My health insurance company won’t use the word “covered.” They only use the word “consider,” even when the category is “benefits and coverage.” One of their agents told me they can’t use the word “cover.” For example, in a recent communication they said, "Home health care must be approved in advance, (pre-authorization), and is limited to 90 visits per plan year. Once approved, services provided by an In-Network PPO provider will be considered at 100 percent of the allowable charge with no co-pay. “ This statement doesn’t make any sense. They said it has been “approved.” What is left to “consider?”

I recently had a doctor’s visit wherein I was given Botox injections to aid with migraines. When looking up the cost ahead of time, I was told that with insurance the cost was typically $200, and without insurance it was about $600. I’ve just received the bill from my health insurance provider, and according to them, they covered approximately $2000 of the procedure which leaves me paying $750. That’s more than even the estimate WITHOUT insurance. I’m not sure how this became such a ludicrously expensive procedure compared to estimates online. Does anybody have experience with this sort of price gouging before? I’ve already called the hospital and they insist that the cost of the procedure is $2000, and then there were additional costs for “processing fees” due to my insurance. What is going on here? Let me know if there’s another subreddit I should be posing this question towards, too. Thanks!

I (23, F) had my first pap smear this year and during the exam, the doctor ordered I have labs done as well. He collected my sample, but now I have a bill in the mail because the lab did testing. I am just so confused because I thought this would be covered since it’s part of my preventive annual exam. I am not sure what to do, should I call insurance or the lab who did the testing? Do I call the doctors office? Do I call insurance and ask to appeal? This is my first time navigating this and I’m not quite sure what to do.

State is Michigan. I want to keep this as private as possible. Basically I had a double mastectomy back in the beginning of January. It was supposed to include liposuction on my sides to prevent 'dog ears'. I traveled 9 hours for this surgery. The swelling was so bad under my armpits I couldn't really see the open wounds. When I would do my cleaning and dressing changes every day I noticed a lot of discharge and blood. I had both of my sisters look at the wounds since I couldn't see them. I ended up going to the ER. The did cultures of both side wounds and started me on an IV antibiotic and an oral one. I contacted my surgeons office and got scheduled with a PA. They tried saying there was no infection and just to put Vaseline on it. They then extended my LOA at work. The ER contacted me and said that I had E. Coli and a staph infection. They changed the antibiotics because the one they prescribed wouldn't treat the infection. I relayed this info to my surgeons team. At this point I still haven't met with my surgeon after two months. I googled how to treat the wounds and took the care into my own hands. No doctor in my area will touch the surgical sights since they didn't perform the surgery. Two months later and I still have an open wound with discharge. Fast forward to this past Friday my health insurance sends me a subrogation claim letter to fill out. I have never heard of this before. It wanted me to file a police report and a LARA report. It also asked if I've hired an attorney. I called the state police post and they said to call the attorney general for any medical malpractice suits. So my question is how do I find the proper attorney and what are my steps now? I live in a small town and don't even think there are any attorneys that deal with medical malpractice. I have very detailed documentation of my infection and medical reports. Any advice is welcome.

I picked up a few prescriptions in January for a Tier 2/$30 copays. This was a transition fill because my employer switched pharmacy benefits manager (PBM) and the medications were not on the new formulary. They said the lower cost was a grace period and standard of care while appealing for an Exception For Coverage. A few weeks later my Exception For Coverage for the medications were approved so I paid Tier 3/30% coinsurance on the next fills in February. The Exception For Coverage was backdated to January 1st, 2025. Then, the following month it looks like the PBM reprocessed the January fills as a Tier 3/30% coinsurance and the additional cost was applied to my out-of-pocket maximum accumulator through my health insurance. I'm not sure what is going on here? I called the PBM and was advised that they will not recoup cost from me and they will not ask the pharmacy to reprocess the claim. The OOP max was never mentions previously, but the representative confirmed that my current out-of-pocket maximum (with the added amount) was accurate as well. Is this common practice for PBMs? Or, could it have been a system error? Has anyone else had something like this happen to them? I am so confused about this because I have not been billed for the additional increase in coinsurance from the PBM, but it feels like fraud since I know the numbers do not add up.