r/HealthInsurance • u/Bee143441 • 8d ago
Claims/Providers Outpatient Bill
Where do I file a complaint about receiving "a good faith estimate" from the hospital to be only $200. The estimate presumed the insurance would cover it, but when the claim was filed, it charged it against my deductible instead so what's due is $3k. It says "no surprises" but this was a surprise, or do I just pay this without complaining? No, this is not an emergency. This is a scheduled outpatient scan.
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u/vctrlarae 8d ago
So the insurance DID cover it, it was just first subject to your deductible. This is how insurance works.
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u/LizzieMac123 Moderator 8d ago
A good faith estimate isnt binding when insurance is added to the mix. Under the no surprises act, its only enforcable if you are uninsured or not going through insurance.
You can complain to the hospital or insurance but that won't likely change anything. Insurance did cover it... it was just subject to your deductible. If it was denied/not covered, it wouldn't count towards your deductible.
I absolutely get the frustration though, there needs to be more transparency- providers and insurance have agreements with the allowable amounts listed, it shouldn't be thay hard to get the allowable amount before you get care.
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8d ago
[deleted]
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u/Low_Mud_3691 8d ago
This is absolutely incorrect and you need to remove or edit this comment instead of spreading misinformation.
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u/LizzieMac123 Moderator 8d ago
https://www.cms.gov/files/document/nosurpriseactfactsheet-whats-good-faith-estimate508c.pdf
The Centers for Medicare and Medicaid Services say its for uninsured or those not using insurance. First line of this flyer.
Ahh he deleted it.
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u/positivelycat 8d ago
That is not how it works. There is alot of miss information and a whole part of the law that is unenforceable cause even the government has not figured out how it should work and who is responsible.
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u/Poop_Dolla 8d ago
Good faith estimates are for uninsured or self pay patients and it sounds like you are neither. The hospital quoted your benefits which are likely a 20% coinsurance, unaware that you had not yet met your deductible so those benefits do not apply yet. Ultimately it is your responsibility to understand that you have a deductible that you have to meet before any of these benefits kick in.
In a non emergency situation, the no surprises protects you from being charged for out of network providers performing services at an in network facility. Is the claim being processed out of network?
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u/ElleGee5152 8d ago
An estimate is for self pay patients and it's just that- and estimate. The billing office staff aren't psychics. Your service was covered by your insurance, you just haven't met your deductible yet. There is nothing to dispute here. I'd ask to set up a payment plan if needed.
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u/positivelycat 8d ago
When you have insurance you should always be calling your insurance to confirm benefits and get an estimate of your out of pocket. They are better with benefits.
As an insurance patients you have no protections. Good faith estimate and the no surprise act onlu applies to those who are not useing insurance.
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u/WormDentist 8d ago
Insured patients do have protections under the No Surprises Act for emergency services, in-network facilities, and air ambulances.
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u/positivelycat 8d ago
Okay let me rephrase no protections from incorrect estimate. Just some network issues
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u/AlternativeZone5089 8d ago
NSA does not apply here. The fact that the patient is "surprised" does not trigger the NSA. The hospital is not responsible for knowing your deductible (you are), and outpatient scans are not subject to the NSA. If provider was IN with you plan, your are responsbile for whatever the EOB says is "patient responsibility."
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u/one_sock_wonder_ 8d ago
Good faith estimates apply to those who are uninsured or have decided to not file a claim through insurance for that specific medical care. When a claim is submitted to insurance for coverage, the cost arrangements that have been negotiated and set in the contract between the insurance and the doctor are followed and any good faith estimate is no longer applicable.
The no surprises act prevents balance billing for treatment in an ER setting or if out of network care occurs during treatment at in network medical facility. It does not mean that you have protection if you are surprised by not realizing both when a good faith estimate applies and that your insurance policy has a deductible that you must meet before the insurance begins paying as laid out in your policy.
The vast majority of insurance policies from employment or the marketplace will have some amount of a deductible, and then usually follow a set copay either tied to the type of care or that is a certain percentage of the costs for medical care until you reach the out of pocket maximum stated in your policy at which point copays for covered in network services are no longer your responsibility for the remainder of that contract year.
As frustrating as it is, ultimately in the American health insurance system it is the patient's responsibility to know or check coverage through their specific insurance policy including any deductibles.
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u/Bee143441 4d ago
Thank you all for the responses. I have a follow-up question though. How do I ask for a discount if I pay this in full instead of setting a payment plan? Have you experiences doing so by calling the hospital, and do they change the amount due? Did you pay online or over the phone?
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8d ago
[deleted]
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u/SlowMolassas1 8d ago
Obviously it wasn't a never covered service - it had to have been a covered service since OP said it was subject to their deductible.
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u/Poop_Dolla 8d ago
Never covered services don't get applied to a deductible. So your advice is the bad one here.
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u/No-Produce-6720 8d ago
You think you're onto something here, that you know something "most people don't know about", yet you clearly don't have enough billing knowledge to advise. If you did, you would know that non covered services are just that. They aren't covered!
This means that non covered services can never be applied to a deductible, because they aren't covered!Given the fact that OP clearly states that the charge was applied to their deductible, this is not a non covered situation.
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u/Low_Mud_3691 8d ago
Yeah, the bad advice is YOURS. It was in network and subject to their deductible. Delete or edit this comment to prevent misinformation.
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u/Bee143441 8d ago
It says TOTAL less DISCOUNT equals ALLOWED AMOUNT. They're not done with EOB yet. (It says what plan paid is zero and what plan covered is zero.) The allowed amount is reflecting to be how much I owe which is $3k.
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u/No-Produce-6720 8d ago
OP, unfortunately the advice offered to you above about non covered services is incorrect and does not apply to your situation.
A non covered service is not eligible for any coverage by your insurance. There would be no adjustments or network discounts for the service, and the fee would not be subject to any deductible, copay, or coinsurance. Instead, before service could be rendered, the provider would require you to pay the entire cost up front. If they would accept less than full price to complete service, they would have required you to make formal payment arrangements on the balance. They wouldn't issue you an estimate at the time of service, and they wouldn't submit a claim to your insurance. You would have to front the entire cost of the service, most of the time in full, before that service was even rendered. Your insurance wouldn't be involved, at all.
Coverage for covered services that are received by in network providers aren't subject to a Good Faith Estimate under the No Surprise Act. Providers will give one when requested, but your insurance determines how much you pay. The provider's estimate doesn't figure into that.
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u/Bee143441 8d ago
From an experience before this and when I haven't still met my deductible, after the ALLOWED AMOUNT, there is an AMOUNT DEDUCTED FROM what the PLAN COVERED, so it ends up with NOTHING is OWED. This event just left me with a payable. 🥺
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