How One Phone Call Saved Me $170

When we signed up for our health insurance through Hubs employer back in 2010, it was the first time we had decent, non-state supplied health insurance. There were a few options we could have gone for, but we opted for complete coverage on annual exams, and a larger coverage for emergency room visits. At the time, we only had the two boys, and I had visions running through my head of how destructive those boys would be. As a complete side note, most of the ER visits have been for me than for the rest of the people in this house combined. The coverage we went for had no copay as well. Instead, we pay a 20% co-insurance after we meet our deductible.

Since getting the coverage, I’ve always looked at our Explanation of Benefits for any visit we have. It breaks down for me what was paid by our insurance, what’s been adjusted by the office, and what I’ll be paying. I do this so that when the bill arrives, there are no surprises. I can’t tell you how much I love that last one because we have no regular medical expenses. After we reach our $200 deductible, $400 as a family deductible, we pay no more than $22 for sick visits. For most sick visits, we have owe around $10.60. Since we don’t have many sick visits a year {5 at most}, and well exams are covered, I lump anything medically related it into our annual savings account.

Last August, I scheduled the boys’ annual exam for two weeks before the school year started. For me, it was during a really busy time. In the course of that time, we had doctor’s appointments, dentist appointments, orthodontist appointments, middle school tour and orientation for Bookworm, elementary “meet the teacher” night for Monkey. And somewhere in all of that chaos, Lady Bug had caught a stomach bug. When the EOB came for the boys, I didn’t pay it any attention. I knew they were annual exams, and that they should be fully covered.

It wasn’t until I took Lady Bug into the office at the end of September because she still wasn’t acting right. She had no other signs of a stomach bug, but she wasn’t sleeping well at night anymore, was whiny and downright miserable, and I was worried she had an ear infection. Since my kids don’t show any of the standard ear infection symptoms, I decided to bring her in and see if our doctor could figure out what was going on. As I was checking out, with a diagnosis of some virus in her GI, I was told our balance was $185.60.

Wait. What?! It’s September. We hadn’t had any sick visits lately, and I *knew* that I met the deductible during my week of the cold turned asthma exacerbation in January. How on earth did I owe that much?!

After talking to the billing officer, the amount broke down into three charges. First one was a $170 charge on Bookworm’s annual exam that insurance had denied paying, saying we met the lifetime maximum for his annual exams between the ages of 0 and 10. Had I looked at the EOB when it came in, I may have caught it then. The remaining $15.60 was for a “sick visit” for Bookworm on the same day as his annual exam, stemming from my request for Bookworm to have a replacement inhaler on hand for the beginning of school {which is a whole different can of worms, believe me}, and $0.60 that they had misread the last amount on the check I sent them in April {this one I already knew when reconciling our checkbook}.

Since we had money in savings for this purpose, I paid the bill. When we got home, I leafed through our insurance coverage booklet, and called the company.

After connecting with a representative, I explained when our coverage began, what their policy terms are according to the booklet I had, and asked if I was missing anything. He was as confused as I was. I was so relieved to know it wasn’t just me! He immediately put in an appeal claim, and said that they would look into any accumulator issues within their system.

A few weeks later, I received another EOB from the insurance company for Bookworm’s annual exam. This time, the EOB showed that they had reprocessed the payment, what portion they paid, as well as any office adjustments, and that my payment portion was $0.

When I went in for a sick visit for Monkey at the beginning of the year, I was happily surprised to see that I had a credit sitting on our account to the tune of the full $170 denied charge. Thankfully, this credit will be rolled over to what we would have paid on his sick visit towards the deductible.

If I had not taken the time to call our insurance company and ask why their system denied the claim, even though this was the first time their system denied a claim, I would have been out the $170 for the visit in general. If I had checked the EOB in the first place, I could have taken care of it right away. Life lesson: always check the EOB, and if your coverage isn’t jiving with their terms, give them a call! At the best, you’re saving a bunch of money. At the worst, you’ve got an explanation.