Just off the phone trying to unscrew a mess with my wife's health insurance and I have to say that I am not a happy camper.


Essence Healthcare is the pits.

but this is so weird.

You wouldn't have to deal with this under the ACA/Medicaid.

you got screwed. They are excellent at that.

fuckers

on the out-of-network stuff, especially if it covers what the assistant's group wants you to pay.

With that said, this out-of-network junk is just not necessary. I do not understand why doctors or hospitals put up with that junk. They could put a stop to it, easily if they wanted to, as could Congress (Moscow Mitch, where are you on this?).

I am guessing it was kind of their error for doing the pre-approval on it?

On the last go round for some minor hand surgery, the day of I asked people in the surgery center and none of them knew if they were or not. I even called ahead of time and they couldn't answer the question.

The system we have is all f'ed up.

could have been drugged out, though.

The IRS is looking for income reported to them on a W2 or 1099. Insurance refunds don’t fall under either.

the check stub just references the name of the assistant, no dates, no services. just the name.

1) You received a large check from the medical insurance company. You deposited the check.

2) The person to whom the money is owed has not yet sent you a bill.

3) The proceeds remains in your bank account. The bill has not been paid yet with the funds in your account, because you have yet to receive a bill.

I am not a tax accountant, but here is the case I would pitch to the IRS if I ever got audited:

1) This is nothing more than a timing issue.

2) The money is due to a provider, and will be paid with the money that you received and is sitting in a bank account.

3) You have been in contact with the provider, and they have told you that they are in the process of sending you a bill.

4) Therefore, you are not claiming this money as income because it will be used to offset a medical expense that is legitimately owed, and will be paid when the bill is received.

5) If you were to claim this money as income, you would have no legitimate offset, tax wise, since it is likely that you are not able to claim your medical expenses as an itemized deduction.

6) The money sitting in your bank account is simply insurance reimbursement for a pending bill that must be paid when all of the paperwork has cleared. This is not taxable.

7) The funds you received are not reportable on a 1099.

That's my view...I was give a quick phone call to a tax accountant to be sure. But personally, there's no way in hell I would claim that money as income.

thanks!

But you would usually only deduct the medical expenses insurance didn't pay.

Not a tax scam.

As for assistant surgeon being paid more than main surgeon is all because of this in and out of network business. Surgeon is in network, gets paid the agreed rate, often a whole lot less than the billed rate. Assistant surgeon is out of network and is paid what is "usual and customary" - often this is less than the billed rate, but usually always more than any negotiated rates for in network medical providers.

Insurance companies can choose whether to send payment direct to the medical provider or to you for out of network claims. Depends on how much out of network the provider is. I've had both - insurance company pay me directly and insurance company pay the provider directly. Either way, I'm on the hook for what the insurance company didn't pay.

this was totally a first for me.

That check was sent to you for payment of your medical bill. When I used to do medical billing/coding, many patients would simply deposit the check like you did. However, when later they received the bill, they freaked; the money had already been spent. No one EVER gets money for no reason, especially from an insurance company. That money didn't belong to you; it was to pay a doctor's bill. You now owe this amount. You can make payments on the doctor's bill without interest. Do not simply pay it off on a credit card. You'll be paying a lot in interest. Good luck.

but since there is obviously negotiating with insurance and bills I wonder if I am supposed to do that. whether they would actually drop the bill I have no idea. this is totally new to me. I spent my entire adult life with no insurance. since 2014 and the ACA is my whole experience and I have had a couple of surgeries, and a long case of a slow healing wound. never got a check for something that wasn't covered by them before!

They sent me a check to pay the surgical staff and anesthesiologist - both were out of network. Their bill is more because they do not have an agreement with the insurance company.

Demand a bill then pay it. No tax burden is involved on this.

first time for me.

It's kind of freaky to get those big checks for sure. LOL

for sure it was some kind of mistake!!!

I was freaking out when I got those bills from them. The hospital contracts with the surgical teams and anesthesiologist who were in the OR. I didn't pick them so had no idea they were out of network.

The insurance company just paid them when I told them that and I'm sure it's common. However, I know next time to ask and get prior approval so I don't have to deal with it again.

And yes.. they got more than my surgeon which was really annoying to me.

They will settle with you right away I bet. I have done it.

better be! I sure as hell am not paying them more! what I wasn't sure was should I try to get them to lower it? if they did lower it, I suppose I would be morally obligated to give the difference back to the insurance company. not sure I am a true saint, though.

If you claim a medical expense, you'll have to offset it with the compensation you got from your insurance company. If you still have medical expenses over and above that amount, they'll be subject to being above 10% of AGI (or whatever it is) rule as to what is deductible. The insurance payment is not counted as income.

Tell the out-of-network doctors, you will pay them no more than the insurance company reimbursed you. They'll take it. Right now they are just trying to get you to pay what they want, not what they'll accept.

but it is way more than the insurance paid the actual surgeon.

Insurance companies usually have a rule that they don't make payments directly to providers who are not contracted as part of their network. They send the payment to the patient instead. It's not unusual that you never met the assistant surgeon for your case. The AS is called in by the surgeon if you are having something more than very simple surgery. When I managed a claim office some years ago the general rule is that the assistant surgeon was paid 20% of the amount charged for the surgery.

I wonder if she is kicking him back some money, cause this is like 40% MORE than he got.