Is my insurance scamming me…
Is my insurance scamming me and can I do anything about it?!
Back story: in early December I had surgery on my hand where I had two severed tendons repaired due to an accident. I then went on to have physical therapy in December, January, and February.
Between the ER visit (from the accident) and the surgery, I had met my deductible and max out-of-pocket expenses, so December’s physical therapy claims were completely covered by Cigna. I just received January and February’s physical therapy claims and, no surprise, I’m starting over on my deductible and max out-of-pocket expenses. But, what is surprising is that the amounts allowed to be billed for specific billing codes were quite a bit higher than the allowed amounts in December, so much so that I’ve already reached my max out-of-pocket again. It’s not that the amount billed by the provider is higher (per item), but that the allowed (amount to be paid) is higher.
Just to be clear, I’m not talking about the difference between what the plan will pay or what is my responsibility- I’m talking about the amount the provider is “allowed” to charge and how Cigna is changing that amount based on if they, or I, am responsible.
For example, Cigna processed the following codes as such:
CPT 97010 2024/ billed $45/ allowed $10 2025/ billed $45/ allowed $18 Difference of $8/ +44%
CPT 97530 2024/ billed $228/ allowed $53 2025/ billed $228/ allowed $92 Difference of $39/ +42%
CPT 97035 2024/ billed $192/ allowed $44 2025/ billed $192/ allowed $78 Difference of $34/ +43%
CPT 97110 2024/ billed $239/ allowed $55 2025/ billed $239/ allowed $156 Difference of $101/ +64%
As you can see, in 2024 after I’ve reached my out-of-pocket and Cigna must pay all, it’s giving itself a 42-64% discount, but when I’m to pay, I get a different price. Is this legal? I understand that the contracted rates could have gone up in the new year, but the provider has been consistent with the amounts billed, so the seems unlikely.
With deeper discounts for them, than for me, this just feels like Cigna is scamming me. Or maybe I’m looking at this wrong and Cigna is actually scamming the provider. Haha!
So, what do you think? Can I contest the amounts, possibly saving some money and not paying my max out-of-pocket for a second time?
Thanks for your time and advice!
BTW, my hand is doing great.
