Question:
TO ANYONE WITH PPO+ INSURANCE. I NEED HELP !!!!!!!!!!!!!!!!!!!

I HAVE MET MY $200.00 DEDUCTABLE, AND MY OUT OF POCKET IS $1500 PER YEAR. i HAVE MET $482 TOWARD MY OUT OF POCKET (CAN THE DR. ASK ME FOR THE WHOLE $1500, SINCE I'VE ALREADY MET $482.- SHOULDN'T I ONLY HAVE TO PAY $1018.00) WILL THE REST OF MY BILLS BE PAYED AT 100% SINCE I WILL HAVE MY $1500 OUT OF POCKET MET. THANKS CHERYL    — [Deactivated Member] (posted on June 18, 2003)

June 18, 2003
Cheryl, are you going to a participating surgeon? hospital? etc... if you are then you will have to pay up to your $1500 and everything after that should be paid in full or written off by the doctor... now if you are going to an out of network provider, that's another story. The way these situations work in most instances (not all, but most, please keep this in mind) let's say your doctor charges $4000 for surgery... your insurance says that $3000 is reasonable and customary for the procedure... they'll base their payment on the $3000 not the $4000 and the surgeon has the right to charge you the difference, because he or she is not under contract to not pass along those losses. I hope this makes some sense. Lots of luck!! ~ Kim ~
   — Kimberly J.

June 18, 2003
Yes and no. After the out of pocket is met they pay at 100%, however, it goes by which claim is paid first - so the surgeon may send his bill in a week later, but the anesthesia department or hospital may get theirs in sooner so the $1018 could be applied to anyone who sends in a bill, which would mean your surgeon would get paid at the 100%, or maybe there would be part of his charge paid at the lower percent and you'd meet your OOP and they'd pay the rest of his fee at 100%. So I would offer the surgeon a flat $1000 if they insist on the money up front, and speak with the office manager personally about how long they take to process refunds if other claims are paid first and the surgeon's bill is paid at the 100% or somehow you just don't owe them the whole amount. Definitely do NOT pay the whole $1500.
   — bethybb