Not receiving the full amount for Claim Reimbursement
Hi!
I started seeing a specialist about 4 years ago for psychiatry and because they were out of network, they would charge me the full cost of the visit ($150) and then submit my insurance for reimbursement and I would receive a check in the mail each month ($68.36). I switched jobs two years ago and continued the same process, however the doctor was in network with my new job's insurance so I would receive a slightly larger reimbursement.
I've been doing some admin work for my FSA claims and I noticed that on my EOB there is a discount amount that I have not been being reimbursed for.
Amount Billed = $149
[Insurance] Network Discount = $50.64
Amount Not Covered = $0
Allowed Amount = $98.36
Copay = $30
Deductible = 0
What my plan paid $68.36
Coinsurnace 0
What I owe = $30
I reached out to the doctors office and explained that my insurance says I should only be paying $30 for the visit instead of the $80.64 and they explained the following:
"Our team courtesy bills your insurance the fees you pay us out-of-pocket as incident-to-claims. That essentially means you work with your provider, [NP who I have my appointments with], who is out-of-network and [In Network Doctor] is the supervising physician with the claim submitted under his information to help you achieve the highest reimbursement. Otherwise, if the claim was submitted under [NP] information, the reimbursement would be much lower.
Per your screenshot in the other email thread, we submitted $149 and [Insurance] states they'll reimburse a maximum of $98.36. The "savings/discount" is the difference between what your insurance will reimburse vs. our fee, which is $50.64. That doesn't get paid to anyone. Then $30 went to your copay. You've met your responsibility of paying us $149 out-of-pocket and I can confirm that $68.36 is what the correct amount you're due."
My insurance company said that I shouldn't be paying more than $30 and they could follow up with an agent. I'm concerned because I've had a really great experience with them and they've been very helpful with my medication that is often out of stock and requires resending the script a bunch of times which other doctors don't do. If I press on this issue could they get in trouble and retaliate against me as a patient? $50/month isn't chump change but if there's a likelihood this will get me black-balled as a patient, I'll just drop it. But if this happens all the time and is likely just an unknowledgable billing assistant then maybe i'll go forward.
I know that sounds sad and I'm likely entitled to the money but healthcare is a nightmare and I want to make sure I pick an chose my battles I guess. Any advice would be much appreciated 🙁
submitted by /u/Lovelybonezzz
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