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CallaFirestormBW -> RE: HEALTH CARE (7/22/2009 10:20:42 AM)
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quote:
The answer is no, thats what Out of Pocket maximums are for.
Out of Pocket Maximums -only- cover allowable charges -after- deductibles have been paid. Any amount -over- the allowable charge can be charged back to the patient and is -not- covered by 'out of pocket maximums'.
Example: I have renal arterial stenosis, secondary to spasticity from multiple sclerosis. Two years ago, I had to have a stent placed in my renal artery, on an emergency basis, when the renal arteries spasmed shut and my blood pressure went through the roof, causing a number of secondary symptoms. I was admitted through the Emergency Room (after a 6 hour wait for treatment and a 2 hour wait after the doctor had decided I needed to be admitted, in order to find a bed for me in the ICU -- which ended up being in the CICU). It took 2 days to arrange for the stent placement, which was placed through minimally-invasive surgery via the femoral artery. I spent 3 days post-op in the ICU, then 2 days on the regular ward. The cost for my treatment was $125,000 (rounded to the nearest $1000), inclusive. The -allowable- charges were $114,000 (leaving $9000 in charges the insurance company wouldn't pay). My insurance company paid 80% of those allowable charges ($91,000). My deductible amount was 20% ($23,000). Three months after I got out of the hospital, I was informed by my insurance company that the hospital was not a 'Preferred Provider' (now mind you, I'm with Blue Cross/Blue Shield here -- the most common carrier in the business -- and this was the main regional hospital in our city) and that I was responsible for the charges in excess of the "allowable charges". My total bill for that stay was $32000, between the deductible and the excess allowable charges. My -maximum- out of pocket for any given year is $5000, which ONLY covers the 20% deductible amount, NOT the "excess charges" amount. What that meant for -me- is that, even after the 'maximum out of pocket' clause, I still ended up owing the hospital $14,000. They were nice enough to give me a $3000 discount because I am a health professional at a nearby hospital -- so after all was said and done, I ended up owing $11,000, even with insurance and even with a 'maximum out-of-pocket' clause in my policy.
(From the Benefits booklet for my insurance plan)
Out-of-Pocket Maximum: Your share of eligible
expenses incurred during a plan year excluding the
copays (medical and prescription drug). After you reach
the out-of-pocket maximum, BCBS SELECT pays 100% of
the allowable amount for covered charges for the rest of
the plan year. Copays do not apply to the out-of-pocket
maximum. Preauthorization penalties and billed
charges exceeding the BCBS-- allowable amount
also do not apply to the out-of-pocket maximum.
Lucky you that you've never encountered any of this in your own experience, and I hope you never do. However, the proof is in the pudding... or the bills, as it were.
Dame Calla
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