The order health insurance claims are processed: does it matter?
February 22, 2015 11:48 AM   Subscribe

I have some health insurance claims getting processed out of order and I'm wondering how this affects what I'll owe. I'm also wondering what happens when you go over your deductible with a claim rather than hitting it exactly (which must be what happens most of the time, since I doubt most people hit their deductible exactly).

Let's say your health insurance deductible is $2000. Your plan is such that you pay in full up to the deductible, and after that you only owe a small co-pay.

You have three doctor's visits: January 1st for $1500, January 10th for $500, and January 20th for $800. The January 1st and 20th claims get processed by your health insurance company first; the one from the 10th is held up because of some glitch. The total cost from the 1st and 20th is $2300, so you've hit your deductible, but actually you've gone *over* your deductible. Is the overage ($300) treated differently or do you just have to pay the entire amount?

Later, when the claim from the 10th gets processed, is anything adjusted retroactively or are you simply charged the co-pay?
posted by sunflower16 to Work & Money (3 answers total) 2 users marked this as a favorite
Regardless of the order in which claims are processed, the determination of when you meet your deductible should be based on the order which the services are received (there may be some exceptions if a provider visit is processed as a sub-claim to another visit). In cases like yours where claims processed out of order effect the amount being paid out, the insurer should make a correction, resulting in either a refund or a revised bill.

Just a friendly warning: I work for a health insurance company, and while I think we're pretty darn good to our subscribers (that's people like you), dealing with the claims department for my personal claims drives me absolutely crazy. Eventually everything should get processed correctly (since payments and claims that don't add up will eventually get caught and are a pain to fix after a while), but if you need your claims sorted out correctly in the short term you may need to badger them a bit.

Your insurance company (or TPA*, if you're filing through one) should have an email address specifically for claims that you can find via their website, an EoB (Explanation of Benefits) from a processed claim, or your plan documents. Sending them an email about your concerns is a good starting point, although calling them may be quickest if you have time to hash out the situation during working hours.

*if your claims are filed through a TPA, the likelihood of correct processing taking a while is going to go way up. Feel free to memail me if you have any other questions or have any trouble getting through to the correct people.
posted by a box and a stick and a string and a bear at 12:53 PM on February 22, 2015

With my own insurance, if I had a claim for $1500 and then one for $800 with a $2000 deductible, I would be expected to pay $1500 for the first one, $500 (+ maybe copay - not sure) for the second (so insurance would pay $300 (-copay?) and then just co-pay for anything after. If the claims came in $1500 then $500 then $800, I would pay $2000 for first two visits plus copay for third, so the difference, if any, would just be one co-pay.

If they already processed the visit on the 20th, look at your EOB and see what happened. If they didn't make a partial payment (either $300 or $300 less copay), call them now. (Phone calls involve being on hold but work far better than email in my limited experience) If they did pay what you expected, then wait for the EOB for January 10 and then decide if you need to make another phone call or not.
posted by metahawk at 1:05 PM on February 22, 2015

Keep your EOB's and make sure that if anyone got over paid, that you get it back.

I got checks last year from my insurance company, my dentist and a lab. It happens.
posted by Ruthless Bunny at 2:48 PM on February 22, 2015 [1 favorite]

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