mrsperez2015
Junior Member
What is the name of your state (only U.S. law)? California
The issue is coverage for my children. They are covered by my employer group health plan as primary since my birthday comes earlier in the year. My PPO plan has a high family deductible. My ex-husband provides and HMO through his employer. Our children have multiple visits per year. Since the primary plan is a PPO I work with the secondary to meet requirements and maximize the benefits for all their care. I have no issue with the HMO Physicians but with the vendor/delegated services that the HMO does not provide. My primary physicians and medical specialist do not bill me copays or any out of pocket cost. They generally get paid for all routine care and once deductible is met way in excess of what my secondary copays would be. The issue is the other service provider group that the HMO contracts to provide specialized care that both my children need. Once I solved the issue of the variable copayment amounts which floated from $25 to $80 per visit, they finally settled that the correct copayment is $25 per visit. In 2014 Child A had had 26 visits and Child B had 32 visits. Ten of these visits were covered by my EAP plan at 100% so those were removed and they were compensated $750. This left Child A with 21 visits and Child B with 27 visits.
After the deductible was met on the primary plan paid $313.12 towards the 21 visits for Child A and $721.82 towards the 27 visits for Child B for a total of $1034.94.
The provider group has been balance billing all along and after letters and appeals with little to no progress the HMO finally interceded and reviewed the charges. They are now advising me that my balance is $445 for Child A and $325 for Child B they provide a sample explanation of why but no detail or summary of claims. And no matter how many times I ask I can never seem to get a straight answer on what the HMO pays the provider group.
The HMO basically is asking me to pay for the claims applied to deductible earlier in the year 17 for Child A $445 and 13 for Child B $325 for a total of $760. Forget that the summary amounts don�t add up, that is the least of my worries.
I have tried to explain that with 27 and 21 visits the total copayments would have been $1200. They received $1034.94 from the primary plan so my balance would be at most $165.06.
All in all with EAP, the PPO they have received $1784.94 which I can also say would be more than the sum of copayments for 58 visits at $25 which would equal $1450.
I have taken one more step and filed a complaint with the DMHC because I really would like to see a summary of my 2014 claims.
My children have been in treatment since 2013 and we had no issue in 2013. What�s more we have the same benefits in 2015 and will most likely have more visits since one of my children is receiving treatment for Autism.
I know most would just pay, but we pay so much from premiums and I work hard to make sure I follow all the rules so being asked to pay an additional $760 just doesn't feel right.
Any suggestion on how I should proceed? Am I entitled to know what they are being compensated or what the contract specifics are with the HMO?
The issue is coverage for my children. They are covered by my employer group health plan as primary since my birthday comes earlier in the year. My PPO plan has a high family deductible. My ex-husband provides and HMO through his employer. Our children have multiple visits per year. Since the primary plan is a PPO I work with the secondary to meet requirements and maximize the benefits for all their care. I have no issue with the HMO Physicians but with the vendor/delegated services that the HMO does not provide. My primary physicians and medical specialist do not bill me copays or any out of pocket cost. They generally get paid for all routine care and once deductible is met way in excess of what my secondary copays would be. The issue is the other service provider group that the HMO contracts to provide specialized care that both my children need. Once I solved the issue of the variable copayment amounts which floated from $25 to $80 per visit, they finally settled that the correct copayment is $25 per visit. In 2014 Child A had had 26 visits and Child B had 32 visits. Ten of these visits were covered by my EAP plan at 100% so those were removed and they were compensated $750. This left Child A with 21 visits and Child B with 27 visits.
After the deductible was met on the primary plan paid $313.12 towards the 21 visits for Child A and $721.82 towards the 27 visits for Child B for a total of $1034.94.
The provider group has been balance billing all along and after letters and appeals with little to no progress the HMO finally interceded and reviewed the charges. They are now advising me that my balance is $445 for Child A and $325 for Child B they provide a sample explanation of why but no detail or summary of claims. And no matter how many times I ask I can never seem to get a straight answer on what the HMO pays the provider group.
The HMO basically is asking me to pay for the claims applied to deductible earlier in the year 17 for Child A $445 and 13 for Child B $325 for a total of $760. Forget that the summary amounts don�t add up, that is the least of my worries.
I have tried to explain that with 27 and 21 visits the total copayments would have been $1200. They received $1034.94 from the primary plan so my balance would be at most $165.06.
All in all with EAP, the PPO they have received $1784.94 which I can also say would be more than the sum of copayments for 58 visits at $25 which would equal $1450.
I have taken one more step and filed a complaint with the DMHC because I really would like to see a summary of my 2014 claims.
My children have been in treatment since 2013 and we had no issue in 2013. What�s more we have the same benefits in 2015 and will most likely have more visits since one of my children is receiving treatment for Autism.
I know most would just pay, but we pay so much from premiums and I work hard to make sure I follow all the rules so being asked to pay an additional $760 just doesn't feel right.
Any suggestion on how I should proceed? Am I entitled to know what they are being compensated or what the contract specifics are with the HMO?
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