High-deductible health insurance plan: Who do I pay?

June 3, 2016 10:46 AM

I have a high-deductible health insurance plan ($6,000) and this is the first year I will max it out due to a costly and ongoing medical issue. Bills are beginning to arrive from my GP, my specialist, and the hospital where I had bloodwork and surgery (outpatient but full anesthesia). There will be more as treatment continues. How do you figure out who to pay first?

This is all new to me and I'm not sure how this works, but I really want to stay on top of everything as much as I can.

Do you just pay $6000 of the bills and then push back on your insurance? Do you pay partial for each until you hit $6,000? I have a prescription coming up that the pharmacy wants $1400 (oh dear god) for -- do I pay that, knowing it will be longer for the previous bills from my doctors/surgery to get sorted out?

I have paid maybe $200 of my deductible already with standard prescriptions, which goes toward my deductible.

(The bills I have received so far are insurance adjusted, which I think means it's just the insurance-negotiated price for those services -- $1000 of bloodwork/diagnostic tests was adjusted to $641, for example. I am assuming I would pay the $641 and keep paying those adjusted amounts until I hit the $6K deductible but I have no idea.)

I do have an HSA and will be throwing this at the hole. I'm not currently working but am on my previous employer's health plan and paying premiums accordingly. I am in the US.

Thanks for your help!

posted by mochapickle to Health & Fitness (16 answers total)

Best answer: I have this type of plan, too, and this is what happens:

1. You incur charges at the doctor, hospital, lab, pharmacy, etc.

2. The charges are submitted to your claims administrator ("insurance plan") and the claims are adjudicated. Often this means the original charges will be adjusted down to the negotiated rate (if you are in-network).

3. Your portion of the charges (the original bill adjusted down) will be billed to you by the service provider (doctor, hospital, etc.). In the case of a pharmacy, you pay your portion based on your formulary and tiers.

4. Your portion is applied to your deductible--the $6,000. Once you pay out $6,000, you then are responsible for a co-insurance amount (usually, you pay 20% on in-network charges) until you hit your out-of-pocket max.

This is general info on how my plan works. Use your HSA, that's what it is for. Let me know if you have any other questions.
posted by FergieBelle at 11:00 AM on June 3, 2016 [2 favorites]

Best answer: Insurance should realize when they've passed along $6k of total allowable bills and take over paying their percentage. You pay each provider your share (currently 100%) directly.
posted by teremala at 11:02 AM on June 3, 2016 [3 favorites]

Best answer: The total will be the same and the doctors don't care if you write the check or if the insurance does. Since the claims are being sent to insurance first, once you hit the deductible, the insurance will automatically pay out their share and your bill should reflect that. Are you are having cash flow problems, coming up the money to pay the $6,000 and wondering which bills need to paid first? I would suggest going to the hospital and clinic with the largest bills and working out a payment plan (they do this all the time) and paying the pharmacy (because they are more likely to insist on being paid and you need to keep the drugs flowing) and smaller bills (less to keep track of) as they come in.
posted by metahawk at 11:12 AM on June 3, 2016 [1 favorite]

Best answer: Does your insurance plan also have an out-of-pocket maximum? Lots of them do -- you may not be on the hook for as much as you think.
posted by ananci at 11:14 AM on June 3, 2016 [1 favorite]

Best answer: I have a high deductible insurance. For my plan:

* The provider bills insurance for $1000.
* Insurance applies discounts and then says the patient owes $641. The insurance notes that you have used up $641 of your deductible.
* The provider bills patient (me).
* I pay $641 to the provider.

The insurance company receives all the claims and orders them, and keeps track of how much of my deductible I've used. Once I hit the deductible, the insurance automatically starts paying the claims.

You can sometimes choose to pay directly with your HSA. Or pay out of pocket and reimburse yourself from the HSA at any time (including decades in the future).
posted by ethidda at 11:22 AM on June 3, 2016 [3 favorites]

Best answer: You don't wait to submit the bills until you hit your deducible (as described well above).

In my experience, it's important to submit all claims as soon as possible and then track them all. Keep track of your deductible on your own. Call them regularly and check each claim. They are supposed to handle everything automatically, but in my experience they suddenly get much slower and/or start loosing bills once you hit your deductible.

(unless you happen to have much better insurance than I do)
posted by lab.beetle at 11:25 AM on June 3, 2016 [3 favorites]

Best answer: Pay for things as you go, assuming your insurance company will process bills as they receive them, which should be in the same order as when you receive the treatments. And take heart: if this all gets messed up and you overpay a doctor or hospital, they will send you your money back. I've had some crazy bills myself in the past eighteen months or so and have been been extremely pleasantly surprised by how smoothly this worked. Hospitals will generally send you money as soon as they realize you've overpaid, without you having to take any action.
posted by something something at 11:32 AM on June 3, 2016 [1 favorite]

Best answer: I highly recommend shooting money into your HSA first and paying from there, if you can. However much you contribute to your HSA is deducted from your taxable income at the end of the year, meaning you're saving whatever your tax bracket is. You can also do this retroactively, paying the bills now out of pocket and adding money to your HSA as you're able and then reimbursing yourself. (As I did over two tax years, to maximize my HSA contribution/tax savings when hit with an expensive appendectomy while on a high-deductible plan.)

Keep very careful records and receipts. If you're the spreadsheet type, put it all in one place so you know who's paid what when. Mistakes do happen, and if you have good records it's a lot easier to fix them.
posted by writermcwriterson at 11:41 AM on June 3, 2016 [1 favorite]

Best answer: I agree that it's very important to keep track of all of the bills, how much you've paid to whom, etc. I'm still getting random bills that have been paid, should have been paid by my insurance, or that the hospital refuses bill to my insurance for for some reason (they say the claim was rejected but my insurance has no record of the bills - they refuse to communicate with each other so I just keep getting the same handful of bills over and over) from when I had my son almost 2 years ago. Even though I kept extremely detailed records and have spent countless hours on the phone it is still a problem.
posted by tealcake at 11:49 AM on June 3, 2016

Best answer: Also: have a notebook (or spreadsheet, if you hate analog) in which you write:

--Entity and phone number called (including extension)
--Rep ID, if they have one, and name
--Time and date called
--What they said they/their organization would do, and by what time
--What you need to do, and by what time

Particularly if the organization/entity has an automated message saying the call is recorded, this gives you some documentation if you start to get a run-around.

Also-also: see if your insurance provider has a care coordinator (or similar) that is supposed to help people manage complex cases. It doesn't hurt to ask, and it's the sort of thing they won't volunteer to you unless you ask. Having some key people within the organization(s) who know your situation and are relatively empathetic is immensely helpful.
posted by tivalasvegas at 3:13 PM on June 3, 2016 [3 favorites]

Response by poster: All your answers are so helpful -- this was stressing me out and I feel like I have a better handle on it now. Thank you all.

I've created an Excel with a line for each bill -- who issued it, what it's for, the date of service, the invoice number, the due date, the amount, the date I paid, and notes on payment/issues as applicable. Each line subtracts from my deductible amount. It's a good start, I think.
posted by mochapickle at 10:44 PM on June 4, 2016 [1 favorite]

Yay mochapickle! Don't let the bastards get you down. :)

Actually, as someone who's often on the other side of the phone -- we're not all bastards, although the system probably is. Another suggestion: don't be afraid to politely ask for a supervisor if the frontline rep or whatever is giving you info that you're not sure about, that you don't understand, or that contradicts what you've been told by someone else. Or even to call back later and get a different rep. You never know if the person on the other side has been doing their job for three days or three years, and they may through no fault of their own be giving you unhelpful guidance. Particularly in large organizations, I think the turnover can understandably be kind of severe and that of course leads to mistakes.
posted by tivalasvegas at 6:51 AM on June 5, 2016 [2 favorites]

And to add, save all receipts to document your out of pocket expenses in case of insurance company "error." Secondly, work with your accountant at tax time to see if you can take itemized deductions related to medical expenses as well as all applicable expenses.
posted by WinstonJulia at 1:27 PM on June 6, 2016 [1 favorite]

Response by poster: So everything has worked exactly as you all said. I hit my in-network deductible, which was admittedly pretty painful, but now all of a sudden providers are like, You're all set! And the pharmacy is all, Here you go!

Thank you all for being the voice of reason at a confusing time!
posted by mochapickle at 5:05 AM on July 1, 2016 [1 favorite]

Glad everything worked out!

Is your deductible the same as (equal to) your out-of-pocket maximum? If so, you should be able to get insurance to pay 100% for covered services thru the end of the plan year. Which means that now is a good time to get medically necessary things done that you might have been putting off because of cost... make sure you cross your t' s and get prior auth for elective services, of course....
posted by tivalasvegas at 9:08 AM on July 1, 2016

For example if your insurance covers dental and vision, make sure you take advantage of all those benefits while you're in an advantageous payer situation.
posted by tivalasvegas at 9:13 AM on July 1, 2016