by spatchel » Fri Dec 11, 2009 03:09 am
Hi, I have had the same employer-sponsored health care plan for several years now. Just this past year, they changed how deductibles are applied. Instead of applying the entire cost I incur to the deductible, they are only applying the amount they would have covered once my deductible was met.
Ex. $200 out-of-network doctor bill and $1000 deductible. Instead of applying $200 towards the deductible, they apply my co-insurance and then only apply the amount remaining. So, say my co-insurance is 80% "reasonable cost". First, they say the "reasonable cost" is something less than the bill, of course. So, they say that service should cost me $150, and then their 80% would be $120. I get an EOB in the mail stating, of the $200, they are applying $120 towards my deductible. The remaining $80 will be completely out-of-pocket now. So, instead of $200 going to my deductible, I am only getting 'credit' for $120 of that.
Of course, that makes it very difficult to meet the deductible.
Everything I read says that co-insurance is the % I am responsible for ONCE the deductible has been met. It is legal for them to process claims in this manner? I have read my policy several times and the process is not explained.
Thanks!!
Ex. $200 out-of-network doctor bill and $1000 deductible. Instead of applying $200 towards the deductible, they apply my co-insurance and then only apply the amount remaining. So, say my co-insurance is 80% "reasonable cost". First, they say the "reasonable cost" is something less than the bill, of course. So, they say that service should cost me $150, and then their 80% would be $120. I get an EOB in the mail stating, of the $200, they are applying $120 towards my deductible. The remaining $80 will be completely out-of-pocket now. So, instead of $200 going to my deductible, I am only getting 'credit' for $120 of that.
Of course, that makes it very difficult to meet the deductible.
Everything I read says that co-insurance is the % I am responsible for ONCE the deductible has been met. It is legal for them to process claims in this manner? I have read my policy several times and the process is not explained.
Thanks!!
Posted: Fri Dec 11, 2009 06:04 am Post Subject:
Going with your example, it seems something is wrong. Its been a number of years, but I believe that $150.00 should have went to your deductible. The $50.00 is above their usual and customary charges and would be taken off the top with the remainder applied to your deductible. I would contact them and see if it was processed incorrectly. Go at them with the knowledge that the $50.00 will not be considered towards anything. It can't hurt to ask, but it is late in the year for your deductible.
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