Insurance out-of-pocket maximum

[y0ssarian87]

Hey guys, I'm hoping you can alleviate my fears. I was hospitalized for appendicitis and had surgery (laparoscopic appendectomy) a few days ago. I'm a student who has insurance through my school (CareFirst BluePreferred PPO), and I just want to make sure I'm understanding things correctly.

https://www.umaryland.edu/studenthe...d-insurance-plans/carefirst-health-insurance/

The hospital I went to is in-network, and the annual in-network out-of-pocket maximum is $2,000. So far this year, I've spent $185 in out-of-pocket, in-network costs. There's no way I'll pay more than that $1,815, is there? I know how expensive these procedures can get, and, like most students, I cannot afford tens of thousands of dollars in medical bills.

Thanks in advance!


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[owlegrad]

Call your insurance company. No one here can really answer this question for you.

From the bottom of my heart I do hope that you are understanding things correctly though. Good luck!

 

[y0ssarian87]

Call your insurance company. No one here can really answer this question for you.

From the bottom of my heart I do hope that you are understanding things correctly though. Good luck!

You're totally right. It's frustrating just thinking about it. I need to lay off worrying about this now and just call in the morning. Thanks though for the kind words!


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[confettiflyer]

Definitely reconfirm with your insurance company, and make sure all the providers that saw you (ED doc if applicable, anesthesiologists, surgeons, etc...) are also in-network....the institution/hospital might be in-network, but since physician fees are often billed separately, there's a chance they might not be.

Other than that, that's how I understand it, the remaining you'll have to pay is $1815 and all care thereafter is free until 12/31/16 (go to town this year and see ALL the docs!)

Get well soon!

Just curious, what's the out of network maximum OOP cost?

 

[owlegrad]

Oh yeah I forgot the best part about meeting your deductible is being able to afford ALL THE HEALTHCARE!

So far I have only done that once. I guess I should be thankful for my relative good health.

 

[PharmtoCS]

Your appendectomy would normally be considered an emergency procedure, so your insurance typically should not require you to pay out of network costs to any provider(s), nor would they be allowed to require prior authorization. They should also hold you to your maximum $2,000 maximum out of pocket costs. I would still check with your insurance company to make sure.

Source: https://www.healthcare.gov/health-care-law-protections/doctor-choice-emergency-room-access/

If it eases your mind a little, the out of network maximum would be $7,000 for the year - not tens of thousands, but still not a small amount of money.

 

[y0ssarian87]

Definitely reconfirm with your insurance company, and make sure all the providers that saw you (ED doc if applicable, anesthesiologists, surgeons, etc...) are also in-network....the institution/hospital might be in-network, but since physician fees are often billed separately, there's a chance they might not be.

Other than that, that's how I understand it, the remaining you'll have to pay is $1815 and all care thereafter is free until 12/31/16 (go to town this year and see ALL the docs!)

Get well soon!

Just curious, what's the out of network maximum OOP cost?

I was worried about that (specialists and individual providers not being in-network), and unfortunately, I don't have the names of all the providers I encountered. I won't be able to look that up until I get the statement and explanation of benefits. Until I get the bill, I'm going to hope they were all in-network :-/

The out-of-network maximum out-of-pocket is $7,000. So, not ideal if I have to pay for out-of-network providers.

Thanks for the kind wishes. I've been improving pretty quickly, and I'll be back at school tomorrow.



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[y0ssarian87]

Oh yeah I forgot the best part about meeting your deductible is being able to afford ALL THE HEALTHCARE!

So far I have only done that once. I guess I should be thankful for my relative good health.

I will definitely see all my specialists if I hit my deductible! I've got a few specialists I should see...


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[Caffeine QAM]

the institution/hospital might be in-network, but since physician fees are often billed separately, there's a chance they might not be.

Until I get the bill, I'm going to hope they were all in-network :-/

If it turns out that you are charged for an out-of-network provider, despite going to an in-network hospital, as in the scenario that confetti describes, you should appeal those charges to your insurance company. I know of at least one case of that happening - in the end, it was successfully appealed and the patient did not have to pay more than their out-of-pocket max. In any case, I wouldn't worry about it until after you get the bill. There's no need to look up every provider.

Anyways, sorry to hear that you had appendicitis. Hope the recovery goes smoothyl.

 

[y0ssarian87]

Your appendectomy would normally be considered an emergency procedure, so your insurance typically should not require you to pay out of network costs to any provider(s), nor would they be allowed to require prior authorization. They should also hold you to your maximum $2,000 maximum out of pocket costs. I would still check with your insurance company to make sure.

Source: https://www.healthcare.gov/health-care-law-protections/doctor-choice-emergency-room-access/

If it eases your mind a little, the out of network maximum would be $7,000 for the year - not tens of thousands, but still not a small amount of money.

Thanks for the info and the link! Much appreciated.


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[y0ssarian87]

If it turns out that you are charged for an out-of-network provider, despite going to an in-network hospital, as in the scenario that confetti describes, you should appeal those charges to your insurance company. I know of at least one case of that happening - in the end, it was successfully appealed and the patient did not have to pay more than their out-of-pocket max. In any case, I wouldn't worry about it until after you get the bill. There's no need to look up every provider.

Anyways, sorry to hear that you had appendicitis. Hope the recovery goes smoothyl.

Many thanks! I'll be on the look out for that.


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[owlegrad]

and I'll be back at school tomorrow.

I am so sorry to hear that.

 

[PharmtoCS]

If you do end up getting charged out of network costs, as @Caffeine QAM says, I would definitely appeal/dispute the charges. You would have two very strong points being that 1) your hospital was in network, and 2) the procedure was urgent/emergent and you obviously didn't have the time to make sure all your providers were in-network, or get prior authorization.

Best wishes.

 

[y0ssarian87]

I am so sorry to hear that.

Eh, it'll be nice to get back to things and to see friends. It's a slow week this week, and I'm tired of just lying down. All my teachers were incredibly kind and accommodating. I'm very grateful this experience has been (relatively) painless.


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[y0ssarian87]

If you do end up getting charged out of network costs, as @Caffeine QAM says, I would definitely appeal/dispute the charges. You would have two very strong points being that 1) your hospital was in network, and 2) the procedure was urgent/emergent and you obviously didn't have the time to make sure all your providers were in-network, or get prior authorization.

Best wishes.

Thanks for the advice and kind wishes! I definitely won't be shy about fighting for appropriate charges.


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[BenJammin]

Your hospital being in network means nothing. Is your doctor in-network? Here in Texas it's illegal for a hospital to hire a physician so you may very well be at an in-network hospital being treated by an out-of-network physician.

 

[y0ssarian87]

Your hospital being in network means nothing. Is your doctor in-network? Here in Texas it's illegal for a hospital to hire a physician so you may very well be at an in-network hospital being treated by an out-of-network physician.

Honestly, I was probably too high to catch the name of a few of my doctors. The attending I saw in the ED and one of my surgeons were in-network, but I don't know about the anesthesiologist or any other providers whom I may not have come in contact with (or remembered). I went to the university hospital and many (if not all?) of the physicians are hired under University of Maryland Faculty Physicians, Inc. I don't know if all physicians under FPI are in-network.

Though due to the fact this was an emergency, hopefully it will be treated as in-network regardless. I'll follow up tomorrow. I need to stop speculating.

Thanks for the additional input though. If you're in Houston, I hope you've been staying safe and dry.


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[rph3664]

Don't call the hotline numbers until you get the bill. Not the statement from the insurance company, but the honest-to-God BILL from the hospital.

If you are an independent student and have a low income, the hospital may waive or reduce some of your charges. When the time comes, it won't hurt to ask. In addition, if they offer a discount if you pay the bill by a certain date, take advantage of it.

Your professors have encountered this situation many times, and in most cases, they will be very understanding about it.

 

[y0ssarian87]

Don't call the hotline numbers until you get the bill. Not the statement from the insurance company, but the honest-to-God BILL from the hospital.

If you are an independent student and have a low income, the hospital may waive or reduce some of your charges. When the time comes, it won't hurt to ask. In addition, if they offer a discount if you pay the bill by a certain date, take advantage of it.

Your professors have encountered this situation many times, and in most cases, they will be very understanding about it.

While I'm an independent student, I have a feeling my income was probably too high this past year to qualify for any waivers, but I'll definitely look into it. Thanks for the tips.

I had already called the insurance company before I read your post, but they weren't able to give any information anyway since they haven't received the claims.


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[rph3664]

It will be months before all the claims are settled. And don't throw ANYTHING away for several years, at least. Keep the paperwork all together and in order by date.

 

[Sine Cura]

My nominal (paper) cost of medical costs in 2014 was ~$300,000 (also hospitalized, ended up in ICU) but my out-of-pocket max was $3,000. I don't see where I or you would have room to negotiate to get the actual bill around $3k versus my insurance out-of-pocket maximum being $3k.

 

[sakigt]

My hospital and insurance battled it out and I finally got a bill 10 months after my son was born

 

[owlegrad]

My hospital and insurance battled it out and I finally got a bill 10 months after my son was born

The warranty is almost expired by then!

 

[confettiflyer]

If it gets to that point, certified mail return receipt is your best friend.


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[y0ssarian87]

Just an update: I received all the bills related to the appendectomy and its follow-up, and everything has been processed through insurance. I ultimately only had to pay about $700. $50 for the hospital stay and the rest was to cover provider charges. Labs and imaging were fully covered. The total cost of all the services, providers, and hospital stay came to $27,000.

Thanks for all the advice everyone. It's nice to have this behind me.


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[BidingMyTime]

Your appendectomy would normally be considered an emergency procedure, so your insurance typically should not require you to pay out of network costs to any provider(s), nor would they be allowed to require prior authorization.

Depends on the insurance, many insurances have ZERO coverage for out of network providers, but in an emergency situation, they will pay the lower coverage (which means higher deductible for the patient) for the out of network provider.

So yes, the OP could be looking at the out-of-network maximum (and as confettiflyer mentioned, just because the hospital is in-network, that doesn't mean their ER, their lab services, every doctor and specialist who is associated with their hospital, etc. is in-network on that insurance plan.

So yeah, OP definitely needs to call their insurance.

 

[rph3664]

I'm glad things worked out for you, and you aren't stuck with a big bill.

 

[y0ssarian87]

I'm glad things worked out for you, and you aren't stuck with a big bill.

Many thanks


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[maria1oh]

You can usually work out an interest free payment plan with hospital for the 700 bill. Like offer 50/month

 

[y0ssarian87]

You can usually work out an interest free payment plan with hospital for the 700 bill. Like offer 50/month

Only $50 was for the hospital. The rest were the provider charges (which do not go through the hospital). Regardless, I've already paid it off using money I had saved from work. It feels good to have it all behind me.


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