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I am currently in a conflict regarding insurance overpayment and reimbursement. I gave birth at a birth center and the total fees were $4500. They had estimated that my insurance would pay 70% of that, and so I paid the remaining 30% out of pocket. After they filed the claims for the birth, my insurance actually paid 100% of the fee - and actually paid them way more than the fee, close to $12,000.
I inquired about getting a refund of the 30% I paid out of pocket since the insurance paid the entire cost, and the center told me that I do not get my portion back at all. I am really confused about this - firstly I am not sure why the center filed so many claims (10 total) and got such a large reimbursement, and secondly I am not sure why I am not entitled to get my money back. It seems like in other circumstances where I have overpaid estimated medical fees and the insurance paid more than estimated, I have gotten a refund in a timely manner. Am I missing something because this is related to birth? Any advice or help would really be appreciated.
You need an itemized copy of your bill and the explanation of benefits (EOB) from the insurance company.
Go over the bill to find out why the actual bill was so much higher than the estimate. Make sure there are no obvious duplications of charges, for example. Ask for clarification of anything you do not understand. Discrepancies are usually mistakes, not deliberate overcharges.
Your share of the bill is not determined by the birth center. It depends on your contract with the insurance company and should be spelled out on the explanation of benefits. The amount depends on your coinsurance and deductibles.
If the patient responsiblity amount on the EOB is less than the amount you paid the birth center, then you are due a refund.
Remember that your share of the cost is paid first, then the insurance share.
There may be additional charges for things like anesthesia that were not included in the base charge, also.
Thanks for the response. As far as I know, there is no itemized bill, simply a $4500 fee that encompasses all prenatal care, labor, delivery, and post-partum visits. I do have the EOBs and have looked at them pretty thoroughly. It appears to me that the birth center filed 3 separate claims for the same labor and delivery, but they are all coded differently and they were all paid separately, at varying amounts. One of the EOBs does indicate that I am responsible for the 30%, but the other 2 do not. There are 7 other EOBs breaking down postpartum care and well child visits for my son. I am not sure if the birth center filed the 3 separate labor/delivery claims on purpose, or if it was a mistake, or what.
When I signed on as a patient, the insurance was called and they said they would "probably" pay 70%, however if I participated in a Healthy Pregnancy program they would pay 100% of prenatal care and 70% of labor and delivery. I did participate in the program and this 100/70 split is noted on one of the EOBs for the labor and delivery.
I called my insurance yesterday to verify that they had actually sent checks in the amounts on my EOBs and that they had indeed paid close to $12,000 for the same birth that is only supposed to cost $4500 and the person I spoke with verified this and did not seem like she thought it was any sort of mistake. I am not sure if I should pursue this further with the insurance company.
The receptionist at the birth center said she will speak with their billing specialist and get back with me, but she seemed pretty certain that no matter how much the insurance pays them, I am not getting a refund. I just don't see how that can be right, to make nearly $13,000 from a birth that should only be $4500. If she does get back with my after speaking with the billing specialist and again says I am not getting a refund, where do I go next?
I would demand an itemized bill from the birth center--they have to have one. I would then talk to someone at the insurance company that investigates insurance fraud. Hopefully you have the paperwork you signed originally that showed how much the birth was going to cost. Also, I wouldn't take the receptionists word that they won't refund your money but if they don't, report them to the state medical board. This is total and complete fraud and a BIG reason why our insurance costs are so high. Please do something about this!
I would demand an itemized bill from the birth center--they have to have one. I would then talk to someone at the insurance company that investigates insurance fraud. Hopefully you have the paperwork you signed originally that showed how much the birth was going to cost. Also, I wouldn't take the receptionists word that they won't refund your money but if they don't, report them to the state medical board. This is total and complete fraud and a BIG reason why our insurance costs are so high. Please do something about this!
We really do not have anything at this point to suggest that there is anything fraudulent going on. We also do not know whether the OP is due a refund even if the charges were higher than originally quoted.
We really do not have anything at this point to suggest that there is anything fraudulent going on. We also do not know whether the OP is due a refund even if the charges were higher than originally quoted.
The OP was told that the birth would cost $4500. The birth center sent in bills to the insurance company for $12,000 and you don't think that there is fraud going on???? The OP is most certainly due a refund if the total bill was supposed to be $4500 and her insurance company paid $12,000. This whole thing SCREAMS fraud. OP, PLEASE, PLEASE call your insurance company and ask to speak to someone in their fraud department.
Thanks for the responses. I do have the paperwork and it states that the birth is $4500. Claims were submitted to the insurance company in the amount of $15, 380. Close to $12000 of that was paid out. At this point I am not sure if the center realizes that so many claims were filed and that they have gotten so much money from one birth - only 4 people work there total and I think they are very overwhelmed. I became close with all the employees and it absolutely sickens to me to think that this could be on purpose.
I feel like at this point I need to physically go to the center with all my paperwork and point out what is happening and hopefully they will realize that something HAD to be misfiled. Golfgal, if they still don't seem to think something is amiss and then try to fix it, I will definitely go back to the insurance company and see what to do next.
That being said, on the one and only claim that is actually for $4500, the part that my insurance says I am responsible for is less than what I actually paid them out of pocket. So just looking at that one, that should mean that they DO owe me a refund for what I paid, correct?
Thanks for the responses. I do have the paperwork and it states that the birth is $4500. Claims were submitted to the insurance company in the amount of $15, 380. Close to $12000 of that was paid out. At this point I am not sure if the center realizes that so many claims were filed and that they have gotten so much money from one birth - only 4 people work there total and I think they are very overwhelmed. I became close with all the employees and it absolutely sickens to me to think that this could be on purpose.
I feel like at this point I need to physically go to the center with all my paperwork and point out what is happening and hopefully they will realize that something HAD to be misfiled. Golfgal, if they still don't seem to think something is amiss and then try to fix it, I will definitely go back to the insurance company and see what to do next.
That being said, on the one and only claim that is actually for $4500, the part that my insurance says I am responsible for is less than what I actually paid them out of pocket. So just looking at that one, that should mean that they DO owe me a refund for what I paid, correct?
TX, I sent you a DM. If you will share the codes for the delivery charges, I may be able to help you figure out what is going on.
Sorry Suzy, I just saw it. My EOBs do not have the codes on them, just descriptions. One is HOSPITAL MISC (3400), one is BIRTHING CTR (1200), one is SURGERY (4500), and another for BIRTHING CTR (5800). I am especially stumped by the one marked surgery since nothing even remotely close to a surgery happened. The first of those four has my son listed as the patient, and the other three have me listed as the patient.
I would demand an itemized bill from the birth center--they have to have one. I would then talk to someone at the insurance company that investigates insurance fraud. Hopefully you have the paperwork you signed originally that showed how much the birth was going to cost. Also, I wouldn't take the receptionists word that they won't refund your money but if they don't, report them to the state medical board. This is total and complete fraud and a BIG reason why our insurance costs are so high. Please do something about this!
THIS!!!
Look, this is FRAUD, plain and simple. Triple billing, plus. Write your state insurance commissioner. Copy your insurance company and the birthing center.
I guarantee you will see some action in short order.
People are much too passive and accepting. I've raised Cain a number of times when I encounter a Chinese Wall like this with excellent results. The receptionist at the birth center is NOT the last word.
Take action.
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