Most people are probably thinking "ask your insurance provider", problem is I have a broken jaw, so talking is quite the problem for me right now lol.

Anyway, I've just started receiving explanation of benefits from my insurance provider, Horizon BCBS.

I've never had an injury which required multiple doctors/emergency room visits, so I'm having difficulty comprehending the statements. I guess my biggest question, and this is for someone who hopefully has the same insurance, is what is the difference between "subscriber responsibility" and "amount not covered"? They're always two different numbers, but from how I understand it, the subscriber (me) is responsible for the subscriber responsibility, but the not covered amount needs to be paid too. If it's not paid by the insurance company, who is it going to be paid for besides me?

That's getting me nervous, because the subscriber responsibility amounts are not terrible, but the amount not covered numbers are pretty intense, even if I can pay monthly for a while. I was hoping someone could shed some light on what the differences in these two areas are. Thanks!

I can't speak for your insurance carrier and its practices. However, with my insurance, the distinction has a two part meaning. If I use a physician or service that participates in my plan, the doctor/service provider eats the "amount not covered" portion of the bill. The "subscriber responsibility" is all I am obliged to pay. But if I use a non-participating service provider/physician, I am also responsible for that amount.

With a participating provider, they have an agreement with your insurer to take their payment as satisfaction for their services, minus any co-pay or deductible. Therefore any and all costs that are incurred (again, minus co-pays and/or deductibles), satisfies their compensation.

In the case of a non-participating provider, they have no agreement with the insurance company. Technically, you are responsible for the entire bill. However, your insurer pays either you or your provider, according to the their schedule of payments, the amount of money commensurate with the schedule for the services provided. Any amount billed beyond the schedule then becomes your responsibility.

Phew, that's a relief. I didn't want to put numbers up before, but the subscriber responsibility comes to about a grand, which isn't awful. The "amount not covered" was reaching close to five grand, which would've been a real problem. The service provider I'm going to is in-network, thank goodness. Thank you! If anyone else has any info on the BCBS billing policy, let me know if you could.

doowop14 has it right, but I'll also add I'm a Horizon BCBS subscriber in NJ and I can confirm that "subscriber responsibility" is the only number you have to worry about.

Just to provide my two cents, I have an hourly rate that I charge, but have an in network contract with each insurance company where they agree to pay me a set amount for providing services to their members. This contracted amount is less than my hourly rate, thus the "amount not covered." Your "subscriber responsibility" is the amount you are responsible for. And BTW, it is illegal for your doctor to charge you the difference between the hourly rate and the contracted amount.

It is also illegal for your provider to not collect the "subscriber responsibility," and can be insurance fraud. This is looked at as a significant problem by the insurance companies. Look at it this way - let's say I charge $200 for an hour of services. My contract is for $150 with BCBS, with you paying $30 of that. BCBS gets a little peeved if I expect them to pay their share of the contact but don't expect you to pay your share. It's essentially as if I am accepting $30 less than I agreed to bill.

The standard is that a provider needs to make a "reasonable attempt" to collect this amount. Some doctors will send you a couple of bills and forget about it, but they may be playing with fire.

I did not know that part about the provider collecting the subscriber responsibility. I thought it was something they were free to do, but I fully understand after reading your post. Thanks

I edited my first post so people wouldn't read it and think it was an endorsement of what I now know is a shady practice.