Last year, my wife and I had UMR insurance. In July, she traveled out of state to California to start a four-month in-person residency at a mental health facility. Our insurance offers an Individual Out-of-Pocket MAX of $20,000 for out-of-network care. So far, none of the claims have been denied.
However, even after reaching our Individual Out-of-Pocket MAX, the insurance dashboard shows we might owe $93,000. For example, one provider billed $6,000, and the insurance only paid $246. They didn’t deny the claim, but shouldn’t insurance cover all the claims after we’ve hit our out-of-pocket max?
What would I actually owe? Does the provider expect to just accept what insurance paid and write off the rest? I really doubt it. Also, it’s been months since care ended in November 2024, but we still haven’t received any bills from the providers.
Insurance keeps saying we’ve reached our out-of-pocket max, and that the most we should have to pay is $20,000. But why isn’t that reflected on their website?
We’ve tried calling the provider, but we’ve only been able to play phone tag for weeks! Any advice or insights would mean a lot.
When you go to an out-of-network provider, they can charge whatever they want. Insurance showing you might owe the full balance is normal. Your best option is to call the facility and ask about their expected payments. Just a heads up, the out-of-network limit only applies to what insurance considers your responsibility. If the provider is out-of-network, they aren’t bound to accept what the insurance pays.
I rushed into this because when my wife was having suicidal thoughts, the last thing I wanted to do was delay treatment over insurance. It was too crucial to wait and potentially jeopardize her safety. I feel awful about the financial mess this has created.
Reeve said: @Arin
I’m really sorry you had to go through that… You made the right choice for her. I hope she’s doing better now. You’ll figure this out.
Thanks for the kind words. She is doing a lot better now. She had some tough post-partum moments but now she’s the mom she always wanted to be.
Reeve said: @Arin
That’s priceless… Make sure to grab all the help you can find, even if it doesn’t cover everything. I know this is a lot to handle.
Having her love life again and being there for our daughter is worth everything. If I had to pay $93,000 to save her, I wouldn’t think twice about selling everything I own. It’s hard not to stress out though lol.
@Arin
Absolutely… That’s a huge amount, and I don’t want to downplay that, but her life is incredibly valuable. You’ll find a way to work through this.
Reeve said: @Arin
Absolutely… That’s a huge amount, and I don’t want to downplay that, but her life is incredibly valuable. You’ll find a way to work through this.
Thanks a lot… Wishing you and your family ongoing health and happiness!
@Arin
That’s such a tough spot to be in… I’m really sorry for everything you have faced. You made the best call for her. As of now, since you haven’t actually received any bills, there’s still a chance that it might not be as bad as it seems. Besides, many providers offer assistance programs to help reduce or even clear medical bills. Just remember that everything can be negotiated, even if you end up stuck with a bill.
You should expect to pay an endless amount for out-of-network services… The so-called out-of-pocket max only applies to what insurance deems reasonable. That means they determine payment based on what they consider the usual costs, which are usually much less than what providers bill. Also, since your provider isn’t part of the network, they won’t write anything off, so they’ll charge you for the balance.
Arin said: @Cleo
How is this not misleading? Can we consumers actually see these contracts?
You’ll need to look at your health insurance policy. It likely states they only have to pay the usual rates for out-of-network services, and you’re responsible for any extra amounts. The insurance doesn’t advise you on what you’ll be covered for regarding out-of-network care, so often it can be confusing. If you haven’t received any bills, it’s possible the provider might write off what the insurance doesn’t pay, but they’re not obligated to. If you want, just call them to clarify. By the way, California has a surprise billing law, which might also help you.
@Haru
Thanks for that! One frustrating thing is we can’t seem to get a hold of the providers due to our busy schedules. Should I take some time off work just to get this sorted out?
Arin said: @Haru
Thanks for that! One frustrating thing is we can’t seem to get a hold of the providers due to our busy schedules. Should I take some time off work just to get this sorted out?
I think you might be better off waiting until the claims are fully processed by both the insurer and provider. Until you get billed, you won’t know what their plan is for the unmatched amount.
Arin said: @Cleo
How is this not misleading? Can we consumers actually see these contracts?
There isn’t a contract with out-of-network providers.
So then why do insurance companies even advertise an out-of-pocket maximum? It really should be stated as ‘the maximum your insurance will cover for out-of-network care.’ Calling it ‘individual out-of-pocket max for out-of-network’ is just confusing.
@Arin
It’s a technical issue, but it certainly doesn’t deliver any real benefit. With in-network providers, once you hit your in-network out-of-pocket maximum, insurance pays the entire covered amount for medically necessary services. This isn’t the case for out-of-network providers since you aren’t protected from balance billing. Your insurance only pays based on a lower rate and your provider can bill you for the remaining balance. It’s one of the major downsides to out-of-network care.