r/HealthInsurance

My husband had an injury to both of his hands which required emergency surgery. He was seen in the ER the same day, given an urgent referral to a hand surgeon who saw him the next day, and taken immediately to the OR. He had staged surgeries over multiple days- all outpatient with no hospital admission. The hand surgeon thoroughly documented that his condition was emergent and a medical emergency per our state's administrative code.

We have Aetna through my husband's job, which is at an HCA hospital. The hand surgeon was in-network, as was the hospital. However, because the hospital was only in-network and not specifically an HCA facility, they're charging us massive penalties based on failure to precertify and not using an HCA facility. However, since the hospital is in-network, we weren't supposed to have to pre-certify at all.

Since it's not an out-of-network provider, all the no surprise act stuff doesn't seem to apply and I'm struggling to find information about our grounds to appeal. Input is appreciated.

Decided to really get it together this year and went to the doctor for so many things that have been bothering me. Between therapy, sleep apnea devices, dermatology appointments, and more, I hit my out of pocket maximum.

I just found out my insurance will likely cover masseter Botox for my migraines so I’m sure as hell gonna get it.

Is there anything else I should consider looking into? I’m relatively healthy but maybe there are some “fun” things I can do to really make sure Cigna has to spend a pretty penny on me.

I'm from a low income family but need an insurance due to having a infection that could come back at any time. What insurance would be the cheapest but isn't scummy?

I'm having a very difficult time with my insurance and the provider I see. We have issues often with billing because of my husband being an out of state employee but never to this degree.

My husband works for Brigham Women's Hospital in MA. We live in the capital region of NYS, outside of Albany. Because of this, we can't use the Mass General Health Plan and we have United Healthcare, Specifically the Options EPO plan. It's the most expensive and comprehensive option for out of state employees. We have no deductible and small copays and pay a premium every month for this.

I have been using Drs within the Albany Med hospital system (including Glens falls hospital and Saratoga Hospital). We live closer to Sar

Saratoga so that's the "hospital" system I use but everyone is under the umbrella of Albany med. Like seriously, pretty much every dr, pediatrician, walk in, specialist is affiliated with Albany Med. The only other small hospital system is St. Peters but they are listed as in network as well.

I have been using Drs within this hospital system, under this insurance since 2022 with no issues. I go into the patient portal and double check before making appointments.

I'm running into a frustrating issue. I had several MRIs and specialty scans in 2024/2025 due to cardio issues and a suspected stroke like event. In Jan 2025 my primary Dr (Wilton primary care, part of Albany Med) ordered a CT of my abdomen, where a small mass on my liver was found. That office contacted my insurance company got a PA for the CT. Then she ordered a MRI that I received in Feb 2025, again PA requested and approved and I had that scan at Saratoga Hospital (in network), small place as the CT. No issues, those claims have been paid.

My cardiologist requested that I get an MRI of my brain to see if there was any blockage or damage. I had this MRI on April 3rd 2025. Unbeknownst to me, the provider (in network) never requested a PA and they proceeded to schedule the MRI (I had to get PA's for other scans from this same providers office) which I got thinking it was fine like the February one.

They were notified that the claim was denied May 15th due to no PA. They didn't reach out until August 3rd inquiring about why it was denied. They were told to appeal by August 11th, they submitted an appeal august 15th which was past the deadline and they were notified Sept 28th that the appeal was denied. They appealed again in Oct and were notified dec 3rd that the appeal was denied due to not submitting the appeal in a timely manner.

I had no idea any of this was going on. June 2026 I got a repeat MRI at the same exact facility, of my brain requested by the neurologist I was referred to in 2025 because the first brain MRI showed lesions on my brain. The neurologists office got a PA and no issues.

The same month I log in to see my brain scan results on the patient portal and see a past due balance of 9k.

I call my insurance and the provider right away. My insurance states that the office never got a PA and since it was an administrative error, they could not balance bill me and they were responsible.

I call the provider who tells me that the provider and facility are not in network so they didn't need to get a PA...?!

I argue that, that's not possible. I've been seeing this Dr since Nov 2024, I had another MRI requested by a DR in the same medical system at the same facility in Feb 2025 and that was approved and processed.

They continue to claim it's not in network so I escalate and it's put into research. My insurance said they are in network and have no idea what the issue is. The annoying thing is I have to call mass general brigham and they communicate with UHC. I have no way to contact them directly. But fine, Mass general teaches out tells them are in network in July and I thought I was good to go.

9k bill is still there and past due, so I call Albany Med billing again. Now I'm told that the provider was in network but the facility was not in network until dec 2025 (UHC says they have been inetwork since 2022) so any scans before that were out of network. Again I explain how I received an ultrasound, a CT, one MRIs and a stress test between Jan 2025-July 2025 without any issues with having those claims processed aside from the April 3rd MRI were no PA was requested.

UHC reaches back out, tells them they are participating that they can not balance bill me. They gave me the name of the rep and told me that she was going to take care of the bill. I wait a week and call this Monday to follow up.

I was told again, it is my responsibility but now they are saying it's because UHC is in network but has no contract... that all they have with Albany med is a "rate agreement" but no contract and there are no stipulations that they need to get PA's and that because there is no contract, they are allowed to balance bill me. I question why all the other Drs requested PAs (I also get Botox for migraines and those need PAs, the echo scan I got from that cardiologist required a PA which they got) and was told they do it out of habit, that there's nothing saying they need a PA. My MIL used to work in PAs for this hospital system and said she has never seen a plan that didn't require a PA for a MRI.

I push back and am told that Mass General Brigham told them in Jan 2025 that they didn't need PAs. I call Mass general and ask for them to find the ref number. On Jan 17th my primary office called inquiring about a PA for the abdominal MRI and was told I did need one. It was approved Jan 28th and I got that scan on 2/11. But also that was a different office. My Cardiologist never requested a PA and didn't reach out to my insurance until August 2025 (Brain MRI was April 3rd 2025).

Albany med is insisting that they can balance bill me because there is no contract and UHC needs to approve it or I am responsible. They have threatened to send me to collections in less than 2 billing cycles.

Mass General and UHC has no idea what they are talking about and told me that a rate agreement is a contract. That an in network provider and facility cannot legally balance bill me but Albany med billing refuses to listen. When I questioned why the other MRI was processed with no issues, I was told that they received a PA but also the PA was not necessary because there is no contract so no language saying they can't balance bill me.

I am exhausted. I have been calling several times a week for over 8 weeks. The provider and the billing department are so rude to me and keep talking to me like I am an idiot. My insurance can not convince them that what they are saying is wrong and fabricated. Mass general said they are just trying to get out of being responsible because they had an administrative error. But I have no idea what to do now? No one can convince them they are mistaken. I didn't schedule a bday party for my 9 year old because I'm terrified I'm going to be on the hook for this somehow. I argued that they shouldn't be balance billing me because of the No surprise bill, but Albany med said that doesn't apply to me because there is no contract. UHC is saying they do have a contract.

What do I do? I called the hospital experience number to complain but no one called me back. I called the federal number to lodge a complaint and am calling the state number tomorrow. Has anyone heard of this?!?

I love my country, USA. I'm 52, and in a position to soon early retire. As I stress test my retirement plan, there are only a few things that could sink it. One of them is healthcare. Though my income will be low and I'll obtain discounts on premiums, healthcare costs are still a major stressor to my retirement plan should I eventually need care.

It seems crazy, but does it make sense to retire abroad (e.g., Costa Rica, Mexico, Malaysia) simply and ONLY because of healthcare costs? Does it seem insane to do that only for healthcare?

It just seems crazy to me to consider where to retire based only on healthcare and no other considerations. I'm healthy, no health concerns, but I have to bridge 52 to 65 before medicare kicks in.

Would you retire somewhere other than USA only because of healthcare? Doesn't that seem totally nuts?

I am a full time college student who is dependent on my dad. I need dental care done, but cannot afford it out of pocket. I tried applying to medicare, but they said my dad makes too much and that once I recieve the decline letter for medicaid I should try applying for marketplace healthcare. I am so confused on what this is... i basically filled out the application (still have not submitted it), but like are they going to email me back potential plans I could qualify for? and do I need to pay for these plans? If I do, can I decide not to go through with it? i am not sure how U.S healthcare works and no one in my family has ever been insured so I have no clue. If someone could explain it like I am 5 years old this would be much appreciated... just trying to fix my teeth :/

My insurance says that it's up to me to contact providers to ensure they actually take my insurance. They say that all they can check is whether a provider is listed in the current directory (the same one I can see on the insurance company website). I can personally attest that plenty of providers in that directory do NOT accept my insurance in reality. And with this insurance plan, it's almost always the case that only a subset of providers at any given location or office are covered -- just because one doctor is covered by my insurance doesn't mean another one at the same location will be.

The big medical group in town says that it's not up to them to determine which providers are covered by my insurance, I have to call the insurance company. They said that all they can see on their end is whether my insurance account is active and if my plan is generally taken by the hospital group. They scoffed at the idea that the insurance said to ask them and said I must've spoken to someone inexperienced. (I've been told this many many times by the insurance.)

There is no way for me to ask the actual provider's office, it's an enormous multi-hospital system and making appointments/insurance/billing are all handled totally separately from the actual physicians.

Who is supposed to be able to say whether a provider is covered?! This buck passing is going to make me tear my hair out.

tl;dr I need to see a hematologist, how do I find out which ones insurance will cover?!

If anyone reading this is searching for an affordable health insurance, please whatever you do, do not make the mistake my family made. We choose MediShare with their seemingly simple process and coverages having what we need. What they fail to let you know is they will fight tooth and nail to not cover a damn thing. I’ve had the coverage for less than a year and will be searching for new coverage beginning of the year. I haven’t had a single defection of a bill from my newborns visits so I am paying the full amount every visit, and when I call MediShare they give some lame ass excuse or simply say you’ll have to call the peds office because they can’t help me. So whatever you do just suck it up and get actual insurance coverage that is guaranteed to protect your family otherwise you have a year full of fighting people on phone calls who don’t know what they are doing or are just making it seem like your fault.

I had a bone marrow biopsy and after my doctor wanted additional testing done on the specimen. Quest submitted a prior authorization request to my insurance, which was approved and Quest then proceeded with the additional testing.

After the results came back and Quest billed my insurance, the claim was denied. My insurance told me the prior authorization wasn’t valid because the date the test was performed was after the date of the bone marrow biopsy/collection (The prior authorization letter stated the dates it was approved from which was after collection date).

When I called my insurance, they explained that because the bone marrow biopsy was performed on X date and the additional testing was performed on Y date, the authorization they approved was considered invalid. Apparently, the service date needed to be associated with the original specimen collection date (Which Quest was aware of as they explained the same to me, but still proceeded with the test).

I’ve contacted Quest numerous times over this because I don’t understand why I’m being held responsible for a $3,000 bill when Quest was the one that submitted the authorization, received the approval, and then proceeded with the testing. The authorization letter even listed approval dates beginning two days after the bone marrow biopsy. If the service date needed to be the specimen collection date, why did Quest proceed with the testing knowing the authorization dates didn’t match?

The frustrating part is that I didn’t even know this additional testing was being performed. I only found out by logging into my patient portal and reading the notes. I never personally requested or authorized this additional testing.

Quest has essentially told me to deal with the insurance issue, while insurance is saying to talk to Quest.

What can I do in this situation? I have filed an appeal with my insurance already and requested a formal review and submitted a complaint to the No Surprises Act which was denied because they're limited to non-emergency services that are out of network.

I’m really struggling to understand how I can be responsible for $3,000 when the testing and authorization process were handled between Quest and my insurance without my involvement.

I have BCBS PPO, So I went to see a doctor that I have been seeing for over a year. The medical group the doctor is with and the doctor are in network. My past 5 appointments have been covered 100% beside a $30 copay.

Well my last appointment was billed at $291 and insurance only covered $95 leaving me with a $195 bill. So I called my insurance and they said basically the only difference between the most recent appointment and the past appointments is the “PFIN number”. Its basically the physicians ID number and for some reason it is different from my past appointments that have been covered.

So even though the insurance person confirmed that the doctor and medical group are in network, because of the way she billed the last appointment, they’re billing it as out of network.

I don’t know what to do next. The insurance person said she’s gonna have the claim reprocessed and corrected but I don’t want this to happen everytime I see the doctor. This pisses me off so much because how the fuck can the insurance company say they’re in network but because of one small ID number bill it as out of network. I’m so angry.

I'll do my best to make this question concise -- I had surgery on May 12, 2026. Bilateral mastectomy with lymph node removal due to BRCA 2 mutation only, no cancer identified previously on either mammogram or MRI.

Because I was the first case of the day on May 12th, I was told I needed to have the lymphoscintigraphy part done the afternoon before the surgery on May 11th.

I was asked to prepay certain amounts by both the hospital and the surgery department itself (to "ensure my place on the surgery schedule"), which I did, knowing those amounts were more than my deductible and OOP maximum and I would just receive a refund after everything worked its way through billing and insurance.

About a month ago I received a refund from the hospital and separate bills from both the pathology provider who looked at my lymph nodes, etc during surgery and US Anesthesia. I paid both of those bills assuming that because I received the refund from the hospital, everything was settled with insurance and that I truly owed these amounts.

As I started to dig into the EOBs from United Healthcare and the bills the hospital provided in MyChart, the numbers don't quite add up and I have a few questions.

1. For the lymphoscintigraphy bill, the hospital billing lists this as one simple entry under the service date of May 11.

From MyChart

UHC has this same service broken out under a few different EOBs:

The pharmacy \"General Classification\" charge

The second pharmacy charge

The nuclear medicine charge

My issue here is the first UHC EOB---the provider billed $5045, but the allowed amount is $8052.30, the amount off which they're basing my 10 percent coinsurance owed amount of $805.23. The claim codes attached to those lines -- ZE says "we have reviewed a claim that had been previously processed. You may owe your health care professional a deductible, copay, or coinsurance." IK says "the unit(s) for this service is within the typical frequency per day. We have based reimbursement on the billed units." 0H says "We received more information and reprocessed this claim. The negative dollar amount shown is the amount previously paid and does not indicate an overpayment." Why would the allowed amount for the procedure ever exceed the billed amount? UHC obviously clawed back some of their payment with their adjustment line but my coinsurance amount is still based off the old "plan allowed amount" Should the "plan allowed" amount have also been adjusted, therefore lowering my coinsurance amount?

https://preview.redd.it/o7lld7cj8lkh1.jpg?width=1447&format=pjpg&auto=webp&s=2e858ec1bb09327cb975ccfad79f454c9fa340ec

I believe this 4th EOB helps partially answer this question as this appears to be the same $5045 pharmacy charge divided by 2 (I assume 1 injection of dye for each boob?) However billed this way, the HH claim code on the second line means "this service has been denied. The number of units billed is more than the maximum allowed per day." Which was the correct way for the hospital to bill insurance? It appears as if split into 2 charges, UHC only allows and pays for 1 charge. But if billed as a single charge UHC allows more and pays more than billed and I get a higher coinsurance charge?

2. For the surgery bill itself (including pathology, anesthesia, PACU, overnight observation stay, etc), the nice neat hospital bill on MyChart and the EOBs from UHC make it difficult to parse out what is what, however, you can get the gist that I paid the $800+ the insurance didn't and have no outstanding balance. However, I received bills from both US Anesthesia Partners and the pathology provider separately. If I paid all remaining responsibility to the hospital, should I have paid these other bills or should these providers have gotten their money from what I paid the hospital? From what I can see on UHC both the pathology provider and US Anesthesia partners are in network to me. I have called the hospital to ask but all they said was "we don't handle their billing."

Surgery bill from MyChart

Or is it that they asked me to prepay $3132.22 on May 8th, They took $2006.13 as part of the lymphoscintigraphy done May 11, they took $849.33 for themselves after the surgery May 12th and refunded me $276.76 on July 21st to cover the amounts I owed the pathologist and US Anesthesia?

Final question: Should the lymphoscintigraphy have been covered by insurance entirely? I've read a couple different things --- sometimes it isn't covered if you don't have a cancer diagnosis (which I don't) and sometimes it is a problem getting it covered if it was done a different day than the surgery itself since usually those things are done same day. I can see that I was billed during the surgery for CPT code 38900 "Intraop Sentinel Lymph Node ID W/ Dye Injection." The lymphoscintigraphy done May 11 was billed with CPT code 78195.

If anyone has read this far, thank you so much

TLDR: if I have questions between EOBs from UHC and the hospital billing itself, who should I be contacting first? The hospital or UHC? I know I can ask the hospital for an itemized bill but without being a coder how would I even know what's appropriate to bill for these procedures or if different diagnosis codes or modifiers would help? It doesn't appear to me that I'm being billed for things not received, just not sure if I: was billed correctly for what was done and if I should have paid the direct bills from pathology and US Anesthesia.

I've been having difficulty breathing and chest tightness for the last 5 days. Chest Xray is clear. I've visited a PCP and pulmonologist, but only given a rescue inhaler with no relief. I run out of breath, just from talking and finishing sentences. I considered going to the ER last night, as I was out of breath, trying to sleep. Being scared of the healthcare bills, does anyone know if medicaid will charge you for ER visit if the findings are normal or if they deem unnecessary?

We have noticed this with both BCBS but mainly Aetna.

When checking a claim, the processed and paid date show up. There’s also usually a “you may owe” amount. But the EOB takes one to two months to process.

For example, for a minor surgery, a claim was received by Aetna on 08/01, processed 08/02, and paid 08/03. EOB Issued date is a big fat ? mark. So it’s still pending with no EOB.

Why is there such a delay? Just curious.

So this morning my wife and I got our healthcare plan through the Maine marketplace for 2025 and 2026. I signed up the both of us with one account via coverme.gov although I have a silver plan and she had a bronze plan. I'm unclear if this is intentional or something I did but we have separate accounts that are also separately paid. Even though I control the coverme account and we're both on it, our actual insurance seems to be separate. We're in a period of financial problems and one of the things we did was take our insurance off of auto-pay. Possibly of importance but I am unemployed applying for disability and have a APTC on the account for my insurance portion. Also not sure if this matters but it is an insurance company that specifically covers New England states (not sure if I'm supposed to/allowed to name names or not)

Earlier this month my wife called in about being behind and what the grace period was. She was told that the grace period was 3 month/90 days and that since she was only in her first 30 days, she should be fine. Since I have a settlement payment on the horizon, she decided to at least pay the last month's premium but crucially made a slight mistake and underpayed her monthly premium by $2.14. We found out it was a mistake and that "partial payments" don't count at all because she got an email that her insurance was cancelled (or she logged into her account and saw it. I'm not 100% sure and she's currently at work). We called to see what happened and was told by the representative that she only had a 30 day grace period, not a 90 day period. We submitted a payment for the missing two dollars but since the coverage was already cancelled paying the balance wouldn't do anything to reinstate the coverage. She also had one unread message but it couldn't be opened and just said she no longer had permission to view it, even though she could view any and all of her previous messages. My only thought here is that the account being linked to me or my coverme account flagged it for the ATCP which gives a 90 day grace period instead of the usual 30 day one.

Is there anything we can do about it? My thought is the call lines are recorded so they should still have record of her previous call, could that be used to re-activate their account as long as we pay the balance due? I don't think losing insurance can be used as a special event for signing up for a new package. Worst case scenario we cross our fingers she stays healthy and just sign up again during open enrollment but I'd like to try and keep her coverage if we can. Secondary to that, her employer doesn't offer health insurance itself but they do give their employees extra pay specifically for insurance coverage. I don't remember exactly how it's worded but its basically like a grant or bonus in place of offering full health coverage since the company is a smaller local business and isn't legally required to offer insurance itself. Thanks!

As an aside, it feels perfectly fitting for the American insurance industry to cancel coverage over literally two dollars though. I understand that it isn't the amount that matter for something like this but two dollars feels like such a kick in the pants

I don't know what to do next, my insurance says there's no record of a claim made on that date/amount, should I contact the provider suing me? I don't live in America anymore (I was there on a student visa) never had issues with this insurance but I don't know if contacting the provider before the hearing date will make it worse?

If this country can put together universal healthcare, I hope it is based off of the KP model. It has its flaws, but it gives amazing access to care because of its semi-closed structure. Near immediate phone or vid consult. If you get a referral, you will receive a same day contact from the dept of the relevant specialist, and your chart follows you were ever you may go. Very streamlined and easy to navigate for patients.

We recently had to switch to Cigna. They have a service called MDLive that their own doctors don't seem to use. Suddenly I am the middle man. I have to find the appropriate specialist from a generic list. I have to contact, schedule and make certain they are in network. Oh but first, I have to arrange for the referral to be sent, and give them 2 weeks to assess before scheduling. "they will contact me" WTF? It is ri-god-damn-diculous. Back to the list I go. Next Dr. same story different bullshit. Just to do a video consult and try to get a consult for 1 referral has been hours online, hours on hold, and multiple conversations with at least 4 different healthcare / insurance industry organizations, and it still isn't booked.

Kaiser spoiled me. There can be long wait times, and it does feel like a meat factory sometimes, but it is professional and efficient. I don't need the illusion of choice to pick a name off a list. I need to be introduced to a competent Dr. so we can get to the issue.

I got a new job this spring and the prescription drug costs under this plan are much higher. Plus, I haven't added a lot to my HSA since I just started and haven't met my deductible yet.

I was just prescribed an epi-pen today and the cost is $370. I triple checked that it was the generic and logged into CareFirst's portal and yep, that's the lowest price they can get me.

Obviously, I need the epi-pen.

But I do not have $370???

I've asked my doctor's office to send to CVS for their out of pocket cash price of $110 for two generics and honestly, I don't even really have $100. But $370 is insane right? Is there any way to get this actually through my insurance at a reasonable price? I don't think I make little enough to qualify for help from the pharma company but ???

And is there any information I can provide to my employer about feedback on this plan?