There are a couple of reasons to share this claim. The first being - OMG, it was expensive! The second being that it nicely illustrates how we handle claims that combine covered and non-covered conditions.
Dallas, a five year old female boxer living in Watchung, NJ, was playing outside for a minute and next thing her mom knows, she's limping. So she carries her in just to find blood all over her hand.
Turns out Dallas had torn a chunk of skin out of her leg, which needed anesthesia to check there was nothing embedded in the wound. While she was under, the vet did a teeth clean and ended up having to pull 13 teeth. Unfortunately, Dallas's policy did not have dental coverage so the teeth cleaning and the extractions were not covered by her policy.
So how did we split the costs of the shared items on the invoice? We estimated that 33% of the surgical time was spent on fixing Dallas's laceration so we split the common items that way.
Here's the invoice without the specific teeth items in it (it would be really really long otherwise - the total bill was $2,696.61) so you can see how the 33% was applied.
|DATE||ITEM||BILLED AMOUNT||Shared?||COVERED CHARGES|
|1/6/2011||Buprenorphine HCL Inj||$42.85||Y||$14.14|
|1/7/2011||Boarding - medical||$52.14||N||$52.14|
The calculation of the refund is as follows (from the Explanation of Benefits):
|STEP 1: Calculate Potential Refund|
|Covered Charges:||(see attached detail)||814.14|
|Annual deductible remaining||200.00|
|Copay 20%||(your copayment)||122.83|
|STEP 2: Compare potential refund against your annual maximums|
|Prior refunds for this policy year||0.00|
|Your total refund is:||491.31|
Eek! That was a big bill. And what's worse is that if Dallas hadn't hurt her leg, her mom would continue to be unaware of her dental issues and Dallas might have ended up much more sick than she already was, particularly as she has a heart murmur.
What do you think?