Hi! I need some advice. I’m having surgery at the end of the month and have Blue Cross Blue Shield PPO with a $2,500 deductible and a $5,500 out-of-pocket max. My provider says the surgery will cost about $7,500, and they insist I have to meet both the deductible and out-of-pocket max before insurance covers 100%.
From my research and talking to BCBS, I was told that once I hit $5,500, insurance covers the rest, and the deductible counts toward that amount. At my appointment, the provider mocked me and said I had to meet both amounts. They even collected $7,500 already and showed me a tracker saying I’ve paid $0 toward my deductible this year and only a few hundred toward the out-of-pocket max.
I’ve never heard of the deductible not being included in the out-of-pocket max, and my insurance seems pretty standard. Can anyone weigh in on this? I’m really frustrated and thinking about canceling the surgery. Thanks!
That’s what I’ve always understood, too. It even explains how insurance deductibles and OOPM work on BCBS website - which is just like this! These ppl will not listen to me. I agree with your assessment. My gut is screaming at me to rethink this. The problem is that the surgery I am having done is so unique that there are only a handful of doctors in the country that can do it. That’s the only thing holding me back right now from cancelling.
Ah… that is quite frustrating. I would be very pissed if they mocked me for asking for a clarification on insurance and expecting me to give 7,000 without questions.
I’m sorry about that! I just realized I misspoke. It wasn’t the doctor but the woman handling the financial side of things who mocked me. It blows my mind that someone managing this wouldn’t know that the deductible and out-of-pocket max are part of the same pool. I don’t think they’ve even called my insurance company—otherwise, this wouldn’t be an issue. I’ve asked about it three times now. I think I need to get something in writing from BCBS with my name on it because the info from the website and my coverage plan isn’t clearing things up.
BCBS should have electronic eligibility verification, so a call isn’t needed.
She likely just handles payments or didn’t want to admit she was wrong—maybe both.
Most patients aren’t fully aware of their insurance coverage, but this is basic info. If you paid by card, they should be able to issue a partial refund. The billing office might be in a different location, so be sure to ask.
Thank you so much for the help! I do think there’s some stubbornness going on here. It’s the doubling down that’s irritating as I thought this was common sense. I then start to question my own ‘common sense’ though. I did pay partial my own card and the other portion is a medical loan. Does this have to do with balance billing? It seems to me that in the end, I will get that $2,500 back regardless of what they make me pay, right? There’s a paper trail. Am I missing anything?
Most staff have little training, and for the practice, getting any payment is a win. She misunderstood, which is crazy, I agree.
She was probably under pressure from a manager to collect payments, and that same manager is likely never around to help or answer questions. That’s how these mistakes usually happen.
Try to find out who’s in charge of billing, whether it’s a manager or someone else. If nothing works, you could request a chargeback from your card company.
Thank you thank you!! I’ve done nothing but worry about this for days (low key weeks) now. In the whole scheme of things, $2,500 isn’t a ton of money. However, I know it’s incorrect so it’s frustrating AF
It sounds like your provider is confused or miscommunicating the insurance terms. Your deductible is part of your out-of-pocket maximum (OOPM), not something you pay separately. Once you meet your deductible, any other eligible expenses go toward the OOPM. After you hit the OOPM, your insurance should cover 100% of remaining costs.
If you’ve already overpaid, request a partial refund based on the misunderstanding. If they refuse, consider disputing the charge with your credit card company or filing a complaint with your insurance provider
Call Blue Cross Blue Shield (BCBS) directly to clarify. Get confirmation in writing or ask for an official breakdown of how your deductible and OOPM work.