Originally Posted by
MikeF16
After 20 years of AD I've been insulated against this and wanted some outside input. I switched to standard about 6 months ago, and have noticed that quite often somebody sees the doctor (or dentist on our private insurance), we get a bill up front then several months later I get a 2nd bill for some additional money because "insurance didn't pay what we thought they would". The amount is usually trivial but the principle of the matter drives me through the ceiling.
My questions:
1. Is this common?
2. Is this legal?
3. Is this just some doc/insurance scam to get more money out of me since they know I won't spend a lot of time over these "small" additional fees?
$30 isn't a big deal, but if every office manager charges every patient an extra $30 for every visit for the entire year it adds up. Shouldn't these guys know what insurance is going to pay and give me an accurate payment amount up front?
Mike;
The whole medical insurance business (civilian and military) is extremely complicated and just when you think you have it figured out, you find out that you really don't have a clue. One of the things that may be impacting your billing is the Tricare Deductible. It is $150 per individual and $300 per family. The deductible starts with the fiscal year; i.e 1 October.
Lets set up a scenario for your family. Your wife has a bad cold and goes to the family doctor. Doctor charges $100 but Tricare only allows $80. So, she has $80 towards her deductible and you have $80 towards the family deductible. You owe the doctor $80 (assuming they accept Tricare.) Your wife doesn't get any better so she goes back. Same bill of $100, $80 allowed. She has now met the individual deductible with $10 to spare. The family deductible is now at $160. Tricare will pay the doctor $8 and you owe $72 ($70 deductible plus 20% cost share on the $10). A few days later your child has the same cold and off they go to the doctor. Same drill; $100 billed/$80 allowed. You owe the doctor $80 since your child's $150 individual deductible has not been met and you only have $240 towards the family deductible. Finally you come home off a trip and you get the same cold. You go to the doctor and again it is the same $100 billed/$80 allowed. You have $80 towards your individual deductible but the family deductible now totals $320. Tricare will pay the doctor $16 and your share of the bill will be $64 ($60 of the family deductible and 20% of the $20 over the family deductible.) You have now met the deductible for the year so from now on any covered family member will only owe the 20% cost share on the allowed amount. Of course in the real world the allowed amount is never an even dollar amount and depending on the diagnosis code filed by the doctor's office, the allowed amount can be different between family members with the same symptoms.
Also follow ugleeual's advice, don't pay upfront. Wait until you get the Tricare Explanation Of Benefits and the doctor's bill before paying and, even then, you may want to wait for another billing cycle before you pay. Tricare has 30 days from the date the bill was FILED to complete the processing. Occasionally the billing office will be a little slow in filing and the doctor's offices tend to bill every 30 days and sometimes these things cross in the mail. This may also be impacting your bill. Just because they send you a bill, doesn't mean you really owe them anything. I am on a first name basis with the three billing clerks in my wife's allergy office. They will tell me the day it was filed and I can see if the Tricare payment is still pending and then figure out if I owe them anything. Most of the time I don't owe them anything even though the bill says I do. The next billing cycle will usually be correct.
Tricare South (I assume that is your region) has a great web site and you can track all of this online. The only thing the website doesn't show is the date the claim was filed. Good luck getting a handle on all of this.
The days of walking into the Flight Surgeons office and walking out with your medications and no bills are a thing of the past!!