Insurance Gurus Come In Please

doozer1345 · November 2015

Here's my dilemma. So I got a bill from my OB saying he wants all appts, US, his fee for birth etc paid for in full by week 16. We have met our deductible (which it says on the bill) for this year and owe $0. Since everything needs to be paid in full by 16 weeks we shouldn't have to pay anything bc by 16 weeks we will still have met our deductible which is what it implies on the bill. Well, I checked with the doc office and the lady said yes it's all paid until January. We will have to pay the difference starting in January. What?! If you require everything to be paid in full by week 16 then since we will be responsible for $0 we shouldn't have to pay anything right? I mean what if I didn't have insurance and had to pay everything by week 16? How is it fair to essentially punish me bc I have insurance?? Does any of this make sense?

TXmamatobe · November 2015

Most plans reset by calendar year or some other date in year long increments. For instance, I've met my deductible for 2015 but will deliver in 2016, a new insurance/calendar year. I would still owe the fees for delivery, etc. but my appointments, ultrasounds (and anything that happens directly in 2015) are covered at 100%.

Eta: you have a new deductible to meet most likely for 2016, which means you will owe.

missnc77 · November 2015

Hm - I'd call your insurance company and tell them what your doctor is doing and see what communications they've had. Since your deductible starts over in the new year, your insurance company may have only paid through the end of the year only. Worst case scenario is that you pay out of pocket in the new year then file claims on your own for reimbursement, but that's a huge pain in the rear. It seems like your doctor and insurance company need to work together, and instead the burden is being pushed on you.

doozer1345 · November 2015

@TXmamatobe Oh I know it starts over but the bill they sent said everything has to be paid in full by week 16. For me, week 16 will still be 2015 and I'll still have met my deductible.

TXmamatobe · November 2015

doozer1345 said:
@TXmamatobe Oh I know it starts over but the bill they sent said everything has to be paid in full by week 16. For me, week 16 will still be 2015 and I'll still have met my deductible.

You are paying in advance for services that will be performed in 2016. Most offices do this to ensure payment - some won't continue to see you if you can't work out a payment plan in advance. Not saying that will happen with your doctor but some take it very seriously.

doozer1345 · November 2015

TXmamatobe right... But shouldn't it be the insurance is paying in advance bc I've met my deductible?

TXmamatobe · November 2015

In most cases no because you haven't met your deductible for 2016. you should call your insurance company to discuss.

megmarissa · November 2015

My doctor does the same thing... it is actually illegal for insurance companies to pay in advance for services that haven't happened. Like others have said, they do it to make sure they receive payment. They should estimate the services that would occur up to Jan 1 and then adjust your bill accordingly. Does that make sense.

dsmith211 · November 2015

My midwife office is doing the same thing and it's so stressful. My payments actually span 2015 and 2016 so it's going to end up costing more bc of the way they're doing it, but they won't see me if I don't agree to their payment terms.

My deductible starts over in January so everything I've paid before then won't count towards my deductible for 2016. I'm going to end up paying at least $450 more unless I can work something out with them.

missnc77 · November 2015

@TXmamatobe - Echoing her statements. Basically what happened is probably this -

Your doctor told you they want full payment by 16 weeks.
They billed your insurance company
Your insurance company paid for all services expected in 2015 since 2016 starts a new insurance year
You now have a balance starting January 2016 for services in 2016

Your doctor's office will either need to file for insurance payment at the start of 2016 for the remaining balance, or you will need to. Just because your doctor said you will be paid in full by 16 weeks doesn't mean your insurance company will pay for things that are expected to occur in 2016 until that year starts and you meet your deductible.

Either way, call your insurance company to get the full scoop.

doozer1345 · November 2015

I think the bill just made me think of Christmas come early haha! Too good to be true for sure. Thanks ladies!

proudparent2b · November 2015

Interesting. My doctor's office charges a lump sum for all standrad appointments/delivery, etc after the child is born, so between that and hospital bills, I know I'll hit deductible pretty quickly and a lot will be covered by my insurance.

In your situation, you might want to check first with your doctor's business office to identify how the bill will come across to your insurance. If everything is billed at 2015, you will likely not have an issue. They can also help you with any insurance issues, as this is obviously a standard process for them and they should be aware of how your insurance provider will respond.

doozer1345 · November 2015

@proudparent2b The bill they sent said everything would be put through in 2015 bc my 16th week will be in 2015 but when I talked to them about it they said no I will need to pay the difference after the first of the year and they weren't familiar with my insurances policy since it recently changed. That's why I've been so confused.

Everycol0r · November 2015

If your plan is calendar year, which it sounds like, your deductible will start over regardless. The doctor has no control over this. You might as well pretend that you've met zero percent of your deductible and pay the doctor. They will officially file the claim to the insurance company at the time of birth, as will the hospital. They cannot file a claim to the insurance company for ANY service that hasn't been rendered to you. So the week 16 (or whatever week they choose) they are essentially pretending you'll be giving birth in 2015. You won't be, and you'll have to pay the doctors fees in 2016.

If, after all the claims have been processed, your doctor has been over paid you'll get a refund from them. It does not matter one bit that you've already met your deductible for 2015. Your claims will be filed in 2016.

BostonBaby1 · November 2015

Let me break it down for you another way:

Unless your conception and delivery take place within the same calendar year that your insurance runs over, you're going to have to pay two deductibles and two maximum out-of-pocket amounts. For example, my insurance starts May 1. If I conceived during the month of May or June, I would give birth in the same calendar year and then I would be covered from one deductible. Otherwise, it is always going to be another deductible. Check with your insurance company and see what they have paid the doctor. If the doctor is trying to doublebill you, that's a different situation. This should be something that you can figure out very easily with your insurance company through the toll-free number on the back of your card.

While you are on the phone with them, ask them at what point do you start getting charged the deductible for your baby? Is it during the initial hospital visit when the baby is born or is it at his/her first well child visit?

And I definitely wouldn't look at it is if you're being screwed over for having insurance. It would really be much more difficult if you didn't have insurance. Unless you are in ultra high net worth individual ( in which case you would still have insurance.)

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