may just accept the $649 as payment. The $1583.60 is what the doctor's fee is, $649 is the "allowed" amount by your plan, and $934 would be the balance since he is out-of-network. If he was an in-network dr., he would be requied to accept the "allowed" amount (though you play may say 90% of the allowed amount which means you would only be responsible for 10%.)

What you need to do with that payment of $649 is sign it over to your doctor. Your insurance company "assumes" you laid out the money and they are reimbursing you for $649. In this case, ask your dr to simply accept the $649 check as payment.

I dealt with this a lot with anesthesia for an operation last year. I also have BCBS. Let me know if I can help you further. Basically its just connecting with your dr. and hoping that they accept the $649 as payment. Try to work with them. Unfortunately balance billing is not illegal but they absolutely should have warned you beforehand that you were out-of-network. That is some ammunition for you if it gets ugly and they want to collect more.

I hope this helps and I hope I understood your issue correctly!