My $1140 Medical Mistake (And How I Could Have Avoided It With One Simple Question)


budget, debt, medical bills, Uncategorized / Monday, May 16th, 2016

I try to be responsible about my finances. I track expenses, balance my checkbook, stick to a budget, and am not extravagant with my spending. I compare costs, coupon, research purchases online and by asking friends’ recommendations before I outlay any money. My husband and I talk about money a lot and won’t spend more than $50 without getting approval from the other in advance(unless its groceries or a standing bill). But I still just made a $1140 mistake by not dotting my I’s and crossing my T’s when it comes to medical expenses.

08_CROH_Healthcare Savvy_June14.indd
from Consumer Reports

You see, we pay a hefty sum for health insurance. Yes, my employer subsidizes it somewhat but we still pay around $476 a month for health insurance (I know that others pay much more or much less for insurance, but that’s just what we pay). Granted, we have good insurance with Blue Cross Blue Shield and rarely have complaints with them. In fact, all of my maternity care is paid for and we had to only pay a $30 copay once for my first maternity visit and had to pay about the same for co-insurance for blood work. We also pay extra for dental and vision insurance to have additional coverage since we both wear glasses and contacts, and I have bad eyes and teeth which has meant that I have had to have additional treatments that are not covered by the usual preventative care checkups covered by our health insurance. We can tack these onto our insurance plan for $62 a month for dental and $20 a month for vision so we figure it is worth it to be covered in case I break a tooth or something. A year ago my husband and I took a long look at these insurance costs and thought about changing our plans to cheaper ones, but we decided that it was worth it to keep the coverage because my hubby is often ill or injured (super bad luck + migraines) and we were planning to have a baby.

So what kind of hella expensive mistake did I make even though I am so careful with our hard earned money and know our insurance in’s and out’s? I did not double check when I asked a dental office if they participated with my dental insurance provider. Yup. Simple as that.

Several months ago my husband was having a lot of jaw pain and his dentist referred him to a TMJ specialist dentist since he just does general dentistry. Knowing I needed to check that the specialist took our insurance, I called to make an appointment and asked them if they took Aetna Dental insurance. They said that they just did not file the paperwork. No biggie, I figured. They are a tiny office and I have had other doctors in the past that asked me to submit the forms to the insurance provider that still worked with my insurance. The dental office did not say that they did not participate with my insurance provider and I took their answer to be an affirmative statement. I contacted my insurance company and asked them about their coverage for specialists and confirmed that I would be able to submit paperwork to get reimbursed for the consultation visit which would be covered as a preventative care visit. Perfect. I did not double check the provider name with my insurance company’s website or by telephone because I thought they participated with the insurance.

My husband went in to see the TMJ specialist, who was very nice and knowledgeable by the way, and it was determined that he would need a dental appliance to the tune of $2000 but they would give us a $100 discount if we paid it all upfront. That amount we had to pay totally upfront and then send the bill to our insurance provider, as per the doctor’s office billing procedures. The very nice office staff told me that many insurance companies will not cover TMJ treatment but may cover part of it, depending on the insurance. I understand that caveat and before we decided to pay for the treatment I called the insurance company to find out what they would cover. Aetna said that they would cover 60% of the TMJ treatment if it was caused by coverable reasons like grinding, which this circumstance was. Otherwise they would not normally cover TMJ treatment. I even called my medical insurance to see if they covered TMJ treatment (which was a no by the way because apparently TMJ is a treatment that dental and health insurance both think the other should be responsible to cover so it ends up being an insurance gap, lovely).

So we had our answer. We just needed to pay the $1900 upfront and then would get reimbursed 60% afterwards, which would mean that we would have to pay $760 and insurance would reimburse $1140. Still, this is an expensive treatment but my husband was in a lot of pain so we decided to do it. We took out a $1000 loan from our credit union and wiped out our savings to pay the upfront cost. That made us uncomfortable because we have a baby on the way and need to save to cover our expenses while I am on maternity leave, but we were comforted to know that we would be getting reimbursed 60% of it and that we also had tax refund money coming our way. We also figured we were being financially savvy by paying upfront and getting that $100 discount since we figured we would have the loan paid back in a month or two and spend way less than that in interest.

I submitted the forms to get reimbursed for the initial dental consultation and check up visit and received a check reimbursing us, no problem. And we went ahead and got the dental appliance done then I submitted those forms to the insurance company.

Then the dance began. No word from the insurance company for a month so I called to find out when we could expect this check. They said that they had not received the claim. Uh what? I had filled out the forms and sent them to the doctor’s office who had assured me that they had submitted them the same day. Well, maybe there was a problem with the mail so this time the doctor’s office sent the forms via fax. Ok, try again.

Then I got a letter a few weeks later saying that the claim was denied. Uh, what? Calls to the insurance company and the doctor’s office revealed that the doctor had used the generic medical code rather than the specific one that the insurance company had said they would approve. I had already identified the codes needed to use when submitting the paperwork to the insurance company but I guess they made a mistake out of habit. No problem, just submit a corrected claim form with the specific and correct medical code.

Then I got another letter from the insurance company saying that they could not process the claim and needed more information from the doctor’s office. Ok sure. I’ll keep playing. I called the insurance, got them in touch with the doctor’s office, and followed up a few days later to make sure the doctor’s office had sent it.

Boy was I surprised when I made the follow up call to the insurance to find that they had processed my claim (finally! yay!) and were sending me a check for about $340. Wait, what?

My insurance informed me that the doctor was out of network. Hold on. Out of network? That couldn’t be so. The doctor had said that they took my insurance but just that I had to file the claim forms. Semantics apparently and Aetna has never worked with them. I called the doctor’s office again and when I again they said that they don’t file the paperwork. I asked again if they worked with my insurance and they said they don’t work with any insurance providers at all. So, its all in how you ask. Apparently asking “Do you take Aetna?” elicits a different response than asking specifically about whether they were a preferred provider in my insurance company’s network. I assumed that the office manager was giving me an affirmative answer and she assumed that she was giving me a negative. And you know what happens when you assume? You make an ass-out-of-you-and-me. And after countless back and forth with the insurance no one had mentioned that they were out of network and I had not noticed it on the previous claim that they had paid (which I will now go back and double check). This is what happens when you think you know and don’t double check.

Going back to the insurance, Aetna told me that they will only 60% of what they thought was an allowable charge since the doctor was out of network and had no pay agreements with them. Okay, what does Aetna consider an allowable charge? Answer, about $580, or, about one quarter of what we actually paid for the dental procedure.

Holy crap. We got screwed.

So after venting on the phone for a bit and giving both the insurance companies and the doctor’s office a (somewhat polite) piece of my mind about this lack of clarity, here’s the lessons learned and why it hurts so much:

  1. I did not ask specific enough questions and assumed that the unclear answer we got was the one we wanted. If the doctor’s office had said straight away “No, we don’t take any insurance”, I would have wished them a good day and contacted my insurance company for another TMJ specialist that was in network.
  2. When told that the insurance would pay 60%, I did not ask “of what?”. I unfortunately assumed that the 60% they would pay would be for the whole amount. Likely if the doctor was in network it would have been 60% of the whole amount paid, but I did not ask any follow up questions because I thought that I had gotten my answer and thought that the doc was in network.
  3. We didn’t shop around. I know that different doctors charge wildly different amounts for the same procedure, but it seems so opaque and difficult to truly compare the costs of procedures with the different doctors. It may be difficult, but I could have at least called different providers to find out what they charge for the same work and if I got really different numbers I could have bartered with the doctor’s office. It was at least worth a try and would have made me better informed.
  4. We overleveraged ourselves. We thought we had the money figured out but nothing goes according to plan. We got our tax refund and used it to pay the balance on my husband’s tuition that we owed. Then we put the rest in savings. We wanted to be prudent and not pay off the $1000 loan just in case something came up with the insurance company and we didn’t want to have no money in savings. Makes sense. But then we needed to pay for my husband’s summer class tuition and had not yet saved enough money outside of savings since we had a lot of additional expenses come up that we used my side hustle money to pay for (read: over $1000 in plane tickets but that’s another story). So we threw our savings at the tuition payment and I felt comforted that at least we didn’t take out another loan, though nervous to see the drained savings account. Now instead of having a check for $1140 we have $340 to put in savings and more stress about paying our bills while I am recovering from childbirth in a few months. We should have been more conservative and saved more instead of banking on the insurance check.

Have you made these mistakes before? If not, please learn from mine and avoid them.

 

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