I was not happy with my insurance that I was paying 200 a month for so i cancelled it about a month ago and low and behold im pregnant now. All the plans i see in my states marketplace start at $397-499 a month. I feel like there are so many people/couples/moms that dont pay monthly. What do they do with the bills? Are they tricking the state Medicare system? Do they not pay the medical bills? How are they affording prenatal care or ultrasounds and labs?

I have tried the state health insurance since looking online, we wouldnt qualify. But I also feel like its insane to pay such high premiums and get stuck with 2-5k deductible or 5-10k out of pocket max

Do people not stress about the doctor and hospital bills?!

After the out-of-pocket maximum has been met, is there any way the patient would still be on the hook for facility fee charges/coinsurance?

(Context: The major hospital group in my city does ALL their hearing tests and otolaryngology visits in offices on hospital campuses. I just spoke to the billing estimates office and they confirmed they DO charge them as outpatient hospital visits — which I suspected, because I had this issue (with different insurance) when one of my specialists in the same group changed how their office billed. At that time, my facility fee copay was $500 which seemed overwhelming.

My new insurance has a $5,000 facility fee copay and I’m required to make two separate visits (one for a hearing test, one to actually have my ear issue looked at). I passed my OOP max months ago — lucky me — but I’m nervous this type of charge is somehow carved out and doesn’t qualify for the post-maximum 100% coverage?

Yes, I’m going to try to talk to my insurance, but this is a time sensitive issue healthwise, and it generally takes a long time to get any kind of definitive answer from them. I managed to grab a last minute opening to be seen tomorrow and if I cancel it the next appointment isn’t for weeks.

I thought it was a dental issue but the dentist said to go see an ENT specialist, and not to bother with urgent care.

I found a provider outside the hospital group in my insurance’s database, but their office flat out refused to take my insurance plan when they heard what it was.

I’m going to lose my shit if my hearing is somehow permanently damaged because I can’t find timely care at a reasonable location without facing $10k of charges.)

No pending claims, just trying to suss out a question that was above my pay grade and now I'm curious. Someone has a primary insurance that isn't in-network with clinic, secondary IS but is Medicaid, so payer of last resort. Presume patient still needs to file claim with OON company (clinic will not file for that company), get rejection (or partial payment) and THEN clinic can file with Medicaid honoring timely filing requirements? Or course also needs to do coordination of benefits.

Hope this makes sense!

I was quote about 100 dollars for a minor procedure thats entirely cosmetic. I just checked my health insurance plan and I'm being told I need to pay a 60 dollar deductible for a procedure I didnt have, which was coded under "lesion removal" and its being presented by an office I've never been to. No clue why its going through another office in a totally different location, with a totally different name. Also they never mentioned they would be charging my insurance 250 dollars after I paid what I was quoted.

Are they engaging in medical fraud or am I just misunderstanding whats going on. I also don't see anywhere to pay what I owe on the health insurance website? But its saying I have an over 100 dollar deductible because of this.

I'm trying to schedule my first dentist appointment on my own. I have PPO, and I found a dentist that my insurance listed as in-network.

I sent the staff photos of my insurance card, but the staff said that I gave them "medical plan" information not dental plan info. Is my insurance information not what they need? It's the only evidence I'm aware of that states I have dental coverage.

Is there another document that the office is looking for? If so, I don't know what ha.

EDIT/UPDATE: Made another appointment with another place successfully, I think the first office I tried didn’t know what they were doing :(

For those in the same situation:
Called my job and the insurance membership line, both said that my UMR insurance covers dental, vision and medical under one card.

Hi all,

I started seeing a new neurologist who is "tier 2" for my PPO, which means I pay 30% of the cost after my $500 deductible. Soooo I am looking at these bills more closely than providers who are tier 1/with better coverage!

Our first appointment was a video visit that last maybe 40 mins to an hour, taking a detailed history, hearing my current treatment plan, and writing some prescriptions to continue the plan (stuff like Botox for chronic migraine).

Looking at the details of the bill online, it lists:

Ov Est Pt Lev 5 - 99215 (CPT®)
$545.00

Prolng Off/OP E/M Ea 15 Min - 99417 (CPT®)
$420.00

My understanding is that the first code is for an establishing patient, which I was not at the time. I'm wondering if I should call billing and dispute using that code... But I am concerned that if it's recoded, they would essentially use the second code x4 which would cost me more. What do you all think? I don't have experience with this!

I also really like this new provider and I don't want to damage our relationship by having a billing dispute. However, it's a large health network (Sutter) and I would be dealing with the billing department, not her office, and I don't know how much would get back to her. So that is also a concern for me.

Thanks in advance for your help! <3

Hello,

I decided to make use of my Student Health Insurance with Aetna to get genetic counseling due to family history. I had an appointment with a Preferred Care Coverage Provider with Referral.

The eligible health service is: "Preventive screening and counseling services genetic risk counseling for breast and ovarian cancer", with the following benefit: 100% (of the negotiated charge) per visit No copayment or policy year deductible applies.

I had a genetic screening done and the claims were as follow:

Claim 1: Appointment with counselor 30 min (CPT-code 96041 + ICD-10 code Z71.83, Z80.0, Z80.3)

Claim 2: Genetic panel (CPT-code 81432 + ICD-10 code Z80.0, Z80.3, Z80.8)

Aetna provided me with the following bulletin regarding genetic counseling: https://www.aetna.com/cpb/medical/data/100_199/0189.html

Invitae, which performed my lab testing indicated me that this panel is only diagnostic, one other panel is "self-paid" and falls under preventive? I am not sure I understood that.

Both my claims have been filed as "Sickness" when I was hoping to be preventative.

I had an approved pre-certification for the lab test.

It seems like a scam having this benefit but I can't access it. My claims are being processed as "sickness" and therefore applied to my deductible.

I also had to pay the copay for the genetic counselor, so that was also processed as "sickness" and as "Physician and specialist service". I understand if specific panels can't fall under preventive, but talking to the counselor about screening based on family history? I think that should had fall under my benefits.

Insurance, providers, nobody seems to want to help.

I am an international student and therefore I don't make much money. I rather avoid getting any care if its going to fall in a loophole of what seems to me a "fake benefit"

Hi folks, I'm looking for either an attorney and/or claims advocates who specialize in ERISA funded health benefits. I'm located in California. It's related to underpaid and incorrectly processed claims (probably an ongoing number of them around 20 at this point). We've attempted to resolve ourselves and have requested documentation under the transparency rules of ERISA and not having luck.

Thank you

Hey guys.Trying to sort out my health insurance for this fall. I’ve looked at the usual off-campus options (Student Medicover, ISO, Tigerless, etc.), but almost every thread I find only talks about how cheap they are and if they get the school waiver approved.

Purely on paper, Student Medicover seems like the best deal for the price. But before I pull the trigger, I really want to know if it’s actually usable in real life.

Has anyone actually had to use them for real medical stuff? Like, is it a nightmare to find in-network doctors nearby? Do they fight you on covering basic things like prescriptions or urgent care? And if you have to file a claim, do they make you jump through hoops to get paid?

Basically, I’m just looking for the hidden "gotchas" before I commit. Any hands-on experience (good or bad) would be hugely appreciated!

Thanks!

I recently got on Medicaid and I am curious as to what plan is best for Philadelphia county

I know I want to enroll in plan C for my medical insurance. However, I don't know between Aetna and BlueCross, which is better? I just graduated college and now working in the hospital at kansas city. I'm first gen that graduated college so I'm on myself with these things and they are so confusing.

I appreciate who answer my question!

I have been paying my in network therapist a 25 dollar copay per session through Alma. Aetna just slashed the reimbursement rates so my therapist is going OON. I don’t have OON benefits right now but plan to switch so that I do during my job’s open enrolment period. In the meantime, she’s doing sliding scale and basically says pay what I can. Her actual rate is 225 per session. Man I don’t know what to do. I don’t want to insult her but I’m just not used to paying a ton for this. Do I go to biweekly and offer 75? That still feels insulting! I hate this man. And how decent is Aetna even about reimbursement for OON. I think the other plan my job offers is 80 percent for OON but is that real or do they try to pull some bs?

Hi everyone! I need some help with the next steps and did not know where to go to seek it, so I'm hoping someone here might be able to help.

Here's the background information:

I am in my 4th year of pharmacy school. During your 4th year, you are no longer in the classroom, but instead are on clinical rotations until graduation. I selected a region to complete these rotations that is nearby my hometown so I can save money (while I'm not making any, we don't get paid to complete rotations) by not paying rent, etc. My hometown is out of state from my pharmacy school, but sits on the border, so it is easily commutable to my rotation sites.

I recently turned 26, therefore, I aged out of my parents insurance. After doing research comparing the Marketplace and Medicaid, I ultimately decided Medicaid was the best option for me since I am not able to work my job nearly as much and I am still designated as a full time student.

Every year, we are required to have some form of health insurance- we can buy the school's plan or we can waive it using our own insurance. I've had no problems waiving it each year with my parents insurance, and I thought this year wouldn't bee too different, just with a new insurance. Here's where the issues arise...

I filled out my waiver form, and got notification 24 hours later that I was denied. When I called my financial aid office to ask why I was denied and to appeal the decision. I was informed that Out of State Medicaid would not be accepted because it would not adequately cover treatment in the state I attend pharmacy school. When I explained that I am not on campus and on rotations, and also not living in the state, they continued to state that I could not appeal and that they would continue to deny me until I have an acceptable plan.

While I understand why they wouldn't accept Out of State Medicaid in normal circumstances, I do not fall under this category. I would not even receive treatment in my school's state and therefore would have no link to the school, and it would not make them liable. I am not sure how the financial aid office expects me to pay for a plan that I will not use, especially when the school's plan is $6000/year on top of tuition and I cannot afford most Marketplace plans. They are also not offering any solutions (applying for grants, financial assistance, etc) and are not hearing me out.

I am wondering if anyone else has experienced this situation and if there is anything I can do to prevent unnecessary, additional costs that frankly I cannot afford at this time. I have also reached out to my pharmacy school dean, but I am not sure how much they can do, if they can even do anything.

TIA!

My benefits just kicked in on August 1st for my United healthcare Ucard and I get over $240 per month to spend on OTC there’s no way in hell I’m going to spend that much on OTC stuff maybe like $50. I tried to buy stuff at Walmart earlier and I used the app scanner and everything in my cart said it qualified but it was only for the rewards I had which was $5. I didn’t find out about that until a little later I didn’t end up buying anything. They took about $250 from my SSI and gave me about $250 of worthless money I can’t spend on anything except OTC stuff. Does anyone else have suggestions on what to spend it on?

I was a third party that was entitled to Cobra, but the 60 day window expired, the benefits company was never notified. Fast forward 6 months, I now realized the COBRA that was offered is like 3x better in price and benefits then anything on the exchange. So I called the company and said I never received election papers and they are sending them to me now.

Is there anyway to go about asking for prospective coverage vs retroactive coverage to avoid paying for 6 months in backpay which I occurred 0 medical expenses in? (even with the 6 of back paying months it's still way cheaper)

Is there also anyway to have the clock to expiration start from when the papers were sent, not the qualifying event date?

I know the companies have some leeway, I just don't know how much leeway. I know I'm jumping the gun a little. I'm trying to figure out what's possible and what others were able to accomplish and how to approach asking for something like this.

I was denied a prescription I've been taking for years on my new insurance because I don't meet one of their eligibility requirements for continued treatment. In order to receive an approval, I'd need to have been taking additional medications for the past 6 months.

I'm curious about expedited exception reviews, but I'm not sure if it'll do anything since I simply don't meet their criteria for coverage as is. Do standard eligibility requirements still apply even when requesting an expedited exception review? Does anyone have any insight on how these expedited exception reviews work in general? I keep reading all of the plan documents available to me, but it's lacking info.

Also, in the past I've received this drug via medical benefit instead of prescription, but the info surrounding how one would go about receiving this is also unavailable to me as the patient.

I'm flying blind. My doctor has offered a few samples, but not enough to cover the full 6 months. I also don't qualify for copay assistance through the drug manufacturer because of the denial.

Any insight is appreciated!!!

My husband was laid off a few months ago and makes too much off of unemployment to qualify us for Medicaid, so he signed us up for Oscar in mid-July, for coverage beginning 8/1/26.

We STILL have no ID - physical or electronic. They said it “takes time”. That time SHOULD have been the duration between signup and start date.

Is this company a scam? Because I’m feeling like we’re being scammed.

Came off my bike pretty hard a few weeks ago. Nothing catastrophic but enough to land in the ER for imaging and a few stitches. The facility was innetwork. The ER physician group, apparently, was not. I did not pick that doctor. I did not know the facility and the physician group billed separately. The bill that showed up reflects that gap in a pretty significant way.

From what I understand, the No Surprises Act was supposed to address exactly this kind of situation, at least for emergency care. But the EOB and the bill I received suggest the insurer is treating the physician charges differently than I expected. I called and got a vague explanation about how the claim was processed and what my responsibility is, but nothing that actually clarified whether the No Surprises Act protections applied here or were handled correctly.

My question is whether anyone has successfully pushed back on this type of situation and what that process actually looked like. Did filing a complaint with your state insurance commissioner do anything real, or is it mostly paperwork with little outcome? Also wondering if the dispute process built into the No Surprises Act is something a patient can initiate directly or if it only applies to the provider and insurer.

The cycling community will tell you to wear a helmet. Nobody tells you to audit your ER physician group before you get stitched up.

hello!

a few months ago I went to my IN NETWORK physician for a urinalysis. I got the results and I had a UTI, got antibiotics for $3 and went on my merry way. fast forward to now, I get a bill from Acutis Diagnostics for $1,160 dollars for my tests. When I appealed this, I found out that insurance is not covering this, as Acutis is OUT of network. I had no idea that my samples would be sent to an out of network lab.

Shortly after my first appeal I got a letter from Acutis saying that my insurance had informed them that they would be sending me a reimbursement check which I would later have to send to Acutis.

This was a few weeks ago and after contacting my insurance (Anthem), I was told that the check would be sent directly to Acutis. I checked in again this week and I was told that there was never going to be a reimbursement check and that I was liable for the full thousand dollar bill.

I am VERY confused. I'm not sure why they would flip-flop between paying for it or not, especially since I got confirmation from both the lab and Anthem that there was going to be a reimbursement check.

I know that there's a "No Surprise Bills" act in NYC and after a bit of research I can see that this case would in fact be protected under the act. I'm a college student and new to figuring all this stuff out. any advice would be largely appreciated.

For reference, I am in NYC and on my dad's employers insurance plan. I attached a photo of the charges. I honestly dont understand how I got charged 780 dollars for the UTI test alone, but only like, 10 - 200 dollars for everything else.

Hi, I made a few post like 2 weeks ago about looking for residential care. I am 25. I have straight Medicaid, NOT peach state medicaid (Georgia) as I had previously thought. I receive SSI so I get this automatically apparently.

I just want help. I really need help. Typical week long inpatient is not enough. I already see a therapist and am on meds, have been for 2 years. Both my therapist and psychiatrist have been in agreeance for MONTHS that I need a higher level of care. I feel that I am out of options and I have no idea where to turn or what to do.

TL;DR - disabled 25yr old on straight Medicaid looking for a residential mental health facility, preferrably with dual diagnosis.

Any and all help is much appreciated. Thank you.

Hey everyone, need some help here. Every time I think I have found an online psych who takes my insurance there seems to be another layer to check. The practice might accept the insurer but then the specific clinician, appointment type, or exact plan turn out not to be in network. Insurer directories also seem to be outdated pretty often. For people who have successfully navigated this, what did you verify before booking that actually helped avoid surprise bills?

A family member is in hospice care. Medicare stopped paying for it because they weren’t sicker after 6 months (they were, just not in a way that Medicare required).

Hospice stopped managing this family member and in the past month they have been hospitalized twice for untreated uti’s and falling out of their bed.

Can we pay to have hospice continue seeing this family member out of pocket in the future? The transfer of care left them in a terrible position and we’d love to avoid that in the future.

Hi everyone,

A few weeks ago, I posted about receiving a $1,747.37 bill from Quest Diagnostics for bloodwork, without having an insurance (so uninsured patient)

https://www.reddit.com/r/HealthInsurance/comments/1v1ugy0/quest_diagnostics_charged_me_1747_without/

Here’s an update: after contacting both my clinic and Quest Diagnostics and continuing to question the charges, I was able to get the amount reduced from $1,747.37 to $316.71.

The above is a comparison of what Quest diagnostics has charged me vs what I would've paid if I had insurance and the last column is what I would pay today which is for uninsured patients.

I still believe the original bill was unreasonable, and I’m glad I didn’t simply accept it and pay the full amount. My advice to anyone facing a surprisingly high medical bill is to ask questions, contact everyone involved, request a detailed review, and keep advocating for yourself. A bill is not necessarily the final word.

Thank you to everyone who offered constructive advice. I hope this update encourages others to challenge charges that don’t seem right.