Carefirst out of network benefits suck / allowable charges racket

[Anonymous]

balance billing / allowable charges... horrible concepts. buyer beware.

We have out of network benefits that kick in once we meet the deductible for out of network of $1,600 per individual. (we pay that, then the benefits kick in).

Example: Someone sees a provider weekly - for a year - that charges $190 per hour.

However, only $77.40 (40.7%) of that $190 is "allowed" by Carefirst. Meaning only $77.40 gets applied to the deductible amount. Good luck finding a therapist in the DMV for $77.40/hour.

So now, instead of needing to fork out $1,600 before getting benefits, I have to pay out $3,928 to the provider to fulfill my $1,600 deductible. (Scam one)

Now, by halfway through the year, I'm getting benefits. But wait, there's a $50 copay per visit (which I knew about but figured a greater percentage of the charges would be paid) (Scam two is only an issue once you realize you get so little back to start with)

So, for each $190 charged, they "allow" $77.40, then knock that down by $50 to give me a check for $27.40 per visit.

For a full year, I would pay $9,500 for 50 weekly visits (not saying we do this, but for illustration purposes). On the 21st visit I would start getting some benefits. By the end of the year, I would have 29 visits "covered" and receive a check for $794.60, about 8% of my total expenditures FOR THE YEAR.

To get this money I HAVE TO SUBMIT TONS of paperwork and SUPERBILLS,

I took some time to figure out how little payback there was for this. It's not fair to the average person at all.

[Anonymous]

It's not fair to the average person at all.

Welcome to America.

[Anonymous]

Anonymous wrote:balance billing / allowable charges... horrible concepts. buyer beware.

We have out of network benefits that kick in once we meet the deductible for out of network of $1,600 per individual. (we pay that, then the benefits kick in).

Example: Someone sees a provider weekly - for a year - that charges $190 per hour.

However, only $77.40 (40.7%) of that $190 is "allowed" by Carefirst. Meaning only $77.40 gets applied to the deductible amount. Good luck finding a therapist in the DMV for $77.40/hour.

So now, instead of needing to fork out $1,600 before getting benefits, I have to pay out $3,928 to the provider to fulfill my $1,600 deductible. (Scam one)

Now, by halfway through the year, I'm getting benefits. But wait, there's a $50 copay per visit (which I knew about but figured a greater percentage of the charges would be paid) (Scam two is only an issue once you realize you get so little back to start with)

So, for each $190 charged, they "allow" $77.40, then knock that down by $50 to give me a check for $27.40 per visit.

For a full year, I would pay $9,500 for 50 weekly visits (not saying we do this, but for illustration purposes). On the 21st visit I would start getting some benefits. By the end of the year, I would have 29 visits "covered" and receive a check for $794.60, about 8% of my total expenditures FOR THE YEAR.

To get this money I HAVE TO SUBMIT TONS of paperwork and SUPERBILLS,

I took some time to figure out how little payback there was for this. It's not fair to the average person at all.

Ask them to find you someone in network. If it's for something they say they cover and they can't find anyone in network, appeal to get more covered. If you're in MD complain to the state insurance commissioner

[Anonymous]

If it's for something they say they cover and they can't find anyone in network, appeal to get more covered.

This can be done. But it takes a lot of work. You will have to talk and write to many people to make this happen.

[Anonymous]

That seems like a really low allowed amount …

[Anonymous]

Anonymous wrote:

Anonymous wrote:balance billing / allowable charges... horrible concepts. buyer beware.

We have out of network benefits that kick in once we meet the deductible for out of network of $1,600 per individual. (we pay that, then the benefits kick in).

Example: Someone sees a provider weekly - for a year - that charges $190 per hour.

However, only $77.40 (40.7%) of that $190 is "allowed" by Carefirst. Meaning only $77.40 gets applied to the deductible amount. Good luck finding a therapist in the DMV for $77.40/hour.

So now, instead of needing to fork out $1,600 before getting benefits, I have to pay out $3,928 to the provider to fulfill my $1,600 deductible. (Scam one)

Now, by halfway through the year, I'm getting benefits. But wait, there's a $50 copay per visit (which I knew about but figured a greater percentage of the charges would be paid) (Scam two is only an issue once you realize you get so little back to start with)

So, for each $190 charged, they "allow" $77.40, then knock that down by $50 to give me a check for $27.40 per visit.

For a full year, I would pay $9,500 for 50 weekly visits (not saying we do this, but for illustration purposes). On the 21st visit I would start getting some benefits. By the end of the year, I would have 29 visits "covered" and receive a check for $794.60, about 8% of my total expenditures FOR THE YEAR.

To get this money I HAVE TO SUBMIT TONS of paperwork and SUPERBILLS,

I took some time to figure out how little payback there was for this. It's not fair to the average person at all.

Ask them to find you someone in network. If it's for something they say they cover and they can't find anyone in network, appeal to get more covered. If you're in MD complain to the state insurance commissioner

Even if you do this they still might not cover the entire amount right? the fundamental issue is that their allowed amounts are far too low, both for in network and out of network therapy.

[Anonymous]

Look at the Propublica series on how to challenge insurance companies. Excellent roadmap.

[Anonymous]

Anonymous wrote:

Anonymous wrote:balance billing / allowable charges... horrible concepts. buyer beware.

We have out of network benefits that kick in once we meet the deductible for out of network of $1,600 per individual. (we pay that, then the benefits kick in).

Example: Someone sees a provider weekly - for a year - that charges $190 per hour.

However, only $77.40 (40.7%) of that $190 is "allowed" by Carefirst. Meaning only $77.40 gets applied to the deductible amount. Good luck finding a therapist in the DMV for $77.40/hour.

So now, instead of needing to fork out $1,600 before getting benefits, I have to pay out $3,928 to the provider to fulfill my $1,600 deductible. (Scam one)

Now, by halfway through the year, I'm getting benefits. But wait, there's a $50 copay per visit (which I knew about but figured a greater percentage of the charges would be paid) (Scam two is only an issue once you realize you get so little back to start with)

So, for each $190 charged, they "allow" $77.40, then knock that down by $50 to give me a check for $27.40 per visit.

For a full year, I would pay $9,500 for 50 weekly visits (not saying we do this, but for illustration purposes). On the 21st visit I would start getting some benefits. By the end of the year, I would have 29 visits "covered" and receive a check for $794.60, about 8% of my total expenditures FOR THE YEAR.

To get this money I HAVE TO SUBMIT TONS of paperwork and SUPERBILLS,

I took some time to figure out how little payback there was for this. It's not fair to the average person at all.

Ask them to find you someone in network. If it's for something they say they cover and they can't find anyone in network, appeal to get more covered. If you're in MD complain to the state insurance commissioner

oh like filing a letter with the insurance commissioner in MD is going to do anything.

[Anonymous]

Insurance companies don't want to pay out. how do you not know this? See the in-network doctor. That is why they are doing this - they want to funnel you to the less expensiv in-network-doctors. You don't like that? well fine, then you are obligated to be full pay. Or send endless certified letters to the insurance company and commisioner. Most of us have lives so aren' going to do this.

[Anonymous]

Anonymous wrote:

It's not fair to the average person at all.

Welcome to America.

+1 you can own a gun, and shoot yourself by accident, then pay up the nose to get medical care. It's grand. Pardon pun.

[Anonymous]

Anonymous wrote:

Anonymous wrote:balance billing / allowable charges... horrible concepts. buyer beware.

We have out of network benefits that kick in once we meet the deductible for out of network of $1,600 per individual. (we pay that, then the benefits kick in).

Example: Someone sees a provider weekly - for a year - that charges $190 per hour.

However, only $77.40 (40.7%) of that $190 is "allowed" by Carefirst. Meaning only $77.40 gets applied to the deductible amount. Good luck finding a therapist in the DMV for $77.40/hour.

So now, instead of needing to fork out $1,600 before getting benefits, I have to pay out $3,928 to the provider to fulfill my $1,600 deductible. (Scam one)

Now, by halfway through the year, I'm getting benefits. But wait, there's a $50 copay per visit (which I knew about but figured a greater percentage of the charges would be paid) (Scam two is only an issue once you realize you get so little back to start with)

So, for each $190 charged, they "allow" $77.40, then knock that down by $50 to give me a check for $27.40 per visit.

For a full year, I would pay $9,500 for 50 weekly visits (not saying we do this, but for illustration purposes). On the 21st visit I would start getting some benefits. By the end of the year, I would have 29 visits "covered" and receive a check for $794.60, about 8% of my total expenditures FOR THE YEAR.

To get this money I HAVE TO SUBMIT TONS of paperwork and SUPERBILLS,

I took some time to figure out how little payback there was for this. It's not fair to the average person at all.

Ask them to find you someone in network. If it's for something they say they cover and they can't find anyone in network, appeal to get more covered. If you're in MD complain to the state insurance commissioner

Yes, this. I work for a federal insurance regulator. Keep complaining until you get assigned a case manager.

[Anonymous]

1) This is how a PPO works. If you don't want to be paying out of pocket like this, you need to find an in-network provider. If you have trouble doing that, call the insurance company and ask for help doing so.

2) Most of us can't afford weekly therapy. If you are able to swing it at all with copays and deductibles etc, consider yourself very fortunate.

3) Of course you have to submit paperwork. That is also one of the benefits of using in-network providers; they handle billing.

[Anonymous]

If you’re a Fed and this is psychotherapy or psychiatry, switch to GEHA High. MUCH higher usual & customary.

[Anonymous]

It varies by the plan your employer has selected. I have Carefirst and my allowed amount for a $200 therapy appt is $150. For many years, we had a different Carefirst plan that had super low allowed amounts, so I feel your pain.

[Anonymous]

Is this for mental health therapy? This is t a care first thing. This is a problem across the board. We did this for years and it sss a big pain to submit all those bills to get back a bit of money. The FSA is helpful if you have one—at least it can be pretax money. Now we only go quarterly and I don’t even bother to submit.