Deductible and out of pocket

[deeclem19 24]

I have a surgery scheduled!!! And I was so excited until I talked to the financial person.......

However I am confused. She told me they take what is left on the deductible and add it to the amount left for out of pocket maximum and that's how much I have to pay for the surgery. Isn't out of pocket maximum, just that..... Maximum? Well, my deductible is $3000 and my oop is $6000, they want me to pay $5700. I spoke with my insurance and they said the deductible counts. I've dealt with insurance billing for over 10 years and that was my understanding. I didn't think to ask because I was just overwhelmed with the whole day today. But you bet I'll be calling tomorrow.

Just wondering if anyone else had similar issues?

[losergrl75 277]

How much of your deductible have you met?

Sent from my XT1565 using the BariatricPal App

[deeclem19 24]

$1600

[Jesm1029 101]

i had to pay deductible i used an in network doctor for my surgery and the amount i had to pay was 3300 and they bill it to you like 2 moths after surgery i have anthem blue cross blue shield

Sent from my SM-G935T using the BariatricPal App

[deeclem19 24]

They are wanting this money in like 2 weeks...... I'm stressing about it. That's a lot of money and we are already spread so thin.

[losergrl75 277]

Your plan should be able to provide you with a letter showing your benefits and how much you have met. You have $1400 deductible left and $3000 coinsurance so oop left to meet is $4400. But your provider can require you to pay the $4400 up front before services are rendered. I would ask where they are calculating the rest of the charges from, perhaps the anesthesiologist or radiologist are out of network which is quite common.

Sent from my XT1565 using the BariatricPal App

[KristenLe 5,979]

@@deeclem19 That makes no sense to me. What is your portion of the cost of surgery? My surgery has a $1,000 deductible. So - that's all I should have to pay to the surgeon. If your surgery isn't covered until you've met your deductible - then I would think you would owe the surgeon $1,400. Out of Pocket is how much you should have to pay in total before insurance covers 100%. That's my understanding anyway. I think you need to get clarification from the insurance and surgeon. You wouldn't owe the surgeon up to out of pocket expenses. You should only owe them the deductible (up to the max deductible met).

[deeclem19 24]

I just called the insurance lady and she said I was right. I most I ever have to pay is $6000. And I've already paid about $1600. She apologized and said it was her mistake. So better, but still a lot of money. Which I expected.

[Purple lady 15]

I agree with @losergrl75. Let's say the total bill for all services is $20,000. Assume everything is in-network. Insurance would first subtract your remaining deductible. 20000 - 1400 = 18,600. You have now met your deductible of 3000 by paying the 1400. The remainder of your bill is 18,600. You most likely have some kind of co-insurance requirement. So let's say that is a 20% co-insurance. 20% of 18,600 is $3720. 3720 owed plus 3000 already paid is 6720 which exceeds your OOP. So you would only be responsible for $3000 of the co-insurance plus $1400 deductible = $4400.

One thing I have noticed is that you are getting a lot of services in a short time frame, it takes a while for your insurance company to catch up on your deductible balance. So perhaps when the hospital checked your deductible did not reflect $1600 already met.

Sent from my SM-T800 using the BariatricPal App

[kellygirl911 0]

My deductible is $1,000 and a total co pay of $4500. I won't pay over $4500 total for everything.