Question
What is the name of your state? Texas
I live in Texas. I have 2 health insurance - the primary from my work and the secondary from my spouses work. There are the basics of the 2 policies:
primary: deductible $1,000
individual out of pocket $2,000
inpatient charges - pays 80%
secondary: deductible $300.00
individual out of pocket $3,000.00
inpatient charges - pays 80%
My question is that I had surgery over a year ago and I am being billed $1,700 for my portion (the out of pocket). I thought my secondary would pay this?
The primary paid and the bill was submitted to the secondary but they did not pay. I have the eob from both companies.
The primary eob shows:
Total Bill - $21,418.53
Non-Covered - $3,202.04
Covered - $18,216.49
Coinsurance - $1,933.97
Benefits paid - $16,282.52
The secondary eob shows:
Total Bill $21,418.52
Provider Discount $12,487.84
Non-covered - $3202.07 ($150 for private rm -which we paid upon checkin.
& $3,052.07 for primary insurers discount - I do
not see this discount listed on the primary eob
however)
Deductible - $156.95
Copay - 0
Coinsurance - $557.17
Other Plan - $5014.50
Benefits Paid - 0
Any input would be appreciated - I am trying to have a good understand before I call - since I have spoken to them before and felt clueless. I'm afraid they tell me something and I won't know any better.
Please advise. Thanks! Jean
Answer
It is unfortunate that so many people assume that a secondary carrier will automatically pick up any portion of the bill that is not covered by the primary carrier, leaving them with no out of pocket at all. That happens rarely, if at all.
What generally happens is that the secondary carrier looks at what they would have paid if they were primary, and pays any difference. For easy arithmetic, assume that a bill is for $100 and the primary carrier pays $80. If the secondary carrier would have paid $80 or less if they were primary, they will pay nothing. If they would have paid $90 if they were primary, they will pay $10. ONLY if they would have paid $100 had they been primary, will they pay the entire outstanding balance.
They also are not responsible for paying for any services that are not covered on their plan. For example, if speech therapy is excluded from their plan, they don't have to pay any charges for speech therapy, regardless of what the primary carrier does. And if it should happen that the primary carrier doesn't pay for speech therapy either, then despite the fact that you have two insurance plans, you have to pay the speech therapy bills.
That's a very general description, and I can't know the specifics of your particular plans, but it will give you an idea.
Generally, unless the secondary carrier has significantly better benefits than the primary carrier, it is not cost effective to carry two policies.
Answer
The numbers still look a little funky here to me. His coinsurance under the primary plan was $1900, his out of pocket under the secondary would have only been $700, so it seems like they should have paid SOMETHING.
It looks like the same $3202 was non-covered by both plans, but you didn't post the reason code for why it wasn't covered by the primary.
Answer
The OP should contact the secondary insurance carrier for more inforamation on the second processing (Thats what customer service is for).
*Ecmst12 the below statement explained the rejected $3202.07*
Non-covered - $3202.07 ($150 for private rm -which we paid upon checkin & $3,052.07 for primary insurers discount - I do not see this discount listed on the primary eob however).
*jean100 the discount ammount is on the primary eob take the billed ammount "$21,418.52" allowed/covered ammount "$18,216.49" and you get "$3202.04" the discount.*
Non-covered - $3202.07 ($150 for private rm -which we paid upon checkin & $3,052.07 for primary insurers discount - I do not see this discount listed on the primary eob however).
What I cant tell is if the deductible on the secondary is actually the co-pay for the private room. If it is why is $6.95 applied and if its not was the secondary deductible not met because if the primary applies to ded the secondary wont?
There are alot of questions that the insurance carrier is best to answer.
Answer
The $3,202.07 on the secondary eob is coded a "68 - The excluded amount is the primary carrier's discount".
I already paid the difference, when admitted, for the private room.
Answer
Was the provider contracted with both insurance carriers at the time of service?
Primary Bens:
-----------------
Primary: deductible $1,000
Individual out of pocket $2,000
Inpatient charges - pays 80%
Primary EOB:
-----------------
Total Bill - $21,418.53
Non-Covered - $3,202.04
Covered - $18,216.49
Coinsurance - $1,933.97
Benefits paid - $16,282.52
When you take the covered amount and subtract the benefits paid it should give you the Co-Insurance. Your EOB information seems to be correct as the primary co-insurance would be $3,256.50. Your out of pocket max is $1,933.97 so anything over that will be paid at 100%. If the provider is contracted they could only bill you for $1,933.97 after the primary payment.
Secondary Bens:
---------------------
Secondary: deductible $300.00
Individual out of pocket $3,000.00
Inpatient charges - pays 80%
Secondary EOB:
---------------------
Total Bill $21,418.52
Provider Discount $12,487.84
Non-covered - $3202.07 ($150 for private room & $3,052.07 for primary discount)
Deductible - $156.95
Coinsurance - $557.17
Other Plan - $5014.50
Benefits Paid - $0
Your secondary EOB doesn_t look correct, because if you figure the allowed amount (Total Billed - Provider Discount) that only totals $8,930.69 (which would explain the $0 payment because the primary insurance paid more then the secondary contracted rate). Usually however insurance carriers in the same area will be close on the contracted rates.
If the EOB is correct I could read a few different ways:
1. You owe $557.17 because this is the co-insurance after secondary processed. (This however does't add up because if the primary paid everything but $1,933.97 and the secondary's allowed ammount is $8,930.69 <lower then the primary> the most you should be billed for is the $150 co-payment).
2. You owe $0 because the primary insurance paid more then the secondary contracted rate with the provider. The provider would then write off the balance based on the contract with the second carrier.
3. You owe $1,933.97 because the secondary insurance is a maintenance of benefits plan. A maintenance of benefits plan will only maintain the benefits on the policy (I.E If the primary insurance paid 70% and the secondary allowed 80% the secondary would only pay up to the 80% level. On the other hand if the primary paid 80% and the secondary allowed 60% nothing would be paid). Many people are confused with a MOB plan because when it is primary you would never notice the difference, but when it becomes secondary it could potentially pay nothing.
In the end your insurance carrier will be better to answer as they are trained to quote your benefits and claims. When you get your answer please post the outcome since I would like to know if I was close.
Answer
Since we have no idea what is and is not covered on either policy or what charges were or were not covered (or for that matter what the charges are), it's not possible for us to determine whether the EOB's are correct or not.