Inhumana

April 26, 2015 1:28 PM

What does it mean when medical insurance applies a negative exclusion amount to a charge?

(Charge in question: http://i.imgur.com/HZ7y8GZ.png)

Over a year after these services were rendered, our health insurance manifested this item and suddenly we owe extra beyond what we long ago paid out of pocket, which was already a lot.

I'm having trouble understanding what we're looking at because I've never seen a negative exclusion before. It seems like the insurer is negotiating the price up instead of down, like they usually do.

We're preparing for a round of confusing conversations, waiting on hold, etc., so anything we can learn in advance is really appreciated. Also, since we haven't found much by googling, we're interested in learning the correct terms for what's happening to us.

posted by michaelh to Work & Money (8 answers total)

Is the patient in question covered by two policies? For example, one policy from your place of employment and another from your spouse's place of employment?

I worked in insurance for over 5 years. I have not heard of a negative exclusion. But, I have never seen the term co-insurance used to mean you personally owe this much money. It typically means some other insurance company owes it or paid it.

So my first thought is that the company believes you are covered under another policy and that other policy owes them money.
posted by Michele in California at 1:36 PM on April 26, 2015

One policy, just to clarify, but if there are any magic words to uncover that they think there are two policies, I am all for hearing them.
posted by michaelh at 1:38 PM on April 26, 2015

I am spitballing here, but it looks like this was for some hospital stay when presumably other services were rendered? I recently gave birth in a hospital and the EOB statements from my stay had some weird lines like that, but when you added up the different items (charge, exclusion, deductible and co-insurance amounts in play) the math worked out perfectly. Strange accounting but I wasn't charged beyond what I expected.
posted by stowaway at 1:50 PM on April 26, 2015

Ack, didn't make clear - when I compared bills to EOBs, it was clear that the hospital had a way of bundling charges/services that then got separated in discrete charges for insurance purposes.
posted by stowaway at 1:57 PM on April 26, 2015

One policy, just to clarify, but if there are any magic words to uncover that they think there are two policies, I am all for hearing them.

I can't tell if they are saying money is owed or not. That might be more clear to you since, presumably, you see their EOBs regularly (though EOBs are often terribly done and confusing as hell, even if you are familiar). So I would personally call and ask what this line means. Does it mean monies are owed? Does it mean YOU owe them money?

You can tell them "A friend who used to work in insurance suggested that co-insurance usually means there are two policies. I'm confused. Do you think there is another policy? Am I being billed?"

EOBs are often really not well done. They often suck as a means of communicating with the insured what exactly is going on. So I would plead confusion and beg for clarification. I would be very polite about it but also express my distress along the lines of "Oh, god, this is freaking me out because it looks like a bill. Is this a bill? Am I being billed for tons more money? I thought this was taken care of. I thought co-insurance meant there is another policy. I only have one policy!"

The customer service people deal with cranky jerks all day long. Be the one person who is not being a jerk to them and they will probably be happy to find out all they can for you.
posted by Michele in California at 2:17 PM on April 26, 2015

They may have realized after the fact that they allowed the wrong contracted amount the first time they processed the claim. Maybe the hospital initially charged below the allowed amount? Just theorizing. Hopefully the insurance company can explain. Do you know that the hospital will hold you responsible for the revised amount? Start praying that they won't. Definitely call them to complain if they try. The squeaky wheel, etc.

But, I have never seen the term co-insurance used to mean you personally owe this much money. It typically means some other insurance company owes it or paid it. = personal co-insurance is a real thing, more so than it used to be as plans increase out of pocket costs to keep premiums low.
posted by ThePinkSuperhero at 2:19 PM on April 26, 2015

In my experience as a patient, "co-insurance" has always been a way of saying that I have to pay out of pocket, except that it is calculated as percentage of the fee instead of a flat rate (as in a co-pay). For example, a policy might say "In-network: $10 co-pay; Out-of-network: 20% co-insurance". I believe ThePinkSuperhero is correct that this turn of phrase grows out of the idea that you are personally "co-insuring" yourself.

I noticed that this is for a private hospital room -- is it possible that the private stay specifically is not something that your policy covers? It feels like this update might have been the result of some internal auditing that noticed after the fact that they had paid for something they didn't intend to.

Good luck with your phone calls. They are the worst.
posted by telegraph at 3:08 PM on April 26, 2015

Thanks, everyone. I finally was able to get hold of people who would walk me through the entire history of the bill once I used the right words. It turned out that the negative exclusion was basically the insurance and hospital liaisons doing some lazy shorthand to make the numbers work out correctly instead of updating all the individual charges (like I think they should have.) It showed up so late because the insurer had been arguing with the hospital that they were secondary insurance when they weren't. So, we have to pay our 20% co-insurance share, and we're still not happy about that, but at least we understand what happened and reluctantly agree it makes sense.
posted by michaelh at 10:31 PM on July 19, 2015