Plan details: I am covered through the marketplace as I am a contracted employee. My premium is $270/month with $7800 deductible. I live in Utah and have SelectHealth.
I have struggled with TMJ issues for 10+ years. In the past few months, it has gotten a lot worse and I have had a lot of pain that makes it difficult to eat at times. I connected with a TMJ specialist in my area, and they wrote an order for a MRI to find out what’s going on before we move forward with any treatment. I made an appointment with the imaging center he recommended. The center called me the day before my appointment and said they were out of network, but I could pay cash ($500). My insurance plan is connected to a major hospital system in my area, so the only in-network providers are within this system, so I decided to move forward with the in-network provider.
The hospital has a cost estimation line that I called before making an appointment. I was very skeptical going into this because I know 1. My coverage isn’t great and 2. MRIs are more expensive when done at hospitals. I called and gave them the information from the order, and I was quoted $299. The woman I spoke to said it was going to go towards my deductible, but that $299 was the negotiated rate between the hospital and the insurance company. I then called the hospital scheduling and made the appointment. I gave her the code and information from the order, and she told me I could expect to pay around $1100. I pushed back and said that was different than what the cost estimation line told me, and she was dismissive and said “you’ll just have to find out what it costs when you get your bill.” I made the appointment but continued to be skeptical. I called the cost estimation line AGAIN the day before my appointment and shared what the scheduling department told me. The cost estimation representative said “I don’t know what they are talking about, you absolutely will only have to pay $299 which includes the radiologist reading the MRI, though you may get two separate bills.”
I had the MRI done and paid my $299 co-pay. Two weeks ago, I received an email that I had new claims in my account to review. Both claims- one for the radiologist and one for the MRI- were denied. The radiologist claim was $440 and the MRI claim was $2,361. I received a bill from the hospital last week for the radiologist bill at $440. I have not yet received a bill for the MRI.
I called both my insurance and the hospital yesterday to find out what my options are. The insurance informed me that I have NO coverage for TMJ issues, including any diagnostic tests. The hospital said they don’t take diagnosis into account when checking benefits or providing estimates. I asked what the cash rate would be, and was told I could get a 5% discount. I’m pretty sure that I make too much money for any of the financial assistance that the hospital offers, but he suggested I apply anyway.
What are my options here? Here is what I am thinking so far:
I see my TMJ specialist on Thursday to review the MRI and decide on treatment. I received the report from the radiologist and know I have a displaced disc and something is torn in the jaw (not sure what due to medical lingo). I was thinking of asking my doc for support in either revising the order to indicate a different diagnosis (not TMJ), or writing a letter of medical necessity. I would like to talk with financial services at the hospital again and ask what my cost would be if I retracted the insurance claim. Is this possible to do after the fact? If my “cash” rate would be $1500 as an example, I would much rather do that than run it through my insurance and pay the $2700.
What other options do I have? I am so frustrated by this. I know that I should have clarified the lack of TMJ coverage, but I didn’t realize that would be an issue. Thank you so much in advance! I work as a mental health therapist and accept insurance, though I don’t do any of the billing or checking benefits. I feel fortunate to have the resources to cover this if I have to, but would certainly like to avoid that if possible.
submitted by /u/peachpacifist
[link] [comments]
Plan details: I am covered through the marketplace as I am a contracted employee. My premium is $270/month with $7800 deductible. I live in Utah and have SelectHealth. I have struggled with TMJ issues for 10+ years. In the past few months, it has gotten a lot worse and I have had a lot of pain that makes it difficult to eat at times. I connected with a TMJ specialist in my area, and they wrote an order for a MRI to find out what’s going on before we move forward with any treatment. I made an appointment with the imaging center he recommended. The center called me the day before my appointment and said they were out of network, but I could pay cash ($500). My insurance plan is connected to a major hospital system in my area, so the only in-network providers are within this system, so I decided to move forward with the in-network provider. The hospital has a cost estimation line that I called before making an appointment. I was very skeptical going into this because I know 1. My coverage isn’t great and 2. MRIs are more expensive when done at hospitals. I called and gave them the information from the order, and I was quoted $299. The woman I spoke to said it was going to go towards my deductible, but that $299 was the negotiated rate between the hospital and the insurance company. I then called the hospital scheduling and made the appointment. I gave her the code and information from the order, and she told me I could expect to pay around $1100. I pushed back and said that was different than what the cost estimation line told me, and she was dismissive and said “you’ll just have to find out what it costs when you get your bill.” I made the appointment but continued to be skeptical. I called the cost estimation line AGAIN the day before my appointment and shared what the scheduling department told me. The cost estimation representative said “I don’t know what they are talking about, you absolutely will only have to pay $299 which includes the radiologist reading the MRI, though you may get two separate bills.” I had the MRI done and paid my $299 co-pay. Two weeks ago, I received an email that I had new claims in my account to review. Both claims- one for the radiologist and one for the MRI- were denied. The radiologist claim was $440 and the MRI claim was $2,361. I received a bill from the hospital last week for the radiologist bill at $440. I have not yet received a bill for the MRI. I called both my insurance and the hospital yesterday to find out what my options are. The insurance informed me that I have NO coverage for TMJ issues, including any diagnostic tests. The hospital said they don’t take diagnosis into account when checking benefits or providing estimates. I asked what the cash rate would be, and was told I could get a 5% discount. I’m pretty sure that I make too much money for any of the financial assistance that the hospital offers, but he suggested I apply anyway. What are my options here? Here is what I am thinking so far:
I see my TMJ specialist on Thursday to review the MRI and decide on treatment. I received the report from the radiologist and know I have a displaced disc and something is torn in the jaw (not sure what due to medical lingo). I was thinking of asking my doc for support in either revising the order to indicate a different diagnosis (not TMJ), or writing a letter of medical necessity. I would like to talk with financial services at the hospital again and ask what my cost would be if I retracted the insurance claim. Is this possible to do after the fact? If my “cash” rate would be $1500 as an example, I would much rather do that than run it through my insurance and pay the $2700.
What other options do I have? I am so frustrated by this. I know that I should have clarified the lack of TMJ coverage, but I didn’t realize that would be an issue. Thank you so much in advance! I work as a mental health therapist and accept insurance, though I don’t do any of the billing or checking benefits. I feel fortunate to have the resources to cover this if I have to, but would certainly like to avoid that if possible.
submitted by /u/peachpacifist [link] [comments]Read Morer/HealthInsurance