Reconstruction costs and insurance

julianna51

I know I need to call my insurance company, and I will, but I am so confused reading my statements relating to my office visits for fills of my TEs.   It appears that my insurance is not paying any of that???   I don't understand.    My statement shows the original amount billed by PS, the discount negotiated for insurance, and then I am responsible for the balance.   This is not making sense to me.   Anyone have any thoughts?

peggy_j

I'm confused. Is the insurance not paying for something or just doing a partial reimbursement? If it's a partial reimbursement, then I wonder if you went to a doc that's not "in network" and/or "contracted" with your insurance company. Some docs will take the insurance but not be contracted with them. That means, for example, if your insurance sets a contract reimbursement rate of $X, a contracted doc will take the $X and considered it paid in full, even if the rate rack is more. A non-contracted doc will take the $X from the insurance and bill you for the rest.

Of  course, there's always the chance they just screwed up processing your claim. That happened to me. For some reason, they decided to pay $0 on one of my MO's visit. No explanation. I had to call twice to get it corrected.

You might want to call your state's insurance board. In CA, insurance companies have to cover all these breast issues.  For example, I chose a lumpectomy but my BS said if I chose to have a MX in the future for any reason (or even no reason at all) my insurance would have to cover it. This may vary state by state. 

Fearless_One

Some plans require you to pay the balance between "reasonable and customary".  In other words, the difference between what the doctor bills and the insurance pays.   It is common with PPO"s, less common with HMO's.    I would review your policy and then contact your insurance company.  

It is possible there was an error in processing, but without knowing your policy, it's hard to say.