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I've been researching this but have yet to come up with any resolution that makes sense. I thought I'd try here to see if anyone has any ideas.

We were billed for our daughter's room and board and other services when she was born, 3 days from 1/22-1/24. The EOB shows the provider billed a total of $7,400, but the allowed amount from UHC (insurer) is $33,000 resulting in a negative discount. I understand the basics of allowed amounts and discounts and such, but I've never seen such a large discrepancy.

I've reached out to both the provider and UHC and gotten nowhere. UHC just says that that's the agreed upon amount and the billing is correct with no additional information given. The provider states they will send the bill for review but I've not heard any resolution from them. It's mildly frustrating when you're stuck with an $11,000 bill that doesn't feel correct. Link to a screenshot of the EOB below.

I'd greatly appreciate any help or explanation. I apologize if I've left out any much needed information. Please let me know so I can provide if needed.

Thanks!

EOB

  • Is the hospital in-network for your insurance? Did you meet your deductible with this bill? If so, does your insurance cover room and board at different rates based on if you have/haven't met your deductible? – Nosjack Feb 11 at 16:29
  • The hospital is in-network. This bill would've met the deductible for the year. Reviewing the plan benefits, I don't see anything that states a different rate based on deductibles. Thanks. – djradius Feb 11 at 16:47
  • Did you have $5,716.15 left of your deductible before getting this EOB? – Nosjack Feb 11 at 16:49
  • Yeah. It's a $6,000 deductible of which we'd used $283.85 prior. – djradius Feb 11 at 16:55
  • I haven't seen the billed less than the allowed, but I have a seen a large discrepancy between the amounts for labs; the lab billed $750, and the insurance allowed $20. – Andy Feb 11 at 19:32
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This is some screwy math by your insurance, as you suspected.

First, keep in mind that an EOB is not a bill. The EOB just tells you how much insurance covered/paid, so you can then expect the amount that the doctor will later bill you for (unless everything was totally paid by insurance of course). The hospital may bill you this amount or less (but should never bill your more that what the EOB says you owe).

Now, let's figure out what they did wrong. It looks like you met your deductible with this hospital visit, of which $5,716.15 was left over beforehand. After that point you only pay 20% of the inpatient services bill (line 2: ($318.55 coinsurance) / ($1,592.73 billed) = 0.2). Line 1 shows that $5,716.15 was applied to your deductible, as expected. However, the coinsurance column for this line is wrong. It looks like they took the plan discount, added the amount left over after the deductible, and then took 20%:

$25,599.75 + ($5,830 - $5,716.15) = $25,713.60
$25,713.60 * 0.2 = $5,142.72

What they should have done was take the amount left over after what was put toward the deductible and then multiply that by 20%:

$5,830 - $5,716.15 = $113.85
$113.85 * 0.2 = $22.77

So, the total amount you should owe off of line 1 is $5,716.15 + $22.77 = $5,738.92

You have already contacted insurance, which as you discovered is often not helpful. You can contact them again with this explanation and request a new EOB. If that doesn't work then you might have to formally appeal the claim (insurance will have a defined way to do this).

Bottom line, make sure that on the bill from the hospital you do not owe more than $5,716.15 + $22.77 + $318.55 + $40 = $6,097.47.

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  • Thanks for the explanation. The hospital's bill is identical to the EOB, I just didn't have it on hand for pictures. The hospital states they are just going off what UHC provided them, UHC states it's calculated correctly. I'll keep pursuing this, but I'm glad that I'm not crazy in thinking this looked weird. – djradius Feb 11 at 17:25
  • Additionally, have you ever seen such a large discrepancy between the Amount Billed and the Amount Allowed? I've seen where it differs by a couple hundred or so, but never $25,000. – djradius Feb 11 at 17:33
  • @djradius I have seen big numbers, but not $25,000 big. I suspect that the discount being negative (billed amount is less than the allowed amount) is the real culprit for the bad calculation. They would always expect the billed amount to be greater than the allowed amount (as would I). – Nosjack Feb 11 at 17:41
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    @djradius I think they filled in the columns incorrectly. I think $31,429.75 was the amount billed by the hospital. This was reduced by $25,999.75 due to agreements with the insurance company. The full $5,830 was allowed (as there is no non-covered amount). – Eric Feb 11 at 18:19

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