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Health insurance , what to do

  1. Mar 17, 2009 #1
    OK, so I have Blue Cross Blue Shield Federal Employees Program, but have never used it. So I don't have a clue of what all the jargon means and what to do.
    I recently got sick, so had to go to the hospital. The Dr. charged a co-payment of $20, and then sent me to the clinic for "services".
    They had some lab tests, and sent me a bill.

    The bill says that $431 were teh charges.
    it says adjustments -$245
    Insurance paymewnts $72
    and the balance due is $113

    i called my insurance, they tried explaining things but I couldn't understand.
    why do i have to pay so much? they said tehre were diagnostic and preventive tests, and teh insurance covered a 100% of the preventive tests.
    they said the maximum allowance was like a $100 and they paid $72.
    they said my deductible was $113.

    what does all this mean? if i pay do i get anything reimbursed?
  2. jcsd
  3. Mar 17, 2009 #2


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    I would try calling again and finding out. Also, maybe you already used some of the $100 somewhere else.

    I'm just thinking of my experience with dental insurance. Even sometimes, they aren't helpful. Usually, I get them to send it to my insurance and when it comes back, they give me my bill. Then I get them to send it back again if it doesn't look right.

    Note: I think it's easier to just pay taxes and not worry about this stuff.
  4. Mar 17, 2009 #3


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    These days, insurance often covers less than it used to. You might have what is called a high deductible, or you are covered for 80% of 'usual and customary', and there might be a different schedule for 'laboratory or diagnostics' as opposed to treatment.

    You likely to have to pay, possibly as much as 20 to 30% or more of the total.

    I worked for a company that had BCBS and we had to pay a deductible and 20% of the costs.

    One does not get reimbursed by the insurance company for the deductible. That is an out of pocket expense. Check with one's employer or human resources department, or ask an older colleague who visited a doctor and had diagnostic tests done.

    Insurance plans vary considerably.
  5. Mar 17, 2009 #4


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    Here we usually have double coverage for something like dentist plans. One plan covers 80% and the second pays 80% on the remaining. So if it was $100, the first pays $80, and the second pays $16, so you only pay $4.
  6. Mar 17, 2009 #5


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    apples, if you are in the US, the usual drill is that you have to see a doctor that agrees to cooperate with your plan to get the maximum benefits. If your doctor sends you to a non-participating entity for follow-ups or diagnostic tests without getting a referral from your insurance plan, you'll probably get nailed with some pretty big bills. Reform of the medical insurance situation in the US should be a top priority for this administration - obfuscation, over-complexity, and outright denial of benefits are a big drag on our economy. It can be very difficult to sort through what costs you should be responsible for, and the insurance company is not going to help you in this regard. When you pay more than you should, it's free profit for them. Sorry.
  7. Mar 17, 2009 #6
    There are a couple of things going on. The primary considerations with most health insurance plans are:

    Maximum lifetime coverage and event/illness coverage and range from $1.0 to $8.0 million with maximums and $5ok to $2.o million per event
    Personal and/or family deductible...typical range is $500 to $25,000.
    Hospitalization co-pay after deductible is met...50/50, 70/30, 80/20 90/10 or 100% covered.
    Prescription coverage deductible...usually $0 to $500 but can be built in to the hospital plan deductible.
    Prescription co-pay or a tiered pricing matrix
    Wellness Doctor visits co-pay
    Illness/injury Doctor visits co-pay
    Diagnostic testing can go toward deductible or have a co-pay and may be capped on a daily basis and in-patient or out-patient
    ER/accident coverage may be separate
    Ambulance may be separate
    Some plans offer portability and continuation of benefits and/or rate locks of 12 to 36 months
    Vision and dental are usually separate

    Next, most health plans participate in a network of coverage and receive network discounts...network discounts can range from 5% to 45%...25% is typical.

    As for your example, the network discount probably accounts for the adjustments on your bill of $245.

    The $20 co-pay is your share of the Dr. office visits...the insurance covered the (Regular price less their discount with the doctors in the network less your $20)

    If the diagnostic testing was covered 100%...none of it went to your deductible

    I can't tell from this information if the maximum allowance of $100 (which they paid $72) was for out-patient treatment or testing...best guess is testing.

    Your deductible of $113 will accumulate toward your annual (could be calendar or anniversary) responsibility. It looks like your $113 responsibility is for a portion of the testing over the $100 allowed plus a co-pay percentage of the hospital bill.

    Look at it this way...the Doctor probably charged $100 total...you paid $20
    and the hospital charged $431 and you have to pay $113.

    $133/$531 = 25% all-in-all not a bad deal for you...without insurance you would have been billed $531.

    Given their network discounts and other pre-negotiated deals...who knows what the insurance company will actually pay.

    If you also have "association benefits" or Aflac...you might be entitled to a cash payment...inquire at your HR dept.
  8. Mar 17, 2009 #7
  9. Mar 19, 2009 #8
    Hey, thanks for the replies.
    I am trying to make sense out of this stuff, and it does a little.
    I guess the doctor ripped me off.
    I went to a preferred doctor, and the lab was preferred too.
    i guess the doctor scheduled me for too many tests.

    All the doctor told me was to gargle. That's it, before and after the tests.

    And I have to pay a $113 for that!
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