Health Insurance Jargon

I think your are right. However, I warn you that what your insurance considers the allowable amount and what the doctor or hospital charges may differ. Guess who gets to pay the difference?

In response to "So What Happened"
You can ask, but you never know what will happen during and after the birth of a baby. My first son was seen by a neonatal doc right after birth who charged way more than the "allowable amount." However, considering the situation we didn't even think about anything like that until we got the bill a month later.

The problem here is the phrase "allowed amount." Your doctor may charge $120 for an office visit. Your insurance may "allow" $70 for that visit. That means that the insurance will pay 100% of the $70 it allows, not of the $120 the doctor charges. The $50 balance will be written off if the doctor is a participating provider with your insurance, or is in-network. If not, the difference between what was charged and what was allowed is your responsibility.
This would apply to your hospital coverage as well.

"Allowed Amount" simply means the insurance company will not pay more than a certain amount for a specific service.

For example, if your doc would like to charge $500 for a visit, and your insurance will only pay $150 per visit (what they call reasonable and costumary). So the you and the doc would have to hash it out about the balance.

*Customary, tehehe, sorry

However, most providers participate with BCBS (In-Network) they just CAN'T charge any more for anything than the ins co sees fit.

There is no real way to know the "allowed amount" until you get the bill. You *might* be able to contact the insurance company and get a gestimate of the allowed amount, but I seriously doubt this. The reason why, is because it depends on the hospital, what they charge for each item and treatment, and a whole host of other variables. I worked with insurance in the past and it varies on each thing billed. For example, for a manual adjustment they paid 80% of the allowable amount. The allowable amount was only $40. So the patient ended up paying for A LOT of the treatments, if they were out of network...and sometimes if they were in network. Another thing to keep in mind, is you may have a limit to how much your insurance will pay per year. If the limit is say 10,000 for maternity care and your bill is 11,000...they will only pay up to 10,000 and you're responsible for anything over. You can call your insurance for the amount they will pay per year. Also, you want to call your insurance before you start trying to conceive. Insurance is going through a TON of changes right now and in the coming years. The insurance you have now might not be the same when you do conceive.

When I worked for the eye doctor doing insurance billing, the allowed amount had more to do with the doctor's office than it did the patient. Some insurance companies have certain amounts set for different diagnosis and procedure codes that the doctors are allowed to bill. For example, when we filed a BCBS claim, we would file for the eye exam and refraction. The exam was $65 and the refraction was $15. When BCBS paid the doctor, they would pay only the allowed amount for those two procedures. I believe they paid $40 for the eye exam, and $10 for the refraction. We weren't allowed to charge the patient for the difference. So the allowed amount is what the insurance company has agreed that the doctor will be paid for specific procedures filed to them. Another important factor is your diagnosis code. As long as everything is normal, nothing to worry about, but some diagnosis codes can change the type of procedure. Sometimes patients would come in for a check-up and it turned out they had glaucoma, or something. That means the diagnosis code for glaucoma gets tacked onto the procedure, and it becomes a medical necessity. Anyways, you weren't asking about all that. Sorry.

Hope this is helpful.... If I didn't explain it well, and you are just more confused than ever, send me a message, and I will try again.

A.

I just wanted to add onto Bridgett B. When it comes to hospitals, if you are in the position where you can do research before your hospital admission, make sure that all the doctors you will see at the hospital are part of your insurance plan. It happens a lot, and I've seen it on this site, where people go in for a procedure and it turns out one of the doctors, usually the anesteciologist (sp) is not in plan and they send you a separate bill. Also, check with your insurance regarding the "allowed" amount. Some insurance companies will only pay a limited amount of money per year and then you are responsible for the rest.

well since you have some clarification on the "allowed amount" part, then yes talk to your doctor about what they actually charge and ask the insurance compy what the "allowed amount" is for that location. It literally varies by location because insurance companies have different contracts with different hospitals. Currently, my hospital is in-network, but the doctor is allowed to charge me the remaining balance over the the "allowed amount" so you can still get a bill on top of your deductible for whatever costs are over those amounts. I have had to pay about 300 so far and haven't even had the baby because the insurance only allowed for 50 dollars to be charged, so the doctor sent me the extra 50 that they didn't get paid for.

Is this for a family or just an individual?A hospital stay is expensive going to the ER the room alone can be as much as the deductible the total cost for the ER,lab work,ER Dr.,Pathologist,Radiotion Dr they all have their charges & bill differently from the hospital itself.So you get a hospital bill for $6,787 they deducte a certain percent just for having insurance(In-network provider)if not they don't have to cover any of it, then it is applied to the deductible (depending on how much the insurance will allow this visit)then your responsibilty.The second bill ER doc what his charges are the wrie off for having insurance the dedutible then you responsibilty & so on.
To be perfectly clear on your coverages You need to call customer service of your insurance & ask them...They all run different

Seen your update the OB's office have a "Maternity billing" where you don't get a "Bill till it is all said & done with"Then the bills will be from your OB provider,hospital stay,new born care (Nursery),their pediatrician,Pathologist for you placenta,surgery room (c-section)Anteshsiologist for Epudidural or C-section.So there is alot more to this than just the "allowed amount"