Fighting a losing battle over insurance coverage. I was told one thing and billed completely different. I am in desperate need of anyone who would be willing to help me understand what they were billed, what was covered and what was not. I think they are pulling a fast one because we have Delta Health as our plan manager and they are both pointing fingers at each other. I need a baseline to see what is usual and customary for them to pay for the surgical supplies,operating room and overnight stay etc. If you want to do this privately please send me a fb message. https://www.facebook.com/shannon.vanhoosancannizzaro

The fact that you're using the phrase "usual and customary" is worrisome. That means you went to an out-of-network doctor and hospital. The providers can bill whatever they want, the insurance company can declare an amount as U&C that has no basis in reality, they can then pay a percentage of that, and you're stuck with the rest. ALL of the rest.

If you went to an in-plan provider, there are set fee schedules for every procedure.

I regret I use the term usual and customary it apparently caused a lot of confusion. I was given no set fees for anything I was just told a percentage.

Okay, then ask the hospital and the doctor for an itemized list of charges. They are required by law to give this to you. Then contact your insurer or look at your explanation of benefits (eob) to see what the contracted rate is. Calculate your percentage of that. See if that matches the part of your eob that says "your responsibility is...".

That's what your providers should be billing you.

I used BS of CA, and in network providers, but I haven't gotten my bills yet. OTOH, I used the online calculator, which specified my out of pocket maximums and let me know what I could expect the total cost would be. Yes, they should be paying a percentage, but there should also be caps for your max out of pocket for the year, etc.

Honestly, given the severity of the situation and the amount of money, I would recommend you stop asking strangers on the internet (if only because we can't possibly know the complexities of the contracts, your policy coverage, etc) and go see a lawyer. Paying a very small nominal fee for a consultation may save you a lot of money. Go to an expert who does this for a living.

I'm so sorry this happened to you. I got stuck with an additional 700 dollar bill and was upset, but your case definitely puts things in perspective. Good luck.

My surgery was 4 weeks ago, and all the bills have finally been processed. These numbers are, of course, for my county.

These are the fee schedule allowed amounts, not the billed amounts.

Hospital - operating room plus two nights' stay: $10,288.00

Surgeon's fee: $1,267.94

Anesthesiologist fee: $778.77

Labs inpatient: $84.74

TOTAL: $12,419.45

Edited September 7, 201510 yr by Sharon1964