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My explanation of benefits and my statement from my healthcare provider have different amounts on them. I had an xray done in the summer, and my EOB says that the billed amount was $190, but under patient's responsibility it says $48.20. I got the statement from my provider yesterday and it says I owe $190. On my EOB on the row detailing the charges there is a "reason code" and below the summary of the charge there is a reason code description that states: quote:The amount exceeds the Plan's Reasonable and Allowed Amount that generally limits the maximum amount payable to 160% of the Medicare Allowable. What exactly the gently caress does that mean? I've been going to physical therapy for several months now, and now I'm worried I'm going to end up with huge bills.
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Oct 25, 2018 11:54
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That is the fundamental way every insurance claim I've ever seen works. If you go to an in network provider, they bill the insurance $9,000,000 for an aspirin, the insurance company says no we will give you $0.32 (and you get to go bankrupt if the insurance company claims they weren't in network after all). I don't pay any providers until the bill they send matches what the insurance company says I should pay them, unless there is a specific reason why they don't match that I'm aware of.
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Oct 25, 2018 13:30
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So who do I get in touch with? The insurance company, my provider, or that advocacy number on the EOB? Also, the EOB isn't actually the insurance provider, they are a benefits administrator. Our company does self insurance, and there are "no networks" and we are free to go to anyone we choose!* *oh except in this** particular instance we're gonna gently caress you over and say you shouldn't have gone here. ** every particular instance. Edit: I even called and spoke with the benefits administrator to make sure I could get the xray, and had to get a prior authorization through them before starting PT. gently caress this dumb country's health care. BAE OF PIGS fucked around with this message at 13:57 on Oct 25, 2018 |
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Oct 25, 2018 13:54
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Call the billing department of the physical therapists office and tell them your insurance says you should owe $48
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Oct 25, 2018 13:58
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BAE OF PIGS posted:My explanation of benefits and my statement from my healthcare provider have different amounts on them. I had an xray done in the summer, and my EOB says that the billed amount was $190, but under patient's responsibility it says $48.20. Did your insurance send you the check or did they send it to the provider?
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Oct 29, 2018 02:26
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They've never sent me anything before. I called on Friday, talked to someone who said that they have on file that the EOB they got said I owe $48, but there was a note or something about them not having a contract with our insurance provider. The lady on the phone said she didn't know what that meant, so they were going to have their people who talk to the insurance companies call and get it sorted out. I never got a call back on Friday, and I didn't get one today either, but I checked my balance just now to see if anything was updated on the website, and it's been adjusted down to $9.64. I'm cool with that.
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Oct 30, 2018 00:40
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So I’m in MD and currently I have geico for home and auto. They keep bumping my auto premium by a few bucks each period and it’s kind of annoying and beginning to approach the amount it was at my previous provider, which prompted me to switch to geico. I have a good diving record aside from an accident which I was not at fault for last July. My wife is also on the policy and she has a single speeding ticket from like two ears ago. We both drive camrys, so nothing crazy in that regard. Do you typically get better rates going through an agent or direct? I’d be looking to move both policies for a discount.
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Nov 9, 2018 15:55
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Spring Heeled Jack posted:So I’m in MD and currently I have geico for home and auto. They keep bumping my auto premium by a few bucks each period and it’s kind of annoying and beginning to approach the amount it was at my previous provider, which prompted me to switch to geico. An independent agent can get you quotes from multiple carriers for comparison and will have a better understanding of what kind of coverage you should have. Going though an agent is the safest bet.
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Nov 10, 2018 18:52
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Hi insurance thread. What's the consensus on short-term disability insurance? There's a good chance my wife will get pregnant this year. So probably smart to sign up for short term disability now, right?
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Nov 12, 2018 18:56
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AndrewP posted:Hi insurance thread. What's the consensus on short-term disability insurance? There's a good chance my wife will get pregnant this year. So probably smart to sign up for short term disability now, right? This is outside of my realm of knowledge, and you should definitely discuss with her/your HR or plan administrator, but my instinct is that you want to coverage in-force before she's pregnant, not just because it would be a pre-existing condition but in case she needs to leave work early (complications, etc.). It's open enrollment season so she may have an employer paid (or contributed) option for this coverage.
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Nov 16, 2018 01:57
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13Pandora13 posted:This is outside of my realm of knowledge, and you should definitely discuss with her/your HR or plan administrator, but my instinct is that you want to coverage in-force before she's pregnant, not just because it would be a pre-existing condition but in case she needs to leave work early (complications, etc.). Yeah, OE is why it came up. She's not pregnant now and we decided to get it. Thanks!
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Nov 17, 2018 20:44
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I am switching homeowner's insurance and have a couple goofy questions. 1. Is it worth paying for "Open Peril" coverage on personal property? It seems like any insurance company would have lawyers who would button up the list of excluded perils to make this coverage almost completely worthless so I'm not really seeing the benefit. This seems to be equivalent to upgrading from HO-3 to HO-5. 2. Is it worth paying for more than $1 million of umbrella coverage? I have seen people say to use net worth as a guide but that really glosses over a lot of specifics about assets protected from settlements (retirement accounts, home equity) so it feels like there should be a better way.
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Nov 19, 2018 23:39
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Insurance Thread, I need your help....Apologies for the length. My husband became eligible for benefits in December of 2017 with his ‘new’ job, (effective Jan 2018 for their OE cycles). He has his Medical/Dental/Vision through my spousal plan at my employer, (and has), since I’m in a much more stable environment, (over 19 years with same employer). But, we still got the gamut of extras through his employer of STD, AD&D, Extra Life, etc since it wasn’t much, and why not take advantage of those cheap extras on top of what he has through me. A few months ago we got notice from Allstate, (who is their provider for work whole life plans....I know, I know), that due to non-payment the Life on him would be cancelled unless he started to paid directly. Fast forward many phone calls over the last couple months have resulted in this: 1. Fundamental (his employer’s payroll/benefits mgr), has consistently deducted from his pay all dues & they ‘claim’ sent to Allstate the entire year. 2. Allstate shows his life plan was effective 01-01-18, but terminated later that month due to non-payment. 3. Allstate shows his spousal life on me, (50% of his amount), is still paid & fully in effect, (even though my 50% of his amount is based on him, well, having an active policy in the first place, so how can mine even exist?). 4. At one point on a conference call with Allstate & Fundamental, Allstate stated they also showed a child WL plan in underwriting since Jan. ‘18, (um, we have no kids, and also, stuck in underwriting for 10+ months on an 80k policy, even if we ‘did’ have a kid, really?). 5. Allstate refused to say anything else other than direct us to the Fundamental-assigned corporate agent, and said the employee would have to call them. 6. Fundamental-assigned Allstate agent does not return our voicemails x5 over 5 weeks, and Fundamental rep says they can’t get a response either. Soooo, for his new OE effective Jan ‘19, we have dropped the 80k WL employee policy, (as well as the 40k WL spouse policy on me). Fundamental says they are still working to get answers regardless of us opting out of the WL this upcoming year. Are we, (or him in this case), entitled to a refund of dues since it was cancelled, but they’ve still been sent the money, (possibly storing in some random child plan stuck in underwriting), all year? Is it worth it to file a complaint with Texas Dept Insurance? His policy premiums/deductions is about ~$700. But we’re worried the Allstate rep was stating, “If we messed up we’ll retroactively issue the policy”. Seems like a way for them to get out of refunding money on a plan that hasn’t existed all year. Ugh, fawk Insurance.
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Dec 3, 2018 02:28
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#1, what does his company's HR say about this? It' really important to listen to know if this was just a mistake (in which case we can tell you how to proceed) or if your husband just got early notification that it's time to look for a new job.
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Dec 3, 2018 03:16
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Motronic posted:#1, what does his company's HR say about this? I’ve been handling most of it, (he freaks out with anxiety, among other things, when it comes to even ‘routine’ HR things). Thankfully, once Fundamental got their HIPPA release, they’ve been very open with me. I’ve dealt with the same rep on almost all of the calls. I honestly believe they just don’t have any clue though. I get the impression they perform HR/benefit duties for so many small companies, that it’s a guessing game for them. But at least they’ll communicate with us, unlike Allstate. From what I’ve seen on his online Fundamental Benefits account, as well as his myallstate benefits account, I’m leaning towards Allstate dropping the ball. (They even showed an Accidental Injury policy temporarily issued for a few months on him, despite his employer using MetLife for those plans). I suspect the Allstate assigned rep is over-burdened and is screwing up accounts). Edit - his immediate employer/HR person is small enough that they pretty much say, (we don’t even have access to your pay, let alone your deductions or benefits. You need to contact Fundamental/Trion for questions). Madbullogna fucked around with this message at 03:40 on Dec 3, 2018 |
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Dec 3, 2018 03:35
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He needs to go back to his company's HR department and tell them that he is not getting the answers he needs from their outsourced HR. The benefits he is not receiving are part of his compensation, and he needs them to be in place. He should probably be looking for another job, and getting therapy if he can't handle dealing with HR and benefits administrators.
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Dec 4, 2018 20:13
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Alright, a friend of mine commented on a Facebook post and it got me thinking: why the hell would a company choose to self-insure? Google tells me this is to "save money" by cutting the middle man of the insurance company out of the picture and thus not paying the insurance company's slice of profit. The probability and statistics education in me says that this is a terrible idea because it means the company has a razor thin margin of error on its insurance forecasts and is exposed to a lot more risk than by simply sticking its chunk of employees in the much larger risk pool of a dedicated insurance company. Am I wrong? Am I insane?
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Dec 21, 2018 01:20
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Warmachine posted:Alright, a friend of mine commented on a Facebook post and it got me thinking: why the hell would a company choose to self-insure? Google tells me this is to "save money" by cutting the middle man of the insurance company out of the picture and thus not paying the insurance company's slice of profit. The probability and statistics education in me says that this is a terrible idea because it means the company has a razor thin margin of error on its insurance forecasts and is exposed to a lot more risk than by simply sticking its chunk of employees in the much larger risk pool of a dedicated insurance company. Not necessarily. The companies who (smartly) self-insure are huge. There's a tipping point where insurance premiums get so high that it's more cost effective to take on that risk as an expense for a company. We're talking insurance premiums in the multi-millions here.
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Dec 21, 2018 02:09
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Warmachine posted:Alright, a friend of mine commented on a Facebook post and it got me thinking: why the hell would a company choose to self-insure? Google tells me this is to "save money" by cutting the middle man of the insurance company out of the picture and thus not paying the insurance company's slice of profit. The probability and statistics education in me says that this is a terrible idea because it means the company has a razor thin margin of error on its insurance forecasts and is exposed to a lot more risk than by simply sticking its chunk of employees in the much larger risk pool of a dedicated insurance company. Yes, you’re wrong.
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Dec 21, 2018 04:26
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Vomik posted:Yes, you’re wrong. Pretty much. If you're big enough to do this you have an actuary.....more like a team of them.....just like the insurance companies and you can figure out your breakeven. When you achieve that you self insure. This isn't magic. It's obviously a legit business model for insurance companies, so why wouldn't it be a cost saving measure to NOT pay the margin to an insurance company once you achieve a statistically significant risk pool?
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Dec 21, 2018 04:31
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If a company has 50k employees it absolutely makes sense to self insure. My company self insires but has insurance companies administer the plans. Then the company decides each year whether to raise rates or deductibles. They charge extra for smokers which also makes a ton of sense.
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Dec 21, 2018 06:21
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Vomik posted:Yes, you’re wrong. This was pretty glib so let me help explain. Insurance is purchased to reduce the risk of ruin... people insure things they can’t afford to lose. So for example you and I would insure cars but a billionaire for example would not purchase car insurance. The same reason you wouldn’t insure a $5 item you bought on amazon is the same reason google won’t purchase external insurance. Now they still would use networks and administrators to handle claims/premiums most likely. Group insurance is typically rated at the company level anyway so even if a large co bought insurance it’d be priced in a similar way to how they’d measure it. Now this doesn’t get into things like, say, pensions where they may feel it’s worthwhile to externally hand off ownership to a company who specializes in that risk.
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Dec 21, 2018 16:38
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I should also clarify - my earlier post was in reference to P&C insurance.
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Dec 21, 2018 18:10
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Alright. I feel better now. My thought was predicated on a very simple model of "larger pool, lower risk," and wasn't really considering what "sufficiently large" meant in this case. A company that can afford to administer the benefits itself will do so (my friend's employer), but a smaller organization that would be more sensitive to the costs would likely buy insurance (my employer). Does this sound like a better understanding of the policy?
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Dec 21, 2018 22:19
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Warmachine posted:Alright. I feel better now. My thought was predicated on a very simple model of "larger pool, lower risk," and wasn't really considering what "sufficiently large" meant in this case. A company that can afford to administer the benefits itself will do so (my friend's employer), but a smaller organization that would be more sensitive to the costs would likely buy insurance (my employer). Does this sound like a better understanding of the policy? And remember, you can do things like hire Cigna to handle everything but your company pays for the stuff you consume. Basically you wind up with Cigna going: "Ok it's $X/month/person to administer these benefits, and people used $12,000 in services this month, please give us a check for ($12,000 + $X*People). The $X covers all of the network contract management, prescription drug pricing, etc. So even if it looks like your employer is paying for insurance, they might be just cutting a check on the backend for all of the "risk" component.
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Dec 21, 2018 23:15
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Warmachine posted:Alright, a friend of mine commented on a Facebook post and it got me thinking: why the hell would a company choose to self-insure? Google tells me this is to "save money" by cutting the middle man of the insurance company out of the picture and thus not paying the insurance company's slice of profit. The probability and statistics education in me says that this is a terrible idea because it means the company has a razor thin margin of error on its insurance forecasts and is exposed to a lot more risk than by simply sticking its chunk of employees in the much larger risk pool of a dedicated insurance company. What exactly are they self insuring? Health insurance for their employees, Property, Casualty (Liability), etc.? Like most mentioned above, very large companies will self-insure a lot of lines, or have a tremendous self-insured retention (basically, the amount they're on the hook for before any policy will kick in). Disney has millions in liability coverage but they also have a multi-million dollar SIR (that, to the best of my knowledge, has never been pierced, but I've never seen the TPA runs personally to know). You also get very small companies that self-insure because they can't afford coverage, and just pray really hard nothing happens until they can afford coverage. And the mom and pop shops that have never had coverage because pop was a handshake kind of businessman so when 1. he dies and his kids take over they immediately go "holy poo poo, the company has operated bare for 35 years and dad was the luckiest SOB alive to never get sued in that period," and get coverage then, OR 2. he does get sued, nearly loses the business paying out the claim out of pocket, and gets insurance the following year.
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Dec 25, 2018 23:21
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13Pandora13 posted:What exactly are they self insuring? Health insurance for their employees, Property, Casualty (Liability), etc.? 3. Dad ran the business with as close to 0 in assets as possible and closed up shop immediately upon being sued. It's basically a blend of 1 and 2. (And as I understand it, it's the health insurance. They pay the columns in the EOB that Cigna would normally pay.)
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Dec 25, 2018 23:40
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My wife is employed by the State of Illinois, and none of her claims for this plan year have been paid to the providers. On the insurance website, they all say “Approved. Awaiting funding.” Apparently Illinois decides to not pay the insurance company any money yet. Now we’ve started to receive bills from the providers for the full, non-negotiated amounts. So $200+ doctors bills for what should be a $30 copay. Should we be making any payments in the mean time? If so, how much? Like for the above example: The doctors bill was $250 The insurance company’s rate was $160 Our normal copay is $30 Personally I’m hesitant to make any payments at all.
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Jan 13, 2019 23:30
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Initio posted:My wife is employed by the State of Illinois, and none of her claims for this plan year have been paid to the providers. On the insurance website, they all say “Approved. Awaiting funding.” Apparently Illinois decides to not pay the insurance company any money yet. gently caress the State of Illinois they've been playing this game for y e a r s, but also gently caress the providers for not patiently dealing with it. Who's her particular insurer?
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Jan 13, 2019 23:45
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She has Aetna. I’m guessing that it’s too much to hope for that Illinois gets their act together any time soon. Most of the articles I’ve been reading about the issue are from 2017.
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Jan 14, 2019 17:27
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Initio posted:She has Aetna. Regardless they should only be on the hook for the negotiated amount if you went to in-network providers. Make sure all of your co-pays are paid and call them to ask for some time, they may even be required to give it by their contract. Call Aetna and ask them as well. I have a feeling this will sort itself out in a month or so.
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Jan 14, 2019 18:04
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I have an insurance policy for a condo (HO-6) that is expiring soon. The premiums jumped (doubled..) so I'm shopping. The coverage is the same so it's probably just a first year thing. Anyway, I noticed my current insurer offers loss of use "actual loss sustained" but the new quotes I've been getting are all limited (2k/month). Does actual loss include things like rent/hotel/food etc.. for a new place? Or is it just paying for things like mortgage if I can't live in the property? I live in an HCOL area and can't imagine having to pay a mortgage and rent on another place to live.. The price difference isn't crazy ($100), so maybe the year 2 quote is good, but I just wanted to better understand this one bit. Thanks!
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Jan 14, 2019 19:33
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Bank posted:I have an insurance policy for a condo (HO-6) that is expiring soon. The premiums jumped (doubled..) so I'm shopping. The coverage is the same so it's probably just a first year thing. What does the policy say?
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Jan 15, 2019 19:10
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So I'm shopping around for Invisalign and I plan to start my treatment in July since that's when I'll get access to FSA money for 2019. This also means I can change my dental plan during open enrollment in May. Thing is, I don't quite understand which is the better deal listed under the orthodontia benefits: a: Plan paying 50% based on contractual fee agreed upon by dentist b: Plan paying 50% and then paying 50% coinsurance 
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Jan 30, 2019 21:51
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air- posted:So I'm shopping around for Invisalign and I plan to start my treatment in July since that's when I'll get access to FSA money for 2019. This also means I can change my dental plan during open enrollment in May. For in-network they are the same. For example: a: In-network, Billed $6000, Contractual Fee is $5000, they cut a check for $2500, you get a bill for $2500. b: In-network, Billed $6000, "maximum allowable amount" is $5000, they cut a check for $2500, you get a bill for $2500. c: Out of network, Billed $6000, "Maximum allowable amount" is $4000 (gently caress you), they cut a check for $2000, you get a bill for $4000. d: Out of network, Billed $6000, "Maximum allowable amount" is $5000, they cut a check for $2500, you get a bill for $3500. For out of network it depends on how close to the in-network fee your orthodontist is willing to accept. If you have someone you are talking to already I would call and ask to speak to their insurance billing person and ask them which one pays them the most for what you want because you have a choice coming up in May. You should be getting pre-authorization and an exact statement of how much everything will cost before incurring costs. Note orthodontia is always a "lifetime maximum" on every plan I've seen, so it's basically 1-and-done. If you need more in the future you will need to use a different insurance company. (So if you never see Aetna and always see Delta Dental, maybe pick Aetna all things being similar.)
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Jan 30, 2019 22:07
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H110Hawk posted:For in-network they are the same. For example: Thanks for all the tips. I've scheduled appointments with several orthodontists in my area doing comparison shopping and I wasn't sure how to approach this question. Just double checking on the pre-authorization, I was under the impression you had to actually be a member on those plans to get a pre-authorization?
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Jan 31, 2019 16:24
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air- posted:Thanks for all the tips. I've scheduled appointments with several orthodontists in my area doing comparison shopping and I wasn't sure how to approach this question. Correct. But they should have an idea of how these plans work. Bring the printout of your open enrollment descriptions with you. Overall you should go with the best person for the job and expect to pay a bit more for the privilege. (potentially thousands more, I don't know what this stuff costs.) I don't work in insurance but have played this song and dance before. Take notes anytime you talk to someone promising you things and 100% of the time you call your insurance. Name, date, reference number (insurance), and a few words about what you spoke about and any specific promises made. Remember that "covered" could mean example 'c' above.
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Jan 31, 2019 16:41
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Not sure if this is the right thread but my simple question is: I was stopped in traffic, hit from behind and hit the car in front of me. Should I tell my insurance company? Long story: I was driving, stopped in traffic. The guy behind me hit me, and I hit the car in front of me. There is very little damage to the car in front of me, minor damage to my car that I don't intend to fix and heavier damage to the guy who hit me. Should I call my insurance company and tell them this happened and that I don't intend to file a claim? I'm worried that lady in front of me is going to file a claim and then it'll come back to me and I'll be involved. There's also a chance she goes directly to his insurance company. But anyway, I'd rather not tell my insurance company anything, unless, of course, lady comes after me in which case I want my insurance company to have had a heads up and see my dash cam video.
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Feb 7, 2019 18:41
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Yes, file a claim. It will let your carrier do a timely investigation and defend you against any claims. Also your policy likely has a clause requiring you advise them about any accidental you're involved in. LongDarkNight fucked around with this message at 19:07 on Feb 7, 2019 |
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Feb 7, 2019 19:05
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dexter6 posted:Not sure if this is the right thread but my simple question is: I was stopped in traffic, hit from behind and hit the car in front of me. Should I tell my insurance company? Depending on the state, the fault for the accident with the lady in front of you may very well be yours. In a lot of places, you did not leave sufficient distance between you and her, therefore you rear-ended her. It's an odds game, though. Filing a claim if she doesn't file one will probably mean your rates get jacked up for nothing.
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Feb 7, 2019 19:16
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