Joy had her surgery back in December. BCBS of Texas sent a letter saying that she was eligible for benefits. Doctor sent us to a medical facility who accepts BCBS. When the bills were all sent out, totalling $42,000, BCBS paid a whopping total of $1629....that includes what they paid the doctor. We appealed the payment to the hospital and they are standing by their original determination. What the heck? They say we're covered then pay PENNIES on the dollar? Is there a secret list of payments out there somewhere that I'm not aware of? Am I going to be stuck with paying off the other thousands of dollars, now? They only allowed $273.99 for the operating room. Where in the state of Texas can you use an operating room for $274??? And if there is some cheapa$$ hospital that charges that much, would YOU want to go in there for surgery? I can only hope that if the hospital wants me to pay for it, they will accept $20 a month....you can't get blood from a turnip. And you can't get BCBS to pay squat on your lapband surgery......IMHO

Is that the same issue here, or have they done it again?

Maybe the amounts they paid are negotiated rates, and not full coverage rates? My insurance co was billed about $30k for my surgery, and will pay the surgeon about $1700. I'm not stuck paying the difference, it's just that $1700 is all my surgeon gets paid b/c of the negotiated discount.

Wheetsin, Yes, that's the same issue, after the appeal. I can only hope that you are correct. It just seems unbelievable to us that they can get away with only paying $1700 for the whole friggin' procedure.

Randy,

Have you received any bills in from the doc. or hosp. for amounts due?

BCBS of CA paid a sackful of money - to somebody - for my surgery. I can't imagine that BCBS of TX could really only be paying $1683... Maybe there is a decimal place error or somthing. I wouldn't panic - YET. Now, if your doc sends you a bill for thousands - THEN you can panic.

Hugs!

I found out with experience from other medical bills that as long as you attempt to pay even $5 a month they can't do anything to you. Can't garnish wages etc. Is it possible that the hospital has an indigent program and that your income will fall at or below the guidelines then the hospital will write off the remaining debt. Hope that all works out well for you. Medical bills are ungodly sometime. Best of luck!

We had this same situation happen with BCBS.

What you have to do is call them (if you haven't) and get the person, date, time etc., tell them what happened and ask what your policy is about the surgery.

Normally what happens is BCBS will pay X doctor or X hospital a certain $$ of the bill to have their patients at that facility. Under different state laws, the doctors or hospitals CANNOT hold you responsible for a covered expense.

If calling BCBS doesn't help, call your state ins commissioner and find out your rights )

Paula, no bills here yet.

Teresa, Joy and I both feel that the surgery was worth way more than what BCBS paid and we'll pay them what we can, but....

Lisa, that sounds like it might be my next move, calling the insurance board or commissioner. I'm not sure what we have here in Texas.

ReneBean, I haven't paniced yet. I'll probably do like I said, pay them a little each month. It sure doesn't sound as if the dang insurance company is going to pay them any more.

As I read what you've said, you won't owe anything. Here's my info, see if you think it's similar to what you're hearing:

Individual Service: Op Misc Services

Total Charge: $29076.25

Network Discount: $27402.75

Allowed Amount: $1674.00

Patient Copay: $0.00

Deductible: $0.00

Not Covered: $0.00

% Paid by Plan: 100%

Paid by Plan: $1674.00

As it was explained to me by my insurance co, they have negotiated rates that are much lower than what the surgeon normally charges. His charge is $30,000, they actually paid him $1674. That's the rate they've negotiated. My account is paid in full with no outstanding balance.

Randy,

I also have BCBS (TRS Active Care 2) and when I was in admitting getting everything set up I was told that my out of pocket expenses would be no more than $2000 due to my deductible and a surgery expense cap. I had to pay $325 deposit and they said that I would be billed for the rest.

So now I'm waiting to see if BCBS pays exactly what I was told they would pay. Did they give you any information regarding the cost when MsJoy was admitted? I know that they do different things with different plans, so I'll keep you and MsJoy in my thoughts and prayers that this will work itself out.

Audra

Randy,

BCBS has reasonable people to help their members out. Give BCBS member services a call...the number is on your BCBS card. You should be receiving an explanation of benefits from BCBS...sounds like you already have if you know what they are paying. I can tell you for sure that BCBS definately contracts with the hospitals and also has separate contracts with physicians and physicians groups. They most certainly negotiate rates of what they will and will not pay. Some patient's plans differ though and that will cause some fluctuation in payments but, the hospitals and physicians are TOLD by BCBS what they can and cannot charge a patient for on the copies of their EOBs when BCBS pays on claims.

If you do get a bill from the hospital, closely match it with your EOB from BCBS. If you think the hospital is charging you more than what your EOB states you need to pay..CALL the # on your bill from the hospital/doc etc. Tell them you have your BCBS EOB in hand. You can also, get a BCBS rep on the phone with you as a conference call to the billing office. All you have to do is call BCBS, tell them about the bill and they will call the billing office with you on the same line. Happens all the time. BCBS will fight that bill for you. Believe me.....the billing office doesn't want to tick off BCBS because an audit is just unbearable lol.

Sometimes diagnosis codes (Known as ICD-9 codes or signs and symptoms) will throw payment off as well. Some patients plans of BCBS will only cover certain codes etc. If you received authorization for the procedure to be done and the referrals you needed then the highest your bill should be would be for any deductibles and co-insurance amounts that would be indicated on your plan. I highly doubt you'd be responsible for the remaining $40,000.

I have an HMO plan called Tufts Liberty. My plan has a deductible of $1200 for two people. Needless to say with all the pre-op work that went by really fast lol. I owe nothing more. Every patient's plan is different with every insurance as far as that goes. My surgeon takes my insurance but, he also indicated my insurance is one of the cheapest paying ones and he has to adjust the rest off He already knew that before I had the surgery.

Definately DO NOT start paying on any bill received until you match it with an EOB from BCBS. Believe me.....it's not easy to get your money back if you overpaid or paid for something you didn't have to.

I've been doing medical billing now for over 18 years and definately know rates for all Major insurance carriers and HMOs/PPOs are negotiated. In order for that doc or hospital to say they accept those insurances they've already gone through the credentialling and signing of a contract with the insurance carriers before they can serve the patients.

Good luck with all of this and if you need help with understanding any of this or would like some help contacting BCBS etc. Send me a PM. I wouldn't mind giving you and your wife a hand at all.

Hugs

Sherry

Here is a question...even though they are supposed to take what the insurance paid them, will they be sneaky and try to collect more from him??

ALso, in what states is it against the law to do this?

Randy, don't feel guilty about the hospital being underpaid. The hospital had a say in how much they would accept when they negotiated the rate with the insurance company, so they are okay with that amount. Remember, BCBS is a massive organization with bargaining power, so it pays overall for the hospital to accept their patients.

I had a similar situation with United Healthcare... my surgery was billed out at about 29K and the hospital/surgeon was reimbursed 3K. I thought it must be some crazy error, but it was correct. My deductible had already been satisfied for the year, so I had no out of pocket costs for my surgery.

It's against the law for contracted health care facilities to attempt to collect more than the contracted amount from anyone.

Check the EOB (explanation of benefits) that you received that showed how much they paid. It should show an amount that is now due from you. Chances are that it is also either pennies on the dollar or a percentage of the amount already paid by BCBS. (For instance - my BCBS plan pays 80% (of their contracted amount)(0% for WLS of any kind) and I am responsible for the other 20% (of the contracted amount) If the contracted amount for a particular procedure is say $1000.00 they pay $800 and I pay $200 -

Check your EOB - if it's still unclear - call the hospital billing office and they will explain how it was paid and what balance if any is due. They can also set up payment plans if there is a balance. The hospital I work for offers a discount if you pay cash so you may want to ask them if they would as well.

They contract with BCBS because it guarantees them patients from that plan. They contract with hundreds of plans to maximize the number of patients seen. Don't feel bad because you have received great care at the contracted amount! They agreed to perform the surgery for that amount in the contract. Don't feel bad for the hospital - they are making money somewhere

Wow! Thank you everyone for all the advice and information. It certainly gives me ammunition for the fight. I'll let you know how it comes out.