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Why? Can you give me an example here, particularly as it relates to a medically necessary surgery or procedure? Or does it come down to difference in interpreta
by sgerenser 4y ago
Why? Can you give me an example here, particularly as it relates to a medically necessary surgery or procedure? Or does it come down to difference in interpretation of what is medically necessary?
- jjav 4y agoI don't have a specific example handy, it's been a few years. How it works is that blue shield (with employers I've typically always had blue shield in California) sends a statement saying your doctor visit cost $XXXX, blue shield will pay $YYY and this will credit $ZZZ towards your annual out of pocket total. But $XXXX - $YYY > $ZZZ, so what I actually had to pay to the doctor was more than blue shield credits me for having paid. So at the end of the year what I've actually had to pay has been well above the so-called "out of pocket maximum". It doesn't happen most years (to me), but has happened on multiple years.
- sgerenser 4y agoBased on the providers contract with Blue Shield, you should not be liable for anything beyond what they consider to be your out of pocket cost. If they requested more, you could have just refused to pay it, and get your insurance involved if they pushed back.
- maxerickson 4y agoFor covered care anyway. Labs that don't have a clear medical justification are probably easy to end up paying for out of pocket without getting the amount counted against the out of pocket insurance limit. Would expect that to be clearly delineated on the bills though.