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My wife gave birth to our child at home, under the care of both a midwife and doula. Our insurance does cover all of this, but as out-of-network. Total charges for both providers would be $4,600. This is short of our out-of-network deductible ($6k family) and out of pocket max ($14k family). All of our other medical care is in-network, so we won't have any additional expenses to "fill" these up.

Is it worth going through the hassle of collecting all the paperwork from insurance and the providers and then mailing it in? It does not seem necessary to me since insurance probably won't reimburse us anything anyway.

4 Answers 4

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It could be worth it, because even if you expect all other care this year to be in-network, what if you end up needing other out-of-network services out of necessity?

If you prefer to not go through the trouble now, at least find out what the time limit is to submit an out-of-network claim. That way, if you do end up having other out-of-network care that pushes you above your OON deductible, you can go through the trouble to submit this claim later on.

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    OP is only $1,400 away from meeting their deductible. Basically, all it would take is one OON X-ray/MRI or specialist visit...
    – 0xFEE1DEAD
    Jul 19, 2023 at 21:09
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    Or an ambulance, which I've been told are often (but by no means always) out of network, and for which you don't get a choice of provider.
    – Bobson
    Jul 21, 2023 at 0:20
  • Or anesthesiologist, surgeon, certain labs, etc.
    – 0xFEE1DEAD
    Jul 21, 2023 at 20:38
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    @njzk2 it depends... but it's not too far fetched
    – 0xFEE1DEAD
    Jul 22, 2023 at 1:12
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    @njzk2, out-of-network, pre-deductible, yes, this amount is on par with what I (as an American whose household consumes rather a lot of healthcare) would expect. Jul 22, 2023 at 23:48
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Yes it could be worth it. The insurance company will have two deadlines: last day to receive treatment, and the due date for all claims. If you need another claim late in the insurance year you could be scrambling to gather the required documents from the first out-of-network event before the paperwork deadline.

Total charges for both providers would be $4,600. This is short of our out-of-network deductible ($6k family) and out of pocket max ($14k family)

The complicating factor is that when you submit the out-of-network claim you may find that the insurance company only credits you with paying a portion of the full bill. If the in-network negotiated rate was only $3,000 then when calculating the out-of-network deductible they will ignore the extra $1,600.

Knowing your real status before you need to make another decision late in the insurance year would be nice to know. It may be hard to get this information before submitting the claim.

Of course if you have Health savings account or flexible spending account and you want to be reimbursed, then you need to follow those submission rules.

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    In South Africa, i always submit claims even if they are not covered, because they're still a tax deduction. The medical aid submits a tax report listing all unpaid claims and their value for tax purposes.
    – stanri
    Jul 20, 2023 at 17:06
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One time an out-of-network provider that I gave my insurance info to filed the claim for me. I and the provider both knew it was out of network. To my surprise, the claim ended up getting covered as in-network. This was without me even asking for it. Looking back I wish I had inquired about the details, because I'm curious, but I suppose I didn't because in the back of my mind I wondered if I asked for more details if they might change their mind. I've heard that some insurance companies do "internal reviews" and can voluntarily approve out-of-network claims as in-network. I'm not sure if that's what happened to me, or if it was possibly an error. My point here is, other than a small amount of time, it doesn't hurt to submit the claim, especially if the provider can do it for you. The other answers have also provided some other potential advantages. If it were me, I would file it.

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Much depends on what constitutes out-of-network care. Besides the childbirth-related providers you have used, your network may not cover anything out of state. If you have medical needs while traveling, you may get no reimbursement. However, it would be credited to your OOP balance. There should be no financial downside to filing claims for out of network care you received, just the hassle of paperwork.

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