Why did my insurance only pay part of the bill?
There could be many reasons.
Some reasons are:
- your deductible or out of pocket liability was not yet et
- the denied charges are not covered benefits on your plan
- the provider of service is not part of your network
- the denied charges are deemed inclusive to other services
- the insurance considers the denied charges not medically necessary, investigational or cosmetic
- the insurance policy dates back to pre-ACA ("Obamacare") and may have been denied for pre existing conditions.
- the denied charges may not have been pre-authorized or pre-approved
- the denied charges may exceed the number or frequency of services allowed under your policy
Your Explanation of Benefit should list a specific reason for the denial. Your best course of action would be to call Customer Service and have them explain the bill to you in details. It is not only your right as a patient and subscriber, but may uncover processing errors or payment mistakes. At least you will receive the assurance that what you owe is legitimate.
Payment for part of the charges could have been denied for a variety of reasons. Reviewing your Explanation of Benefits (EOB) you will usually find codes next to the amount listed in various columns. These codes will tell you why the insurance company has not paid.
Also, if your doctor or facility participates with your insurance then there is usually a contractual write-off amount. This is an amount that the doctor or facility must write-off as part of their contract agreement with the insurance company. This amount is not your responsibility and you should not pay it. If this amount shows up on your bill, a call to the billing office reminding them that this is their write off amount usually clears things up. You should only pay for the amount deemed patient responsibility.
In both cases, if you are unsure how to read the EOB or think the insurance company has made a mistake, a call or on-line chat with the insurance company is in order. Good luck.
I would reach out to your insurance company to find out why they did not pay the bill in full. There are many reasons why they did not.
Insurance companies do not normally pay 100% because of copay, deductibles, co-insurance etc. but your insurance representative should be able to explain it to you. If it’s something more than the copay, deductible or co-insurance you will want to appeal.
Best of luck to you!
Cheryl Welch, MBA
Hudson Valley Medical Bill Advocates
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