My son had surgery back in February, I received a estimation of benefits once for the surgery. According to the eob we were only suppose to pay 315.90 for the copay and 2.15 for the coinsurance or something like that and we were suppose to be billed for the 317.00 which was the two previous numbers added together. We kept receiving a bill from the doctors office for 501.91 which was basically the total for the entire services minus 18.00 which the insurance paid. Well, I called and talked with the anaestsia office and they told me that my insurance (anthem) wasn't paying enough that's why I received the bill for 501.91. So I talked to anthem and they said I was only responsible for the 317.00 so I sent that and it came out of my bank account. Even after both the doctors office and anthem telling me I paid what I was suppose to, I received an updated eob showing that I still owed money. They even changed around the copay and coinsurance amount to make me look responsible help???
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Here's the big question that you need to ask your insurance company and/or the doctor/hospital: Does the anesthesiologist have a contract with Anthem agreeing to accept their discounted rates? If a provider doesn't have a contract with your insurance company, they can bill you all the way up to the amount that they charged - they aren't obligated to accept a discount. Based on the fact that you received a second Explanation of Benefits from Anthem with the discount removed, it sounds to me like the following happened: Your son's anesthesiologist is not contracted with Anthem. Anthem processed the claim showing their discount. The anesthesiologist protested and argued that they aren't obligated to accept the discount, since they didn't sign a contract agreeing to it. Anthem re-issued a 2nd EOB to you, because they can't stop the anesthesiologist from billing you for the whole amount. (The above paragraph is my gut feeling based on what you typed above - you'll need to confirm with Anthem and the doctor's office that its what actually happened in your case.) If you confirm that's what happened, here are your options: 1) You can try appealing with Anthem to consider the full billed charge on the claim, rather than their discounted rate. (note - was the surgery done in a hospital? If so, use the term "hospital based physician" in your appeal letter to the insurance company. In some states - Ohio for example - the insurer will have to consider the hospital based physician's charges in full if they aren't contracted. If the surgery was in an office or surgery center, that term won't apply of course.) 2) Contact the hospital where the surgery was done and let them know that you are being balance billed by the anesthesiologist. Some (not all) hospitals require that the anesthesiologists who perform services in their hospital work with patients on the discounted rate. I can't guarantee that this will work for you, but the hospital should at least be aware that you're being balance billed by the anesthesiologist. (After all, they are the ones who assigned a non-contracted anesthesiologist to your son's surgery in the first place. Doesn't make the hospital financially liable, but they should be aware that their action lead to greater expense for you.) 3) Try to work out a deal with the anesthesiologist's office. Let them know that you're filing an appeal with Anthem for additional payment. First of all, if they know you're appealing the claim, they're not likely to send you to collections for your outstanding balance. Second of all, their billing person might have additional info/suggestions on what to put in the appeal. Finally, if they know you've exhausted every avenue possible to appeal the claim with Anthem, they might be willing to work out a discount. Doesn't necessarily mean that they'll reduce your bill back to the $317, but they might meet you somewhere in the middle of the $317 and the $501. Good luck!
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