Out of pocket payment before Insurance??

[AmandaD. 35]

Ok, I’m sorry for all these questions I’m just new to all of this… so theoretically I’ll get bills throughout my mandatory procedures (therapy, dietician, appts, etc) that will be my deductible that I would need to pay when due. Then I would tell my Bariatric specialists office that I will pay them after insurance processes the claim? Is the out of pocket maximum part of that small chunk bills that I’ll be getting throughout my appts, etc or is that after the surgery as well??

[LookingForward22 320]

08/02/2022 12:43 PM, AmandaD. said:

Ok, I’m sorry for all these questions I’m just new to all of this… so theoretically I’ll get bills throughout my mandatory procedures (therapy, dietician, appts, etc) that will be my deductible that I would need to pay when due. Then I would tell my Bariatric specialists office that I will pay them after insurance processes the claim? Is the out of pocket maximum part of that small chunk bills that I’ll be getting throughout my appts, etc or is that after the surgery as well??

With my insurance there is my deductible (the amount I first have to pay, before my insurance kicks in - on your explanation of benefits you’ll see the provider charge - the negotiated discount and whatever is left you pay out of pocket, and it goes towards satisfying your deductible). I think my individual is $300 my family is $600. Those are the bills you get if they run tests or there’s charges beyond the office visit.  Your co-pay and out of pocket costs go towards satisfying that amount. 

My insurance has co-pays for office visits (not all ins have this, if you do it’s usually written on the front of your card (ex $25 PCP office visit, $25 specialist, it may even list an ER or urgent care). I pay that every time I check out (or some places process that at check-in). 

Once my deductible is satisfied, my insurance will process the bill from all of the submitted claims (applying their negotiated discount with that provider - again, you’ll see that on your explanation of benefits from your insurance as they process each claim) - and my insurance plan will pay 80% of the allowed expenses and I pay the remaining 20%.

You should see an out of pocket maximum that is set in you benefits booklet or listed on your explanation of benefits that comes in a mail from the insurance company when a claim is processed. (we have a new plan that started July 1st, I don’t remember my new limits) … for example an out of pocket maximum could look like: a set amount for an individual (ex. $4,000) or a higher set amount for everyone covered under a family plan (ex. $18,000). So that means if you tally up all the out of pocket medical bills for a member during a plan year, the plan will pay 100% coverage when an individual or family meets that designated amount that they have spent out of pocket. (I’m not sure I’ve ever met that amount, but I think we came close one year when two family members had a surgery… or possibly when I had my kids 20 odd years ago).

The law requires that a facility give a good faith estimate to you upon request, so if you are concerned you could reach out to your program insurance or billing coordinator to go over the financials and expected insurance coverage. I’ve heard of some places requiring payment upfront before surgery and others (like mine) billing post surgery … so your office should be able to tell you their policy. Since mine is within a hospital network, they will also do the zero interest medical payment plans if requested for balances over a certain amount. They should also be able to tell you that policy if you get a pricing estimate.

  My program - each office bills individually for tests and consults, then the hospital will bill me for the surgery, but all accumulate towards the deductible and out of pocket totals. 

I hope that helps.

[ShoppGirl 3,342]

I had a deductible and co insurance and they asked me “if I would like to take care of it beforehand.” I’m guessing if I said no they would’ve expected some sort of payment arrangement before. That being said the same hospital called my husband less than 48 hours after he left the ER to set up a payment arrangement for their estimated charges. They hadn’t even billed the insurance yet and I said I’d rather wait till he get the bill because I believe their estimate was wrong. They were fine with my waiting. If I had to guess, they are most likely going to want at least an agreement to what you are going to pay and when.

[Tomo 1,135]

Once I met my deductible, every procedure, check up... Etc. was covered and then they would bill me for the 20%. Sometimes they just waived it.

[tranquil_chaos 47]

I have Anthem (BCBS) and my deductible is $400 and my out-of-pocket maximum is $2500. I've paid $2100 already because it was the accumulation of all the pre-op testing and appointments I have had since starting the process in Jan 2022.

When scheduling for my surgery, which was August 9th, the surgeon's office called the insurance company 3x to verify approx what my out of pocket remaining cost will be after surgery is billed and they told me $400 to meet my OOP-max and that anything over that would be paid 100%.

But...my specific insurance plan has a $20K max lifetime benefit on bariatric surgery. And when I went in for my consult in Dec 2021, they told me that, after meeting the OOP-max, it would still be $12k that I would have to pay the surgeon's office.

So...I got two drastically different numbers. Either I'm paying $400 or anywhere up to $12k and I have no idea what it will be until the billing goes through. HOW STRESSFUL IS THIS???

Insurance is crazy!

[AmandaD. 35]

1 hour ago, tranquil_chaos said:

I have Anthem (BCBS) and my deductible is $400 and my out-of-pocket maximum is $2500. I've paid $2100 already because it was the accumulation of all the pre-op testing and appointments I have had since starting the process in Jan 2022.

When scheduling for my surgery, which was August 9th, the surgeon's office called the insurance company 3x to verify approx what my out of pocket remaining cost will be after surgery is billed and they told me $400 to meet my OOP-max and that anything over that would be paid 100%.

But...my specific insurance plan has a $20K max lifetime benefit on bariatric surgery. And when I went in for my consult in Dec 2021, they told me that, after meeting the OOP-max, it would still be $12k that I would have to pay the surgeon's office.

So...I got two drastically different numbers. Either I'm paying $400 or anywhere up to $12k and I have no idea what it will be until the billing goes through. HOW STRESSFUL IS THIS???

Insurance is crazy!

That is crazy. This is the first I am hearing of a “max lifetime benefit” for Bariatric - I’ll have to look into that. I still have time I have three options for insurance. BCBS is one of them but I’ve had them before and they were honestly a complete nightmare constantly messing up claims from a pregnancy, so I won’t go with them anymore haha. That also makes it seem like your surgery is crazy expensive lol which procedure are you getting done? My OOP max across the board is 3000 so I’m hoping that’s all I have to pay out of pocket. Hopefully you only end up paying $400! This whole process seems stressful, and long. Hoping to get my surgery summer on 2023! Good luck in your adventure!

[tranquil_chaos 47]

1 hour ago, AmandaD. said:

That is crazy. This is the first I am hearing of a “max lifetime benefit” for Bariatric - I’ll have to look into that. I still have time I have three options for insurance. BCBS is one of them but I’ve had them before and they were honestly a complete nightmare constantly messing up claims from a pregnancy, so I won’t go with them anymore haha. That also makes it seem like your surgery is crazy expensive lol which procedure are you getting done? My OOP max across the board is 3000 so I’m hoping that’s all I have to pay out of pocket. Hopefully you only end up paying $400! This whole process seems stressful, and long. Hoping to get my surgery summer on 2023! Good luck in your adventure!

Yeah, that max lifetime benefit is a really sneaky way for whoever you work for to save money because not all BCBS plans have it written in them. It's your employer that decides. I had the routine RNY done with a hernia repair. And I get what you are saying, it *does* seem like the surgery is going to cost a lot...$20k max benefit from insurance + $12k from me is $32k and that sounds higher than anything I've read about.

[lussa 21]

It depends on the hospital. Both times I’ve had surgery with my insurance (non-WLS) I was billed for my portion after the fact. It’s usually copays I pay up front bc it’s a small charge but larger charges come later. If you’ve gotten preapproved already then the hospital shouldn’t be too paranoid…