Insurance

[Anonymous]

My child needs to have a Neuropsych testing done. The cost is around $3800. The clinic contacted my insurance and gave me a breakdown of how much would be covered by insurance and how much would be my out of pocket expense ($1000). The new insurance cycle had just started in June and my child’s deductible ($3200) has not yet been met. I would have to pay only 30% after the deductible has been met. Is the $1000 cost after the deductible has been met or can I go for the testing right now and pay only $1000? I did call customer service but was confused by the rep’s accent and didn’t understand (English is not my first language also).

[Anonymous]

Everyone's insurance is different, so you really should call the customer service department back and see if you can talk to someone who can explain it to you more clearly. But with my insurance, the way the deductible works is that you have to pay up front first, and then the insurance company reimburses you for whatever cost they will cover afterwards. (In this case, seems like you'd have to pay the entire $3800; since the $3200 is your deductible, the insurance company would then pay you 30% of the remaining $600).

[Anonymous]

Was $3800 the cash rate? Or the negotiated “allowed” rate?

Usually it’s the full deductible and then coinsurance. But that is based on the allowed rate that the insurance company and the provider agree on.

So generally speaking it looks like this:

Billed rate $5000
Allowed rate $3800
Deductible $1000
Balance after deductible: $2800
Coinsurance $840
Total out of pocket $1840

If $3800 is the billed rate, your total could be lower.

[Anonymous]

Anonymous wrote:Was $3800 the cash rate? Or the negotiated “allowed” rate?

Usually it’s the full deductible and then coinsurance. But that is based on the allowed rate that the insurance company and the provider agree on.

So generally speaking it looks like this:

Billed rate $5000
Allowed rate $3800
Deductible $1000
Balance after deductible: $2800
Coinsurance $840
Total out of pocket $1840

If $3800 is the billed rate, your total could be lower.

Sorry my numbers are wrong:

Rate $3800
Deductible $3200
Balance after deductible $600
Coinsurance $180
Total OOP $3380

So neither of those match the numbers you were given.

I would call the provider back and have them walk you through the estimate.

[Anonymous]

The person who contacted your insurance from the neuropsych clinic may have the answer. When we have done a preauthorization, they usually know exactly how much of my deductible is left.

One thing to know is if this is out of network, the actual cost doesn’t count toward the deductible, only the allowed amount. So if testing is billed at $200/hour and your insurance only allows $100/hour, you pay $200 but only $100 counts towards your $3200.