# I guess we're screwed, right? Healthcare PPO payment issues. **URL:** \ **Category:** Factual Questions\ **Created:** [September 2, 2009, 1:45am UTC](https://boards.straightdope.com/t/i-guess-were-screwed-right-healthcare-ppo-payment-issues/508588 "2009-09-02T01:45:42Z")\ **Posts on this page:** 7\ **Page:** 2
**Author:** ![mhendo](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/mhendo/32/3159_2.png) [@mhendo](https://boards.straightdope.com/u/mhendo)\ **Post date:** [September 4, 2009, 8:08am UTC](https://boards.straightdope.com/t/i-guess-were-screwed-right-healthcare-ppo-payment-issues/508588/21 "2009-09-04T08:08:22Z")
> [@Markxxx](#): > > I’ve actually had this happen to me three times. Because in hotels, the industry where I mostly work, usually every year they switch companies to save money on insurance. > > Anyway when I go to a doctor the first thing they do is ask to see my card. Then they copy it. If the card isn’t valid, two times in doctors offices and once in a dentist, they’ve said to me "Mark, we no longer take your insurance, if you want to see the doctor (dentist) this visit you’ll have to pay. I saw the dentist so he could finish the capping of my tooth, but I found another doctor. > > And when I’ve had tests done, every clinic and hospital I’ve been to has insisted I give them my insurance card first before I get the test done. > > So I think, at least in my experience, that they didn’t see your insurance card and tell you. They did see the insurance card. When my wife called in for the appointment, they knew which health plan she was with, because it was in their records. And then, when she went in for the mammogram, she had to show them her insurance information. And neither time did anyone take five seconds to say, “Hey, just so you know, we’re no longer part of that PPO network.” ---
**Author:** ![mhendo](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/mhendo/32/3159_2.png) [@mhendo](https://boards.straightdope.com/u/mhendo)\ **Post date:** [September 18, 2009, 7:44pm UTC](https://boards.straightdope.com/t/i-guess-were-screwed-right-healthcare-ppo-payment-issues/508588/22 "2009-09-18T19:44:30Z")
An update, and another question: In the last couple of days (i’ve been busy with other things) i finally drafted letters to the insurance company, and to the medical center. We decided not to send the one to the medical center until we actually received their bill. We were about to send the one to the insurance company yesterday, when we received the bill from the medical center. And that’s where i have a question. The original insurance company Explanation of Benefits laid it out like this: Amount billed: $662.00 Amount Not Allowed: $562.00 Copayment Amount: 39.00 Amount Paid: $59.00 **Your responsibility to pay: $603** And here’s what the medical center bill says: Services total: $662.00 Blue X Credit $622.00 (Payment: $59.00; Contract Adj: $563) **Due at this time: $40.00** So, right now the medical center only wants 40 bucks from us. What’s not clear to me is whether this is going to be the end of it, or whether this is just some intermediate step, and we’ll be hit with a bill for the balance later. I guess what i really need to know is: in a situation like this, **what does Contract Adj. actually mean?** I’m reluctant to send off any letters of complaint right now, because i’m just hoping that $40 is all we have to pay, and i don’t want to draw any attention to the situation now that things seem to be working out. Anyone have any insight into what’s actually happening here, and what might happen next? ---
**Author:** ![Dogzilla](https://avatars.discourse-cdn.com/v4/letter/d/e480ec/32.png) [@Dogzilla](https://boards.straightdope.com/u/Dogzilla)\ **Post date:** [September 18, 2009, 8:04pm UTC](https://boards.straightdope.com/t/i-guess-were-screwed-right-healthcare-ppo-payment-issues/508588/23 "2009-09-18T20:04:03Z")
I think I actually called my insurance company and asked them about the EOB because it gave me some hugely inflated “Your responsibility to pay” number. They just said “That’s the amount the doc billed (pulled out of his or her ass), but which was over and above the contractual amount. You don’t owe us (the insurance company) anything, because you have paid your copay, deductible, whatever. The doc will now bill you. They may choose to bill you a fraction of that amount or you might get hit for the entire $603.” (Using your numbers for the example.) Sounds to me like you pay $40 and fugeddaboutit. The EOB is not a bill. The bill from the medical center is. The EOB is just a statement to show you how much excess cost your medical center is trying to rip off your insurance company for. I’d suggest calling the insurance company, but I wouldn’t wish Insurance Company Voice Mail Hell® on anyone. ---
**Author:** ![doreen](https://avatars.discourse-cdn.com/v4/letter/d/858c86/32.png) [@doreen](https://boards.straightdope.com/u/doreen)\ **Post date:** [September 18, 2009, 9:45pm UTC](https://boards.straightdope.com/t/i-guess-were-screwed-right-healthcare-ppo-payment-issues/508588/24 "2009-09-18T21:45:51Z")
When I’ve seen “contract adj” or something similar, it means that the fee has been adjusted and the provider is accepting what my insurance pays . Sometimes the provider is not actually a participating provider but acts as if they were and accepts the insurance companies payment and your co-payment as payment in full. ---
**Author:** ![nivlac](https://avatars.discourse-cdn.com/v4/letter/n/3bc359/32.png) [@nivlac](https://boards.straightdope.com/u/nivlac)\ **Post date:** [September 18, 2009, 11:19pm UTC](https://boards.straightdope.com/t/i-guess-were-screwed-right-healthcare-ppo-payment-issues/508588/25 "2009-09-18T23:19:11Z")
Just pay the $40. You pay what the medical center (the service provider) says you owe, not what any statement from the insurance company says. And “Contract Adj” is an adjustment to the amount billed because of some prior agreement between the service provider and your insurer. ---
**Author:** ![mhendo](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/mhendo/32/3159_2.png) [@mhendo](https://boards.straightdope.com/u/mhendo)\ **Post date:** [September 20, 2009, 6:29pm UTC](https://boards.straightdope.com/t/i-guess-were-screwed-right-healthcare-ppo-payment-issues/508588/26 "2009-09-20T18:29:21Z")
Thanks for the replies. I sincerely hope y’all are right. We dropped the check for $40 in the mail as soon as we got the bill, and hopefully this will be the last we hear of the matter. Knock wood. ---
**Author:** ![gurujulp](https://avatars.discourse-cdn.com/v4/letter/g/ba9def/32.png) [@gurujulp](https://boards.straightdope.com/u/gurujulp)\ **Post date:** [September 22, 2009, 7:03pm UTC](https://boards.straightdope.com/t/i-guess-were-screwed-right-healthcare-ppo-payment-issues/508588/27 "2009-09-22T19:03:56Z")
> [@mhendo](#): > > An update, and another question: > > In the last couple of days (i’ve been busy with other things) i finally drafted letters to the insurance company, and to the medical center. We decided not to send the one to the medical center until we actually received their bill. We were about to send the one to the insurance company yesterday, when we received the bill from the medical center. > > And that’s where i have a question. > > The original insurance company Explanation of Benefits laid it out like this: > > Amount billed: $662.00 > Amount Not Allowed: $562.00 > Copayment Amount: 39.00 > Amount Paid: $59.00 > **Your responsibility to pay: $603** > > And here’s what the medical center bill says: > > Services total: $662.00 > Blue X Credit $622.00 (Payment: $59.00; Contract Adj: $563) > **Due at this time: $40.00** > > So, right now the medical center only wants 40 bucks from us. What’s not clear to me is whether this is going to be the end of it, or whether this is just some intermediate step, and we’ll be hit with a bill for the balance later. I guess what i really need to know is: in a situation like this, **what does Contract Adj. actually mean?** > > I’m reluctant to send off any letters of complaint right now, because i’m just hoping that $40 is all we have to pay, and i don’t want to draw any attention to the situation now that things seem to be working out. > > Anyone have any insight into what’s actually happening here, and what might happen next? When my wife had a Cesarean, the insurance bill showed that the hospital was billing $40K- and the insurance only paid $4K. We got a bill from the hospital showing that the 36K balance was adjusted out, and we paid nothing. I believe, good sir, that you are in the clear! [Previous page](https://boards.straightdope.com/t/i-guess-were-screwed-right-healthcare-ppo-payment-issues/508588.md?page=1)