Just was thinking about this the other day while looking at my insurance. How do people in the U.S. accumulate huge bills without hitting their max out of pockets? Are cancer treatments not usually covered by insurance? Are the doctors that provide the treatment just happening to be out of network?
I guess I’m wondering if there is anyway I can plan to not be in a situation of me or my husband rejecting treatment and dying or having huge medical bills cripple us. We’re relatively healthy now, but the future is near.
I’d like to understand better how it seems to be so *common* for people to not be covered by their out of pocket max.
Thanks.
In: 4623
The out of pocket maximums are for in network, approved treatments.
And your insurances is going to do everything they can to say your treatment was from an out of network provider or that it wasn’t necessary.
For example, I had open heart surgery because of an aortic aneurysm. It was slowly increasing in size for twenty years and finally had a big jump one year to the next that put it right at the upper edge of where repair surgeries are effective.
The thing about aneurysms is that they’re pretty much fine right up until the moment they aren’t. Then you die very fast. Basically the tissue in the largest artery in my body—the one that comes directly out of the heart and splits off to take blood to your brain and literally everywhere else—was stretching out. You can imagine a slowly inflating balloon as a good analogy. They’re built to stretch some, but eventually it stretches too much and rips apart. You can see why that would be particularly problematic for a major blood vessel.
So my open heart surgery was an emergency, but it was urgent. It was to the point where doctors were worried that it was very likely to rupture, and so in the 3.5 weeks between when I had my routine annual scans and when I actually had surgery, I was severely restricted in what I was allowed to do. Ordinarily, the process of getting all the presurgery tests and measurements and consultations takes a week. I did it in two very long days.
Part of the surgery process is getting pre approval from insurance. Basically, your medical team sends a detailed list of what they plan to do to the insurance, and explain why everything is necessary, and the insurance approves or rejects the plan. I got everything pre approved.
Fast forward a few weeks and the bills start rolling in. And lo and behold, the insurance is rejecting nearly everything. Basically they decided that I didn’t really need the surgery, that I had ELECTED to have a chunk of my heart cut out just for fun, and so they weren’t going to pay.
Strictly speaking, there are only two categories of procedure—emergent and elective. If you aren’t actively dying or in imminent danger of dying, it’s elective. At least, so says my insurance. And they have provisions against covering elective surgeries.
It took—and I kid you not—over a year and a half of at least weekly calls to force them to pay it. The only reason I actually got it to work out in my favor is that my mom has been managing my condition my whole life and has learned how to navigate the process and not take no for an answer. If she had been working full time and nit been able to fight for me, I’d be looking at $500k of medical debt. All because my insurance went back on their pre approval and did their best to weasel out of paying.
So, how do you avoid this? Get everything in writing. Keep all your documents—appointment reminders, bills, procedure dates etc— together and organized. Be prepared to fight back and call your insurance every day. Tell your doctor what’s happening and get their office to help you. But most of all, don’t take no for an answer.
Latest Answers