Am I on the hook for this bill?
So my wife is ~5 months pregnant with our first kid (12/31 due date) and we live in NJ (right outside of NYC). Although not all the details are relevant to the question… I wanted to just layout our entire timeline timeline in case it matters for other advice we might need and to make it easier to organize the events.
April: We went to an in-network OB in Manhattan and at this time we started learning all the things related to pregnancy, childbirth, and childcare. One of these things being that OBs only participate with certain hospitals and the delivery hospital this particular clinic works with is a bit far from us, which concerned us since the due date is around New Years Eve and there's a lot of end of year tourists and traffic around that time.
July: We switched clinics to one that's closer to us and at the recommendation of the doula we hired, but is OON. At this time, I naively wasn't too worried about OON because I thought as long as she hits the OOP max, we won't incur any additional cost (OOP individual max ~$7.3k). The hospital they will deliver at is in-network. This clinic also verbally told us that since they're unsure how much insurance will cover at this time, the first visit will be free and offered free genetic counseling too (genetic testing was already done at previous OB; this was just extra counseling). The clinic would send a bill to insurance to test the waters.
August: We went to this clinic a few more times by this point, all just to do an ultrasound to make sure everything's going okay. No additional testing.
September: We get the first claim details from Anthem BCBS. We've never seen any bills yet at this point until now. The claim says that for the first visit, the ultrasound costs $3200. Out of this $3200, ~$300 is allowed as a qualified cost and $200 is given to us as co-insurance reimbursement (60%, we owe 40%). Here's where the issues start.
Obviously we were shocked by the >$3k bill for the 10 minute ultrasound so I first called the insurance asking for an explanation why it was 40% of the ~$300 and not the $3200. This is where I learned about the concept of qualified expenses … The insurance agent says that we have to pay for the remaining $2.9k, especially since we likely signed a form with the clinic acknowledging that we will be responsible for the differential. The insurance agent suggests that I file for grievance though because it's such an astronomical amount for a routine ultrasound. At this time, I thought my wife did sign it already but apparently she didn't sign it.
Next I talk to the OB's billing agent and ask for an explanation. She explains to me that it's standard practice to bill an extremely high amount to get as much out of the insurance as possible. I think that's shady, but fine. Then she says that we don't owe this $2.9k, we only owe the $300 amount. This $300 then goes towards a $7.5k target that the clinic sets for pre-natal care. I asked for some paperwork that describes this $7.5k target and how it gets paid and etc… We've been to this OB a few times now and the claims have started coming with "services not covered" all in the $3-5k range every time. The agent re-iterates that we only need to pay the $7.5k and we're not responsible for any of those large bills since they're not bills. I ask her to please convey that to me in an email or any written form and so far she hasn't responded to any emails – she only prefers to explain or answer questions over the phone. Suspicious.
I receive this billing agreement today for us to sign which describes how we will owe $7.5k (hand-written in by the way) for prenatal care and an estimate of ~$79k for vaginal delivery or $88k for a C-section. I have yet to confirm with my insurance how much they will allow as a qualified expense, but ~$80k is clearly an absurd amount and I doubt it will be covered when I expected normal pre-insurance costs to be around $15-20k. We're preparing to go back to the first OB at this point and go back in-network and going out-of-network for what we thought would be better care for a reasonably upcharge was a mistake.
Thank you for reading this far, but finally my question is here… Am I on the hook for the $2.9k? (And much more, once the insurance sends us the claims eventually for the rest of the visits). We're planning to not sign the billing agreement, but will the clinic come after us for all the differentials? I just want to prepare myself better with some info before we discuss with them again.
submitted by /u/32JC
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