I live in Washington state and got my hospital bill yesterday for giving birth in July. I met my deductibles for both my primary and secondary insurance plans, and I expected to owe about $500 for labor and delivery after all my medical expenses this year.
To my surprise, the hospital billed me about $2,700. My claim and EOB from my primary insurance show that my patient responsibility is around $500, which is what I expected [amount billed: $19,000; primary’s allowed amount: $11,000; amount paid by primary: $10,500]. However, my EOB from the secondary says my patient responsibility is $2,700, and that’s the amount the hospital is billing me. The secondary only paid $27, and there’s no allowed amount listed in the EOB. Here are the redacted EOBs (the first two are from primary, the last is secondary):
The hospital is in-network for both insurance plans. I always thought the secondary insurance would pay what the primary doesn’t, up to the allowable amount set by the primary. Am I misunderstanding this? Or is the hospital supposed to follow what the secondary insurance says?
I plan to call the hospital’s billing department and both insurance companies, but I’d appreciate any insight before I make those calls so I know what questions to ask. Thank you for your help!
From their EOB, I see they deducted what the primary paid but adjusted for all the primary’s contractual adjustments. Your secondary only paid $27 because you haven’t reached your out-of-pocket maximum for them yet this year (you can check the bottom left of your EOB for your progress toward that max). Your bill from the hospital should be $473 ($500 - $27).
I assume the primary insurance is on the first two pages and the secondary is on the last page.
You don’t owe the provider $2,700; the secondary only paid $27 of the $510 that the primary said you owed. So now, you only owe about $483.
Secondary insurance isn’t as generous as it used to be. In the past, if both plans covered 90% coinsurance, you could end up with a bill that the primary covered at 90%, and then the secondary would cover 90% of the remaining 10%.
Now, you need to check the coordination of benefits clauses in your secondary insurance policies. Some are generous, while others are quite stingy.
Bring both EOBs to their attention. I cannot imagine a world in which primary says you only own 510 and secondary would make that amount 2700— secondary shouldn’t mean you owe MORE than what primary says you owe.
My guess is they aren’t factoring in primary, or have them swapped.
I always viewed the total bill as the amount minus any discounts. The primary insurance applies this amount to the deductible and out-of-pocket maximum, then pays according to the contract.
The secondary insurance takes the total bill and treats any amount the primary paid as if you paid it, so it counts toward your secondary out-of-pocket maximum.
If you have met your secondary deductible or out-of-pocket maximum, the secondary will pay. However, the total payments from both primary and secondary cannot exceed 100% of the bill.
It happens sometimes. Assuming they are in-network, they can’t violate their contract with the primary insurance (by charging over the allowed amount) just because the secondary plan allows more.
If they insist that you owe them $2,700, contact your primary insurer. They will explain the contractual obligations to the hospital’s billing office and, if needed, push the hospital to resolve the issue.