Out-of-Network Bills: Understanding Coordination of Benefits

Imagine receiving a surprise medical bill for hundreds of dollars despite having health insurance. It can be a frustrating and confusing experience, especially if you believe the service should have been covered by another policy. This is often the case when individuals have dual coverage, such as under their own insurance and a parent’s plan.

What is Coordination of Benefits (COB)?

Coordination of benefits (COB) refers to the process of determining which health insurance plan is primarily responsible for paying for a claim when an individual is covered by multiple policies. COB is especially important for individuals who have both their own health insurance and a secondary policy, such as a parent’s plan.

In most cases, your own health insurance will be considered the primary payer, and the secondary insurance (e.g., your parent’s plan) will cover any remaining costs up to the limits of its policy.

How Does COB Work?

The COB process typically involves the following steps:

1. You submit the claim to your primary insurance plan.
2. The primary plan reviews the claim and determines its liability.
3. If the primary plan does not cover the full cost of the claim, the remaining balance is sent to the secondary plan.
4. The secondary plan reviews the claim and pays up to the limits of its policy.
5. You are responsible for any remaining balance not covered by either plan.

How to Handle Out-of-Network Bills

If you receive an out-of-network bill, there are a few steps you should take:

1. Determine Which Plan is Primary:

Contact both insurance plans to inform them of your dual coverage. They will coordinate to determine which plan is primarily responsible for paying for the claim.

2. Contact the Doctor’s Office:

Provide the doctor’s office with proof of coverage for both insurance plans. Ask them to submit the claim to the primary plan first and then to the secondary plan.

3. Avoid Using Your Insurance as Primary:

If possible, try to avoid using your own insurance as the primary payer, as it might result in claim denial due to the doctor being out of network.

4. Request an Appeal:

If your insurance company denies the claim, you can request an appeal. In your appeal, you should provide evidence that the service should have been covered by the primary plan.

5. Negotiate with the Provider:

If your appeal is upheld, call your insurance company and ask them what they would have paid an in-network provider for that service. Then call the provider’s billing office and ask if they will accept the in-network price as payment in full.

Conclusion

Understanding coordination of benefits is essential for individuals with multiple health insurance policies. By following the steps outlined above, you can ensure that you receive the coverage you are entitled to and avoid unexpected out-of-network bills. If you need further assistance, contacting a licensed agent who specializes in health insurance can provide valuable guidance.