Author Topic: Insurance question: changing the order in which claims are processed  (Read 821 times)

burninglights

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Hello,

I have a somewhat confusing question. My son recently had a medical procedure at a hospital that cost like $50,000. It involved a specialist who charged about $1,000. Our deductible caps at $7,000. Because we have a low income in 2021, we qualified for a significant write off from the hospital (while still meeting the deductible), but not the specialist. Therefore, theoretically it would seem that if we could get our claims from the hospital first, then the specialist would be paid in full by our insurance, thus saving us $1000.

Unfortunately the opposite occurred, where the specialists' claim hit our insurance first, so we owe the $1000 to the specialist, and then about $1000 to the hospital after our write-off. Does anyone know if it's possible to have a medical office cancel a claim so that it can be resubmitted again in a sequence that benefits the patient, ie get both offices to cancel their claims, and then have the hospital submit their claim before the specialist submits their claim?

Has anyone done this, or does anyone have advice on this process? Or should we just take the discount and run?

Thanks


secondcor521

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Re: Insurance question: changing the order in which claims are processed
« Reply #1 on: July 02, 2021, 10:21:00 AM »
You could certainly try to ask them to do that, but I doubt they would accommodate you as they have no reason to help you, and you already agreed to let them bill your insurance.

In the future, you could accomplish what you're trying to do by not agreeing to let them bill insurance, have them bill you, then you submit the bill to insurance yourself in the order you prefer.

When I was looking into a similar situation years ago, I asked the billing offices involved and they said, basically, "Eh, we know what you're saying, but it's sort of just luck of the draw as to which bill hits insurance first."  And insurance just processes in the order received.

I'd probably just be thankful for the good coverage and the extra discount and let it go.  Good thought though.

Boll weevil

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Re: Insurance question: changing the order in which claims are processed
« Reply #2 on: July 02, 2021, 11:30:13 AM »
I don’t think it makes a difference.

Let’s say hospital reduced the charges to $10000, and the specialist charges you $1000.

As it is currently billed, you paid the specialist $1000, the hospital $6000 (to meet your deductible), and the insurance picked up the other $4000 owed to the hospital.

As you would like it billed, you would pay the hospital $7000, your insurance pays the remaining $3000 to the hospital plus the $1000 owed to the specialist.

Either way, your out of pocket is $7000, and the insurance company’s out of pocket is $4000.

Or do so not understand how health insurance works (a strong possibility)?

seattlecyclone

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Re: Insurance question: changing the order in which claims are processed
« Reply #3 on: July 02, 2021, 11:58:50 AM »
Or do so not understand how health insurance works (a strong possibility)?

I've never dealt with this situation, but what may happen here is that the hospital's discount of out-of-pocket costs happens outside the insurance system and the insurance company isn't told. So for example if the hospital had sent their bill fastest, the insurance company would pay $43k and from their perspective the patient's deductible is satisfied. Whether the patient actually pays $7k or a lesser amount isn't something the insurer actually tracks. The hospital then assumes they'll have poor luck collecting the remaining $7k from someone with your income level, so they write most of that off, but they still get $43k so they're pretty happy. If that's the way it works the ordering would matter.

One scenario I experienced where the ordering definitely did matter was in the birth of my kids. My wife and I were each covered by our own separate employer plans prior to each birth. We used the birth special event to add her to my plan in addition to her own, from the delivery date through the end of the year. The result was that each plan paid her out-of-pocket costs that we would have paid if she had been on only one plan or the other. However the baby was only covered by one plan. This meant that if the baby's expenses were billed faster we would pay out-of-pocket, while if my wife's expenses were billed faster those would use up the deductible first and we'd save money on the baby's care.

secondcor521

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Re: Insurance question: changing the order in which claims are processed
« Reply #4 on: July 02, 2021, 12:00:57 PM »
I don’t think it makes a difference.

Let’s say hospital reduced the charges to $10000, and the specialist charges you $1000.

As it is currently billed, you paid the specialist $1000, the hospital $6000 (to meet your deductible), and the insurance picked up the other $4000 owed to the hospital.

As you would like it billed, you would pay the hospital $7000, your insurance pays the remaining $3000 to the hospital plus the $1000 owed to the specialist.

Either way, your out of pocket is $7000, and the insurance company’s out of pocket is $4000.

Or do so not understand how health insurance works (a strong possibility)?

The only time that it mattered for me was when I had a policy with a deductible, the charges after the deductible were covered at different co-insurance rates (hospital vs. doctor IIRC), and I was going to meet my deductible and have charges in both different categories.  So for example a $2000 deductible, a hospital bill of $3000 covered at 80% after deductible, and a doctor charge of $3000 covered at 50% after deductible.  Something like that is what I had.

ETA:  And it may have involved the fact that my then-wife and daughter had two different individual deductibles to meet; I don't recall.

(It was 19.5 years ago when my daughter was born, so the details are a bit fuzzy.)
« Last Edit: July 02, 2021, 12:02:39 PM by secondcor521 »

burninglights

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Re: Insurance question: changing the order in which claims are processed
« Reply #5 on: July 02, 2021, 12:31:41 PM »
Or do so not understand how health insurance works (a strong possibility)?

I've never dealt with this situation, but what may happen here is that the hospital's discount of out-of-pocket costs happens outside the insurance system and the insurance company isn't told. So for example if the hospital had sent their bill fastest, the insurance company would pay $43k and from their perspective the patient's deductible is satisfied. Whether the patient actually pays $7k or a lesser amount isn't something the insurer actually tracks. The hospital then assumes they'll have poor luck collecting the remaining $7k from someone with your income level, so they write most of that off, but they still get $43k so they're pretty happy. If that's the way it works the ordering would matter.


Yes, this is exactly the scenario.

Thank you all for your your feedback thus far.