Help me to understand insurance and birth medical bills. What am I missing?

posted 2 months ago in Wellness
Post # 2
6389 posts
Bee Keeper

I could be wrong but there’s a difference between paying for insurance and covering what insurance can’t cover.

So you pay $1000/month to have insurance just like you would for car insurance, house insurance, etc.

Your insurance covered a substantial amount of your birth, OB appts and NICU costs.  What you’re being asked to pay is what wasn’t covered under insurance.  It seems reasonable to me.

Post # 3
9244 posts
Buzzing Beekeeper
  • Wedding: August 2012

Unfortunately that sounds about right. The $1000 is only the premium, it doesn’t actually go towards your costs.

Did you pay for any of the previous appointments?

What is your out of pocket max?

Normally you have to pay your individual deductible for each person, even on a family plan. So yes, your baby has to meet his deductible too. It should be listed somewhere in your insurance paperwork.

You definitely should have expected to pay your deductible at the minimum.

Post # 4
215 posts
Helper bee
  • Wedding: October 2017

I work with benefits, but it’s impossible to say without seeing your plan summary. Your $1,000 per month is a premium to have the insurance, so that doesn’t count towards anything. If you have a $3500 deductible, it means you’re responsible for paying all costs up to that $3500, but generally you will still owe a percentage of the bill after you’ve met the deductible, but before you’ve met your out of pocket maximum.

Post # 5
2092 posts
Buzzing bee
  • Wedding: August 2014

mrscb2bee :  It is likely a portion of that is your deductible. If you only had a few OB appointments prior to birth, you would not have met your $3,500 deductible. So, a portion of what you are being asked to cover is your deductible. The remainder is likely a co-pay or co-insurance. Most insurance policies will cover a portion of each covered aspect of billed costs, but the remainder is the responsibility of the patient. For a standard office visit, this can be anything from $20-100 but if you are talking hospital stays and NICU, it would be substantially higher. Given this, the amounts you are being billed are not unreasonable. That being said, if you don’t understand the bill – call them and get clarification. You can also call the hospital and see if they will negotiate the bill down for cash immediately. 

Post # 6
3514 posts
Sugar bee

mrscb2bee :  You can blame the ACA for that….health insurance is now incredibly expensive and coverage is horrible. What you were charged is actually not bad. I paid about $7000 for a csection, I left the hospital two days early, and had no NICU stay on my large company’s plan.


*bows out now before this thread catches fire*

Post # 7
1671 posts
Bumble bee

Hard for anyone to say whether there’s an error without knowing about your plan, but on its face that sounds pretty typical. Medical debt makes up a substantial portion of debt in this country. 

Post # 8
813 posts
Busy bee
  • Wedding: July 2019

whitums :  Actually the ACA lowered the growth in costs. You can blame profiteering healthcare companies and corrupt politicians for that. Prior to the ACA many plans wouldnt even cover childbirth/prenatal/maternity care

Post # 9
3514 posts
Sugar bee

mel2 :  I am thankful that things like pre-existing conditions are protected now, but sorry I disagree on the rest. I work in the healthcare industry, and it is a friggen shit show now. You could get excellent independent coverage 10 years ago for a fraction of what you get for sub-par coverage for these days. It’s bad…I’m not going to fight anyone on it though, honestly.

Post # 10
1451 posts
Bumble bee

That sounds right. You should google how health insurance works and read your specific health insurance plan’s criteria. You pay a premium per month and then in addition to that, you have a deductible you must meet per year and probably also coinsurance (don’t get me started on this bullshit). You should look at what your maximum out of pocket amount listed in your health care insurance info is….that is the real amount you will pay in addition to the monthly premium. 

ETA: health insurance in the US has and continues to be a shit show…it’s not just a recent development. The ACA did a good job of bringing these issues to the forefront politically. For most of my life I had catastrophic coverage, which is what it is. Unless you had employee benefits, you  likely were paying out of pocket for either good insurance or for doctor’s visits. For a long time maternity care was not covered for many people. The ACA had it’s flaws for sure (lack of cost control is #1..hence skyrocketing premiums) but it did at least attempt to do something. Had Congress done their damn jobs, maybe we wouldn’t be still dealing with this.

Post # 11
110 posts
Blushing bee
  • Wedding: November 2020 - North Carolina

whitums :  My fiance is in the health insurance industry. The only reason why independent converage costs went up is because the top dogs didn’t want to bring in less money for shareholders after they lost so much business through medicaid/medicare expansion and the healthcare marketplace. Also, a lot of people don’t realize that you DON’T have to buy you insurace from the marketplace to get the government subsidies. The marketplace is just a hub of different providers showing you what they can offer. You can actually get insurance much cheaper in some instances if you would’ve found a health insurace provider on your own.

Post # 12
7280 posts
Busy Beekeeper

mrscb2bee :  ignore the premiums because that doesn’t factor into the birth. Look at what is being applied to the deductible and what’s a copay or coinsurance. Also check that the birth and NICU stay didn’t cross plan years – that happened to a friend of mine and she ended up having to pay the deductible for the birth at the end of the first plan year, and then the deductible for the hospital stay in the second plan year even though in reality it was all one hospital admission. 

eta: if you think there may be errors asked for an itemized bill! Make sure you weren’t charged $80 for an asprin you never even got, etc. Assuming you hadn’t used any of your deductible prior to birth you’re being charged $1,375 in co-pays and co-insurance. This seems high to me, but I live in Massachusetts so a lot of plans I hear about in the rest of the US sound crazy to me. 

Post # 13
7280 posts
Busy Beekeeper

oh! And make sure the hospital isn’t balance billing if that’s against the laws of your state. 

Post # 14
4902 posts
Honey bee
  • Wedding: October 2017

mrscb2bee :  do you have eobs for the bills from your insurance company? They should have more details of what was covered, what went towards the deductible, and what was coinsurance etc.

We are doing this now, my husband had a heart attack and then my daughter had her tonsils out six days later. Hers was $9k, $4k of that was for an ear tube removal, they did it while she was under but she ended up with a hole in her ear drum that they patched, that was $4k. My husband’s heart attack is at $60k so far. We have great insurance so my cost won’t be helpful to you here.

There’s an additional complication though. There’s a billed rate ($9k from the surgery center was billed to my insurance). Then there’s the allowed rate. The allowed rate is the contracted amount that the insurance company has with the hospital. ($3k was allowed by my insurance instead of the $9k that they billed) The hospital can bill what they want, but based on their contract with the insurance company, the insurance company will only pay a certain amount. From THERE, the allowable amount, you get your deductibles and coinsurance.

Your charges sound about right based on your deductible, you need to meet your deductible before the insurance company will pay. You met your deductible with the birth, so the billed amount to you is a higher portion than the nicu because the insurance started to pay after the $3500 deductible.

I hope this makes sense. You should also have a yearly out of pocket maximum, when that’s met, insurance will pay 100% for the rest of the year. My husbands heart attack puts us at our yearly maximum out of pocket.

Post # 15
2222 posts
Buzzing bee
  • Wedding: October 2019 - Chateau Lake Louise

mrscb2bee :  I am a provider billing specialist for a large NFP health system, so here’s my take. 

Are these amounts that your insurance has advised you that you owe, or is this based on a bill you got from the hospital? Sometimes the Explanation of Benefits you get from your insurance reflects a higher amount than you actually end up owing the facility. There are additional write-offs and adjustments that can occur from the facility, so you should only concern yourself with those bills, not the EOB from your insurance to determine your final balance. 

I am a bit surpised to see a deductible that high paired with such a high premium. Clearly in this particular case, the ship has sailed, but how did you select your plan? Did you talk to an insurance broker? Did they advise you on weighing premiums vs out of pocket costs?

Being self-employed, can you and your Darling Husband create flexible spending accounts? If so, setting aside pre-tax dollars to pay for those out of pocket expenses can be a very good move when you have a high deductible plan. It might make more sense to move to a plan with lower premiums and higher OOP, but fund your FSA more aggressively to lower your overall tax burden. 

I would review other options in your marketplace. You should have options that are either high premium OR high deductible/OOP, not both. You can prioritize which makes more sense for you; a higher monthly cost up front, or higher patient portions on the back end. 

Unfortunately in this case, the relatively high deductible on your policy is at fault here. Some plans waive the deductible for OB care, but if that isn’t the case here, then it’s possible you didn’t meet it prior to hospitalization. Even after you meet your deductible, there’s usually coinsurance that can run up to 20% even in network. 

Personally, I think the only way to really address the overrun of costs – both to individuals and providers – is single payer. The motivation to increase the burden on the patient and pressure providers to reduce costs – often at the expense of quality – is squeezing everyone at both ends and damaging outcomes as well as the financial well-being of millions of people. Reducing variability and expanding coverage to everyone would help stablize costs and increase reimbursement while extracting the motive of profiteering from driving healthcare decision. 

Do feel free to call the hospital and ask for someone to discuss your bill with you if you have any questions. They should be able to help you understand how they arrived at those figures. 

I’m sorry you are in this situation. It’s crummy. Hope you and the baby are doing well, otherwise. 

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