Significant difference between estimate and allowed amount
Had to get ‘helmet therapy’ for twins.
Context: used in-network provider and had previously met deductible. The doctor’s office had taken insurance information and provided an estimate based on the allowed billing amount and our co-insurance.
The following is just for one of the twins as the other claim is stuck in an odd limbo (took 3 months for this claim to get settled).
Signed a guarantor agreement that provided estimated allowed amount of $2,750* and so our share is 25 percent of this.
Claim is submitted for $5,149 and insurance pays 75 percent of this amount without any adjustments, leaving our share about double what was originally communicated.
Get invoice in mail from provider with ‘charge’ amount reflecting the expected allowable amount, insurance payment reflecting 75 percent of the $5k bill, and then an upwards adjustment of 2,399 to allow it to foot across.
I’m really at a lost as to what went wrong and concrete next steps. I’m trying to work it out with provider as insurance is insisting the $5k amount is correct.
*for those interested, this reflects my states Medicaid reimbursement amount for this particular piece of medical equipment.
submitted by /u/cardman08
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