I am so frustrated with this "carrier" I want to scream. I'm a former agent and I do billing for a living now, so I'm fairly comfortable with the industry, but I'm losing my mind here!
Every service I get is balance billed! Every one!
I'm well past my deductible and out of pocket and I just got another balance bill for $517, and Vitori paid…$37. My provider is still billing me for the remainder, and there's no way a carrier can use a claim adjustment reason code of 45 (negotiated rate) when they didn't contract with the provider (because they literally don't contract with ANY provider)! You don't just get to decide you'll pay whatever rate you want and the provider has to take it!
So now I'm sitting on over a grand of outstanding medical bills that I was assured would be okay!
We were told to contact their concierge with any specialist stuff we need. Okay, so I reached out for a cardiologist for an echo. Three weeks later I got a name…and they wanted two grand up front, even though my deductible is already satisfied! The concierge didn't know who to send me to after that!
Do I need to file bad faith or something? I hate asking that, but I'm at my wit's end here!
Posted by BartlebyX
1 Comment
For out if network, they have to pay “reasonable and customary,” (R&C) rates which they should have to provide the basis. It can be a paying to fight that rate. Also, there will be independent deductibles and maximums for in and out of network, make sure your looking at the numbers for out of network. Finally, after deductible, there is still balance billing until you meet the maximum or of pocket.
So…
Before deductible, you pay 100%. They will apply the r&c amount to both deductible and maximum.
Between deductible and maximum, they will pay your contract percentage of the r&c rate, and you will pay everything else on balance billing. They will take the part of r&c that they assigned to you and apply to maximum.
Once you reach maximum, they will pay the full r&c, but you are still responsible for whatever they didn’t pay.
Your day you have rained “out of pocket,” which I assume means maximum. So they paying the full r&c rate, which is almost always lower than the doctor billed rate. They can’t restrict the provider to their rate, and you agreed to pay the doctor the balance, so boom you are there.