6 ms·

This is almost true: you will, in fact, be forever on the hook for any medical expenses charged which exceed the "reasonable" limits your insurer has set for ea

by pinko 5y ago

This is almost true: you will, in fact, be forever on the hook for any medical expenses charged which exceed the "reasonable" limits your insurer has set for each given service, even after you've exceeded your MOOP. So if your physical therapist charges $150/hour and your insurer reimburses $120/hour, you'll still owe $60 OOP for two hours of therapy even if you've exceeded your MOOP. Ask me how I know.

salawat 5y ago
Ah, but I bet if you look carefully, it's probably hidden in the EOB or benefit booklet somewhere, if not, somebody has dome writing to do. Even then, that is not a byproduct of the insurance, but of the "Consent to be treated and statement of patient financial responsibility" form that you almost certainly signed when you went to the doctor. That 120 dollars was still paid without coinsurance or copay from you after MOOP was attained, your physician is just falling back on what you signed to make up the difference. I hate medical billing to the point I dove in to try to figure out how it all works. Can you tell?
OrlandoHakim 5y ago
This happened to me and I found the practice extremely deceptive. In California it is nearly impossible to find therapy or similar services that don’t charge much more than the per service maximums allowed by Anthem Blue Cross (and likely others). This is primarily about out-of-network care, but good luck finding a competent therapist in-network in the Bay Area. For example, the max paid for a therapy visit might be $120 while the providers typically charge $160-180/session. On my plan, out-of-network providers were supposed to be 70% covered but I only learned after the fact that coverage was 70% up to the plan max for the stated service. How was one to know the plan max per service? Therein lies the trick, they won’t tell you until you are on the plan and even then you cannot simply ask for a list of limits by service. You have to ask one by one after you have already committed to the plan. The plan providers do not proactively disclose even the existence of these per service limits during open enrollment, and certainly not the detailed limits. The plan providers continue to do this year after year despite knowing full well that their limits are well below market rates. As a result predicting out of pocket costs for therapy or other mental health services is next to impossible. It feels fraudulent and deceptive even though I suspect they have excellent lawyers who keep them coloring just inside the lines so as not to get sued. Still, I sometimes wonder if a class-action lawsuit might be the best solution.
- sokoloff 5y ago
  > good luck finding a competent therapist in-network in the Bay Area. > For example, the max paid for a therapy visit might be $120 while the providers typically charge $160-180/session. These seem tightly (and unsurprisingly) linked. If you were competent at your job and had a choice to bill $120/hr or $160/hr, which would you choose? If you weren’t competent, having a steady stream of $120/hr customers pipelined to you would be mighty convenient as well.
  - OrlandoHakim 5y ago
    That was my experience in fact. Therapists would participate in-network while young and inexperienced but would move out of network once they had more experience, a specialization, or a more established practice. What that meant was if you had advanced needs you ended up paying out of pocket a lot.
- salawat 5y ago
  Huh. Ya know what? I'm going to go look through some paperwork to see if I can find regular omissions of that sort, because now that you mention it, that seems a rather glaring omission if true.

by pinko 5y ago

salawat 5y ago

Ah, but I bet if you look carefully, it's probably hidden in the EOB or benefit booklet somewhere, if not, somebody has dome writing to do. Even then, that is not a byproduct of the insurance, but of the "Consent to be treated and statement of patient financial responsibility" form that you almost certainly signed when you went to the doctor. That 120 dollars was still paid without coinsurance or copay from you after MOOP was attained, your physician is just falling back on what you signed to make up the difference. I hate medical billing to the point I dove in to try to figure out how it all works. Can you tell?

OrlandoHakim 5y ago

This happened to me and I found the practice extremely deceptive. In California it is nearly impossible to find therapy or similar services that don’t charge much more than the per service maximums allowed by Anthem Blue Cross (and likely others). This is primarily about out-of-network care, but good luck finding a competent therapist in-network in the Bay Area. For example, the max paid for a therapy visit might be $120 while the providers typically charge $160-180/session. On my plan, out-of-network providers were supposed to be 70% covered but I only learned after the fact that coverage was 70% up to the plan max for the stated service. How was one to know the plan max per service? Therein lies the trick, they won’t tell you until you are on the plan and even then you cannot simply ask for a list of limits by service. You have to ask one by one after you have already committed to the plan. The plan providers do not proactively disclose even the existence of these per service limits during open enrollment, and certainly not the detailed limits. The plan providers continue to do this year after year despite knowing full well that their limits are well below market rates. As a result predicting out of pocket costs for therapy or other mental health services is next to impossible. It feels fraudulent and deceptive even though I suspect they have excellent lawyers who keep them coloring just inside the lines so as not to get sued. Still, I sometimes wonder if a class-action lawsuit might be the best solution.

sokoloff 5y ago
> good luck finding a competent therapist in-network in the Bay Area. > For example, the max paid for a therapy visit might be $120 while the providers typically charge $160-180/session. These seem tightly (and unsurprisingly) linked. If you were competent at your job and had a choice to bill $120/hr or $160/hr, which would you choose? If you weren’t competent, having a steady stream of $120/hr customers pipelined to you would be mighty convenient as well.
- OrlandoHakim 5y ago
  That was my experience in fact. Therapists would participate in-network while young and inexperienced but would move out of network once they had more experience, a specialization, or a more established practice. What that meant was if you had advanced needs you ended up paying out of pocket a lot.
salawat 5y ago
Huh. Ya know what? I'm going to go look through some paperwork to see if I can find regular omissions of that sort, because now that you mention it, that seems a rather glaring omission if true.