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My wife and I utilized the services of a chiropractor who happened to be out of network with my insurance provider (will name in an edit if it is important). My Explanation of Benefits says that out-of-network services will be covered 70% (and so I have to pay the 30%). There are no limits and hitting the deductible is not the issue here.

Our insurances are like (acronyms instead of real names):

Wife - WIP (Wife's Insurance Primary through her employer) and MI (My employer provided insurance as her secondary)

Myself - MI (Mine as my only/primary insurance)

MI works such that the patient has to pay the provider and will be reimbursed through a check based on what was supposed to be covered by them. So when I got my reimbursement here is what I got per service.

Chiropractor bill: $125 (for both me and wife)

MI's Cheque received for me: $14.XX - This is clearly much less than 70% of $125. So I looked at their split up. From the $125 they marked close to $100 as not covered or not applicable and then paid $14 (which I am assuming is 70% of what they deem is the eligible service cost ~$20).

MI's Cheque received for wife: WIP covered some amount and then passed it to MI. MI sent a check of $45-$50 for the remaining. This is very odd to me. If the insurance deemed only $20 as payable and paid 70% of it then how is it that they paid more towards my wife's bill?

How does this work? I have had stressful calls with MI, at the end of which, they don't explain anything and refuse to try to give information.

It'd be great if I could also get advice/suggestions on the next steps to salvage this situation because this added a bulk of unexpected and uncalculated expense to our family.

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    They pay 70% of what they would have paid an in network chiropractor, not what you actually paid. This is often much much less. – Vality May 8 at 22:21
  • Still doesn't explain how they paid more on my wife's bill. That is putting aside how low they in-network the payment is compared to any market rate. – perennial_noob May 8 at 22:22
  • Are you and your wine on the same insurance? Im confused if you claimed with both or what? – Vality May 8 at 22:26
  • Edited my post. Wife is covered by hers and then mine as secondary. I am covered only by mine. – perennial_noob May 8 at 22:28
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    All we can do is speculate, this is not an answerable question. It could be that one of the two payors made a mistake, or they're right and something you're telling us is incorrect because you've misinterpreted something. I would not be surprised if "MI" (incorrectly) paid according to what "WIP" allowed, instead of adjudicating against their own benefits, which is something some payors do as default when they're secondary. – dwizum May 9 at 12:57

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