A real life health care payment mix-up

Posted on Posted in Small Business

This is a real-life personal health care story that I am trying to settle right now. I know that the same pattern is repeated for countless health care consumers every day. That’s why I posted it here. I rounded off the numbers for easier communication. The situation unfolds like this:

Last month I required a procedure* on short notice and the medical provider scheduled it and took my insurance information in advance. A day before the procedure, the provider’s office administrator called to say that the procedure will cost $3,200 and that the patient portion is $1,500. I provided a credit card in advance of the procedure and the provider billed the credit card $1,500.

Then about two weeks later I saw the claim processing statement from the insurance company. The benefits statement says the billed amount is $4,200, the allowed amount is $1,500, the insurance company’s payment is $1,500 and the amount the patient owes is $0. There is no indication of an out-of-network penalty and I have no knowledge of whether the provider is legally required to accept the amount authorized by the insurer as full payment.

From the insurance company’s perspective the provider was double-dipping. From the provider’s perspective, he collected only $3,000 of the $3,200 price they quoted me and far less than the amount they later billed to the insurer. From my perspective, the last thing I want is a fee dispute with a provider who I need to trust for my care in follow-up appointments.

So perhaps the best I can do is share the story and ask how others have dealt with similar situations.

* The procedure was for an infection in the upper tooth/gum/jaw/sinus performed by an endodontist that I don’t actually know if this is considered solely a dental issue or a medical procedure so I just said “procedure”; I don’t think it matters for purposes of this discussion.

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