Question:
HAS ANYONE BEEN BILLED ABOVE THE MAXIMUM OUT OF POCKET?

MY INSURANCE IS HUMANA, THEY TOLD ME MY MAXIMUM OUT OF POCKET WAS $2250 AND NOW I'M GETTING A BILL FOR $7000+. BARIATRIC CENTERS SD THE SURGERY WOULD COST B/W 30,000 AND 40,000, MY INSURANCE CO WAS BILLED FOR 62,000! CAN ANYONE HELP??    — Debbie W. (posted on May 12, 2003)

May 12, 2003
Since I'm planning on using an "out of network" facility, I was told that I am responsible for 30% of Reasonable and Customary (R&C) charges up to $4000.00 (out of pocket maximum). However, I am also responsible for all charges billed by the hospital in excess of R&C. Ex. Hospital bills 40,000, Reasonable and Customary is determined to be 35,000. I have to pay 4,000 - my out of pocket maximum on the 30% of 35,000 as well as 5,000 for the difference between the 40,000 billed and 35,000 R&C, for a total out of pocket of 9,000.00. The wording in insurance policies can be very misleading and unless you ask the right people the right questions, you don't always find this out. I was told that you can sometimes get the hospital/facility to work with your insurance to get more covered as R&C. Good Luck.
   — Carolyn M.

May 12, 2003
Carolyn is right on target. I'm a licensed insurance agent in Virginia. Now, also keep in mind that the hospital might be in network and the doctor might be out of network, as you will be getting separate bills. As Carolyn mentioned, sometimes doctors or facilities will discount the amount over and above the usual and custormary. All they can say is no, so don't be afraid to ask. having worked in employee benefits and health insurance for 10 years I also know that hospital/physician billing can make mistakes. I myself have received charged/bills for the amount above the U & C when they were in network and not allowed to charge me that. They will correct it. Also, some things may not be covered by insurance....like supplies used outside the hospital....if they send you home with a hand full of bandaids (silly example)...but my daugther broke her finger and they put a little splint on it....I could have bought at the drug store and it was not a covered item. NOTE TO ALL...ask for an itemized bill....you will be amazed what they charge for a tums...and maybe you never got one!
   — Sharon B.

May 12, 2003
As long as you went to an in-network provider your out of pocket limit is it. You are not responsible for anything above that. Report it to your insurance company! However if the provider you went to was an out of network provider, sometimes there are no limits on out of pocket expense check your policy. Best Wishes:)!
   — Kimmie C.