Why I have to pay out-of-pocket maximum up front??

clarecy

Hey all, it really sucks to deal with those financial issus while catching cancer....I post here to seek advice in case someone else have similar experience.

I'm seeing doctor now in MSKCC, New York. After my first visit, my financial account is being held. The reason is that I have to pay the deductible ($350) and out-of-pocket maximum ($7500) up front. As an insured foreigner student, I really cannot understand why I have to do this.....Any advice?

BTW, the staff in financial department has really unfriendly attitude. They kept transferring my phone calls, and it has been nearly two week when I finanlly got informed of the real problem. They said the manager will call me this morning. NOPE!!!

I'm really frustrating now, not because I got DCIS--I always held positive about that; I just confused why I have these troubles which I never expected.....

 

ballet12

Hi Clarecy,  I believe that you have to pay the deductible and out of pocket maximum up front, because MSKCC probably doesn't "participate" or "accept" your insurance plan on the list of plans that they participate with.  So, I know this will sound strange, but as a courtesy to you, they are going to bill your plan for the thousands of dollars that will be required (surgery, etc.) and then they require you to cover the rest up front.  When they don't participate with a plan, technically they can bill you for all of the services directly, and then you pay them for all of it.  They aren't doing that.  Insurance in this country is crazy, but that's how it works.  Ask them if the reason they want the money up front is because they don't "participate" with your plan.  They might even have a list of all the plans they participate with.  Sorry this has become so difficult, now that you've found a surgeon you trust.  (I'm a patient there, as well, as you know, but I'm saying this for others.) One more thing, if they don't participate with a plan, they may not have negotiated a favorable payment rate from that plan, so they are taking a risk as to how much that plan will pay them.  This, likely, leaves you frustrated, confused, and probably angry, but that's the way these things work.  You have to have the right "plan" to easily get in the front door.

clarecy

I'm insured in UnitedHealth Care (one of its PPO plan), and MSKCC is an in-network provider.....that's why I feel confused.....

ballet12

OK, well, I can't explain it then.  Maybe if you have a large out-of-pocket co-pay they require it to be paid upfront.  Can you just go there to speak with one of the financial reps, rather than waiting for a return call? You can go to the financial office at the Evelyn Lauder Breast Center rather than the main hospital.  I think talking over the phone can cause problems with communication. Again, sorry.

clarecy

Thanks ballet12~

I went there this afternoon, in the main hospital, and talked to the manager. It ended up with me paying all those money....it seems that they want me to pay up front therefore any amount that will not be covered by the insurance company is in the bag.

Anyway, I could continue all the pending appointment and treatment.....that's the most important.

ballet12

Great!  Moving forward.

Rose12

I am sorry you have to do this. I could see if your deductible was not met. But what percent will they be paying? 80% 60% of allowed amount? What is your coinsurance after deductible is met? I know alot of policies coming out of NY area reimburse the member. Meaning the insurance company pays you the check and you have to pay the provider for the services. Maybe this is what it is. Your really shouldn't pay anything until a Explantion of benefits is received from your insurance company showing what they paid. Hope you get the answers you need. Once your OOP is met your coverage should be at 100% coverage. You would not owe anything. 

clarecy

Thx Rose12~before the 75K out of pocket maximum, the insurance carrier will cover 80% and I will take 20%. It seems that the hospital will still file claims to insurance company; it's just they want the 20% up front. 

dogsandjogs

I had to pay the hospital up front. It was at the beginning of the year so I had not used any of my $400 deductible. I guess they wanted it all.  I didn't think that was right. What if I didn't have $400 - would they have refused to admit me for my surgery. I don't think so, but who knows?  

I have had several surgeries since then and was not  billed until after I got the EOBs from my insurance company.

ballet12

Part of the issue, I hate to say, may be that Clarecy is a foreign student, and they may very well have a policy of collecting everything up front from those whose main residence isn't the US.  I know that MSKCC does serve an international community of patients who come from all over the world. They may be concerned that the patient may leave the country and then they can't collect months later.  This has nothing to do with Clarecy, herself, but it's probably a blanket policy they have.

dogsandjogs

That is probably the case Ballet12!