Danilynn,
Ross has good advice on this issue. I would add the following:
Look closely at what your insurance company pays and doesn't pay. If you get what's called an "Explanation of Benefits" (EOB), it will have lots of details, including a line item that says something like "total patient responsibility." My experience with all kinds of medical charges is this:
1) The service provider (doctor/hospital/laboratory) sends in a charge.
2) The insurance company decides whether the charge is "Ususal, customary and/or resaonable" (UCR) and may decline or discount the part of the charge that is more than UCR. You may or may not be responsible for the amount that was declined or discounted, depending on the agreement between the provider and the insurance company. Ask your insurance company to be certain. Both you AND the provider can dispute any declined or discounted charges. Also, if the charges are significantly more than UCR, double check with your provider to make sure they a) charged the right amount, b) submitted the correct procedure code with the charge (proceudre codes are standardized across the medical industry), c) submitted the correct diagnosis code with the charge (diagnosis codes are also standardized, and may affect what the insurance company considers "reasonable"). If all else fails, politely ask the provider why the charges exceed UCR
3) If you're in an HMO or PPO, the insurance company discounts the charges down to a rate they have pre-negotiated with the provider. You are usually NOT responsible to pay for this kind of discount; the provider usually takes a "writeoff". Again, ask your insurance company to be certain.
4) The insurance company calculates the percentage of the after-decline and after-discount charges they have agreed to pay on your behalf (anywhere from 50% to 100% seems typical), and sends a check to the provider for that amount, if they are authorized to pay the provider directly, or sends you a check, if you have to pay the provider yourself and get reimbursement from the insurance company. You are usually responsible for paying what is left of the after-decline and after-discount charges.
While I'm not as cynical about insurance companies as Ross appears to be,
I do agree that you have to keep an eye on what and how much the insurance company is paying, you do need to appeal any rejections or reductions the insurance company makes, and you DEFINITELY need to stand up for yourself in dealing with them and feel justified in doing so (afgter all, you've been paying them premiums for years!). I don't think insurance companies are really treating this as a "game," but they are treating it as a profit-making opportunity. They are also typically very large, and have all the usual customer-relations problems that come with a large, bureaucratic organization.
Also, I have found that providers are very much in the same situation as patients are when trying to get money from insurance companies. If you get a bill, and it is declined, call your provider as soon as possible and give them the details. Your provider can appeal the denial, just the same as you can. If you both appeal, you get twice the opportunity for a reversal. If you get an EOB, offer to send a copy of it to your provider. Your provider has much more experience dealing with insurance companies than you have and can be a great resource in working out insurance disputes: a) they have undoubtedly had to deal with similar denials and discounts from your insurance company, b) they submit hundreds or thousands of claims a year, so they know how the "system" operates, and c) they probably have a group of staff (or an outside service) whose full-time job is to work out insurance issues. Demonstrate to your providers that you are willing to work with them in getting the insurance company to pay up. They will usually be much more friendly and more tolerant about outstanding amounts due if they know you're working with them and if they have all the details of your combined efforts.
I know it's a pain to have to go to all this work to pay the bills when you've just gone through a medical procedure, but, unfortunately, that's the way our medical "system" runs (notice I didn't necessarily say "works").
Finally, in your specific case, the fact that your husband had AVR and a double bypass AT THE SAME TIME, may have triggered a "two-procedures-in-one" clause in your insurance policy. My rough understanding of these kinds of clauses is this: the insurance company will pay a reduced rate for the "second" procedure (they pick which one is "second"), probably on the theory that the provider(s) only had to prepare, anesthetize, open up, close up and heal the patient once, (kind of like getting your tires and your shock absorbers replaced at the same time; the mechanic only has to put your car on the lift once).
Sorry to ramble on... I hope this helps and that you get your billing issues resolved to your satisfaction.
