Question:
Just what do they mean max. out of pocket?

I have a 5000.00 out of pocket max. for out of network. Hospital is out of network, Dr. is not. Does that mean that would be the most I would pay for surgery? I know insurances can vary, I am considered a hmo. Answers anyone?    — [Anonymous] (posted on August 16, 2001)

August 16, 2001
Maximum out of pocket means the maximum money you will have to spend. So that makes sense for your Hospital charges, the phsyican is participating so it would need to be authed and would be considered if approved your in network benefits and who knows what those are?
   — Dawn R.

August 16, 2001
Make sure you check if both your doctor and the hospital will accept customary and reasonable payments, ie the amount your insurance decides to pay for the hospital stay and the surgeon. Even if your max out of pocket is only 5000, but the hospital charges $35,000, if they refuse to accept the customary and reasonable payment, YOU will be responsible for the difference as they are an out of network provider. Make sure you are aware of any paperwork you sign that could be obligating you to pay the difference and see if you can get the hospital to write a statement with the fact that they accept customary and reasonable payment. There have been many people who have gone out of network and just assumed that they are only responsible for their max out of pocket. That maybe true in some cases, but obviously it's something that's really important to get verified yourself. You don't want to take your doctor's office second hand word on it or even the insurance company as once they insurance company pays customary and reasonable on an out of network provider they may not care. Make sure you know all the facts before committing yourself as there are always other insurance companies as well as other doctors and hospitals! Good luck! *hugs* Anita
   — Anita N.

August 17, 2001
I agree w/the good advice on the previous answer. I went out-of-network for my surgeon. I was told my out-of-pocket expenses would not exceed $980. That was a joke because once the surgeon's bills came in they paid a very low "reasonable & customary" amount & I was responsible for the balance. Thank goodness the hospital I used was in-network or who knows how exorbitant my bills would have been.
   — Lori_B