Can Someone Explain What I Am Not Understanding About This Claim?

[kellyfrost]

As the title suggests, I am having some difficulty understanding what needs to happen in this claim and my health insurer and the doctor's office are not being helpful.

Here is the scenario:

While on vacation, my youngest son was sick and we took him to an Urgent Care provider. Because our health insurance card was from out of state (although it is Blue Cross Blue Shield) the doctor's office required us to pay their full fee up front, which was $367.00. I paid that amount.

The doctor's office then filed a claim with my insurance company. The claim was finalized and the "allowed amount" is $128.02. The patient responsibility for the deductible is the same amount, $128.02.

I believed this meant I am only obligated to pay $128.02. Since I had previously paid $367.00, I would be due a refund for the difference. (367-128.02 = 238.98).

However, the doctor's office has told me that they will not issue me a refund until they receive a payment of $128.02 from Blue Cross Blue Shield. I explained the allowed amount, $128.02, would go towards my deductible, and I needed to pay it out of pocket; therefore, since I paid $367.00 I should be due a refund of the difference. They insist I am not owed any money until Blue Cross pays them $128.02.

Blue Cross has told me I need to "settle my deductible with the doctor's office" and provided no further explanation or direction.

Am I missing something here? How is this supposed to work? What should I do next?

 

[STIBROKER]

What should I do next?

Well it boils down to its between your Urgent Care provider....and you.....call them and ask them if they are in your network....the insurance company could have processed this as a out of network charge and they do not take the full against your out of network deductible ....then you are screwed...but if they are in you need to hammer home that you were over charged and they owe you 238.98.........

 

[kgmom219]

You need to ask for a supervisor. The person answering is doing the best they can and probably doesn't understand the situation.

You: "Hi. My name is X and I was seen on X date. You are in network provider with BCBS; however, I was still required to pay the cash rate, which is fine, except that the claim has been processed and the allowable amount is $128. The EOB, which you received a copy of, is dated X. Since I actually paid $367, I am asking when I should receive my refund check."

If that doesn't work, call BCBS back and ask them to notify provider relations that an in network provider is outside the contract boundaries for the SECOND time. (The first time was when they required the cash price up front).

 

[rcduggan]

i need see all the parts to the puzzle: a) your plan benefit details, b) provider bill, and finally c) the explanation of benefits. then i can assist

 

[junkman]

Many providers don't know what network(s) they are in. Network providers are required to file claims timely. If they are a network provider and if they filed timely, then they owe you a refund. The provider used to have 90 days to file.

Blue Cross has 3 networks that may be relevant (P,S & E). You need to see whether the provider is in your network. Your network is noted on your ID card. The easiest way is likely to be looking them up on the Blue Cross site.

The question is (was on that date of service)the provider a network provider. You could call Blue Cross and ask about that claim and they can tell you. Providers sometimes use different tax IDs and it is the tax ID that identifies network participation.

Bottom line: If network, then they owe you. If not, you get balance billed so kiss your money good by.

I'm getting ready to deal with Quest labs. I know that Quest bills ~ 4x the network allowed amount. A family member had a test done during December when we were riding our grace period and didn't ultimately have coverage. I'll slow pay if they won't come off the price. My hard earned money should be worth as much as that rascally Blue Cross'.

Edit: from what you say, they owe you. BC wouldn't have repriced if the provider were not in the network. Go up the line at the provider's office Supervisor-on up. Get to a Doc or president or whoever if the billing people won't handle it.

 

[tonyisme]

That Urgent Care owes you money as soon as they receive payment from Blue Cross.
The supervisor of that Urgent Care could have called the Blue Cross carrier on the back of your card but they apparently want to get their money out of you first and we're a bit lazy about calling. You could have paid only the contracted rate for the office visit.