Are my OON claims correct?

These are questions for anyone with insurance insider knowledge. My questions are related to the ProPublica article that's been posted today.

How can a patient or provider know for certain that a claim has processed correctly? And related, what kind of proof of calculation can I receive from the insurance company to confirm the amount they're covering is correct?

Here's why I ask: As a patient with an OON therapist and self-funded insurance, I worry that years from now I'll be told my claims were miscalculated and that I owe money back. According to the DoL Ask EBSA line, self-funded plans have no audit time limits.

I have doubts about my claims because even though they're for the same provider, location, duration, diagnosis and cpt, the EOBs are calculated month to month with different "discounts" and allowable amounts. The discounts vary, and usually have been for Data iSight, but have also been cited as for Multiplan or other reasons. Each month, I review the EOB and notify the account manager/ client advocate that my HR put me in contact with, and the claims get recalculated with the discounts removed.

I know the advice to get an in-network provider, but I want to use my OON benefits to work with this therapist.

How can I know for sure that everything is being calculated correctly? I wonder if it's true that all the discounts are supposed to be taken off, or whether the client advocate has made a mistake there that I'll have to pay for later. I just want to know the correct amount now, whatever it is. Since the amounts come back different every month unless the client advocate handles the claims, I wonder if anyone at the company really knows the correct calculations.

If the company comes back and tells me there was an error, what proof am I entitled to that can verify they made an error? Can I ask for that proof now in order to confirm my claims are being calculated correctly?

submitted by /u/TweezleSnoofThe2nd
[comments]