What do you think of my health care insurance problem?

How much was the procedure? How much has been paid for by First Choice? I would think that Tri-Care should pay the difference.

My questions are: Did you submit the appropriate paperwork to TriCare prior to having the procedure done? Is there a reason this could not be done a military facility (assuming you have TriCare through the military)? Was the doctor (surgeon) not in the TriCare service provider list?

I would start talking to the billing/claims department where you had the procedure performed. They probably deal with insurance rejection a lot more than you do and may have some advice.

Are TriCare And First Choice two separate coverages? If so, what is written in your contracts or information regarding dual coverage?

And I think that @optimisticpessimist is right in saying to talk to the billing/claims area.

@optimisticpessimis I didn’t submit anything to TRICARE prior to the procedure. I had worked with TRICARE cardiologists for 9 years and they only offered me very strong cardiac drugs that did more harm than good. I asked my TRICARE cardiologist if I could benefit from an ablation but was told that my condition wasn’t bad enough. During the last 1½ just prior to the ablation my life was total miserable and I had to have a second opinion from an expert in arrhythmia’s.

The cost of the procedure was $81,000. First Choice paid $42,253.19 and TRICARE said that they would pay $150.

My assumption is the insurance company is trying to dick you over, because its what they do.

Threaten to get a lawyer if they do not pay you the full amount they most definitely owe you. If they still fail to pay, get a lawyer and follow through.

Turn it over to the hospital billing department and tell them you have no money. They will either go after TriCare or accept the $42,000 they have been paid. At least that is a possibility.

I do not know if you already read this. When I have had to use a provider outside the system, I called the doctor’s office prior to going to the doctor for service. I found out how much they charge and called TriCare to find out how much they would pay of the claim. The only advice I still have for you is to talk to the claims department and see if they know of anything else you can do.

@optimisticpessimist Thank you for the link to: “How TRICARE Calculates Payment with Other Health Insurance”. I had not read that but it is consistent with the information I’ve received from TRICARE. I may have to pay $38K when the bill arrives. I will pay it.

Tricare isn’t necessarily responsible for the payment. I know it stinks, but insurance companies have a lot of different ways of authorizing medical expenses. Whenever you have Tricare and an additional insurance, Tricare is always considered a secondary insurance. When they say that the other compant already paid the amount they would have covered, I think it means that is all they would’ve paid as well. So since they are secondary and the allotted amount has already be met, they won’t go over it. If the primary insurance wouldn’t have paid the allotted amount, then they would have paid the difference between what the other company paid and their allotted amount.

Is the hospital trying to get the remaining money from you or are you concerned that they might down the road?

Before you lay out any of your own cash, I would definitely negotiate with the hospital. Often doctors’ fees are based on an expectation of reimbursement but can be negotiated down. Many people don’t realize this.

@gondwanalon Exhaust other alternatives first, because once they get the money they will not give it back. @janbb had a really good idea.

If you haven’t already received a bill, you might not. A lot of insurance companies make deal with hospitals and other providers for what they get paid so they don’t go after their customers for more money.

If you get a bill, definitely try to talk to them before making a payment.

@Seaofclouds I haven’t been contacted by the hospital, just the two insurance companies. They’ve sent me information about what the will pay. It has been 9 months since the ablation procedure and still I have not received a bill. That seems unusually long to me. If/when I receive a bill, I’ve got nothing to lose by trying to negotiate to get it lowered. Thanks for your thoughts and ideas.

I would consult insurance specialists and lawyers to find out what my options were.

So – what did happen in the end?

LOL I wonder why Fluther offered this ancient question to me. Um yeah, what happened?

Tricare forced the hospital to settled on “First Choice Health’s” payment of $42,253.19 as full payment for the procedure arguing that they were charging too much. I didn’t have to pay a dime. Tricare had poor communication with me but great communication with the hospital. But I’m happy that they were there for me.

As I hoped and suspected.

Awesome! I’m glad to hear that!