I went through every step that my insurance required. The 6 month medical supervised nutrition counseling. All the tests required including pysch eval. I was told my surgery was covered up to 16,000 for a lifetime max surgery pay out. No problem, my surgeon office told me it was 18-20,000 so I figured worst case scenario I would owe 4,000. The hospital just sent me a bill for 32,000.00. They said insurance only covers for entire cost including hospital stay. I would have never done this surgery had I known. I am devastated and don't know what to do!

That is scary but you have several steps before you have to pay. First call your insurance and find out for sure they have paid the correct amount and appeal it if you don't agree. If it is paid correctly, you will be able to negotiate with the hospital. They should only be able to Bill you for that amount above what insurance didn't pay of the CONTRACTED amount. Hospitals are always going to try to bill you the largest amount hoping you don't question it. Question the heck out of it and negotiate. Good luck!

I have already called and talked to the insurance and they claim it was a maximum of anything "connected" to the surgery, but I was never informed of that. The 32,000 is after the "contracted" amount and the 16,000 applied. The original bill was over 55,000. and also my Surgeon has an additional bill to me for 2800. on top of the hospital bill.

Are the hospital and Dr out of network?

Well first call the hospital billing department. Tell them how much you can afford to pay a month, so your credit isn't ruined while you fight with this.

Also anything surgery related doesn't make sense. Escalate with Blue Cross.

Edited August 31, 201510 yr by OutsideMatchInside

The Hospital and Surgeon are in network. Nobody will take responsibility for not telling me. Everyone is saying it's my responsibility to fully understand my benefits. It's an "addendum" that was never disclosed. How the heck would I know to ask if there are any addendums?

This doesn't make any sense. I've literally never heard of this.

Heck, paying for the sleeve out of pocket (with no insurance) at the hospital where I had surgery was a flat $16,000. And it's a huge, full-service hospital and hosts a bariatric Center of Excellence.

I think there's something you aren't understanding about that bill.

Nonetheless, in your shoes, I would find and hire someone who specializes in negotiating these bills. There are people like that these days. Seriously, that's what I would do.

Good luck to you.

Thank you for responding, unfortunately it's true. I have spoken with all parties involved. There is a secret squirrel lifetime max pay out that no one has anywhere in our paperwork but it does exist. My fight will be based on not being properly informed of this limit. I am feeling more confident that this will be won based on that alone. I just was hoping that someone could give me what they were billed and what the co-pays were so I can use "usual and customary" as another tool to fight with.

Usual and customary doesn't apply to in-network providers. Only the fee schedule applies. Do you have a "maximum out of pocket" for the calendar year?

I do have an out of pocket max but they say this surgery is excluded. I know usual and customary doesn't apply to most cases. I am just trying to find out what I know usual it customary doesn't like to know skates is. I am just trying to find what they would normally pay if my employer group did not put this addendum in place

I have no idea how the post above this went weird lol: I do have an out of pocket max but they say this surgery is excluded. I know usual and customary doesn't apply to most cases. I am just trying to find out what blue sheild of CA would normally pay if my employer group did not put this addendum in place

The rates vary by county. You will need to find someone who lives where you live.

Try calling the California Department of Managed Health. 1-888-466-2219. I went to a seminar recently where one of their attorneys told us that they can help people figure out what's going on, they will review bills and coverages.

Honestly, I JUST got done with BS of CA, and here is the breakdown:

18k for surgery, insurance covered all but 293.67 and then 10% of hospital so 1.8k.

Theres no reason in the world they should be billing you 50+k for a surgery when out of pocket you would be looking at 18-22. Someone is ripping you off, and needs to be held accountable.

This sounds like a problem from the surgeon/hospital side. If your insurance paid the 16k, they did their part, your doctor is the one billing you triple the going rate for out of pocket surgery.

Honestly, I JUST got done with BS of CA, and here is the breakdown:

18k for surgery, insurance covered all but 293.67 and then 10% of hospital so 1.8k.

Theres no reason in the world they should be billing you 50+k for a surgery when out of pocket you would be looking at 18-22. Someone is ripping you off, and needs to be held accountable.

I'm of a similar mind, but I have no idea what's up without seeing your Certificate of Coverage and Benefits/Exclusions. In my case, my hospital visit came out to over $88,000 as the sticker price, but the negotiated amount (in network preferred hospital) was closer to $4500, and my share was $502. My surgeon was something like $4000, and my share was about $700, because of meeting the deductible.

The BS of CA website has a tool that lets you estimate how much things will cost you based on your benefits. So, for example, it said my max was going to be about $2200, because of the household out of pocket maximums.

Try calling the California Department of Managed Health. 1-888-466-2219. I went to a seminar recently where one of their attorneys told us that they can help people figure out what's going on, they will review bills and coverages.

This seems like your best best. Something is fishy about this. What did your approval letter state?