Carefirst out of network benefits suck / allowable charges racket

[Anonymous]

Anonymous wrote:

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.

I don't know the exact rules but we have an HMO plan with Kaiser and after they admitted they had nobody qualified to treat my child's condition, they paid the full amount for the out of network providers (aside from our typical in-network copay).

This treatment included a week-long intensive program that cost $3,000. It was time-limited and has been proven to have life-changing effects. Yet most people struggle to get even 50% reimbursement through their out of network benefits. We were extremely lucky to get it all covered, but mainly because it's an uncommon condition and because Kaiser's network is so limited.

[Anonymous]

thanks to all for the comments, suggestions and criticisms. I'm looking into the two telehealth options mentioned and will also likely switch to an HSA next year. The in-network options are limited and not so good near me. I'll probably also go back to my provider with this info and try and negotiate a better rate. Didn't have luck earlier in the year because I didn't realize how little would be paid out. Providers should say to their patients, call your insurer with these codes and find out what they will pay.