Cannot afford out of pocket maximum

toughcookie_21

I am wondering if anyone else is in the same position. I have $11,000 out of pocket maximum with a $5,000 per person deductible. I had $4,100 in an HSA and about $8,000 in savings, but that's almost gone and that's it. I have already received bills for more than the $11,000 out of pocket max due to certain things that the hospital says weren't covered by insurance. I haven't even started chemo yet and I continue to get bills over and above the out of pocket max. I have been paying the medical bills as they come, but we are out of money and I don't know what to do.

Although my husband and I have good jobs and make decent money, we have over $100,000 in student loan debt and we owe more than our house is worth (purchased at the height of the market in 2006.) other than that, we live very frugally. This is hopefully the last summer that our 8 and 10 year old children will need childcare which is another major expense. But that doesn't help us now. I don't seem to qualify for any financial assistance because they just look at income, not debt. This was supposed to be our big decade. I finally finished my doctorate and am decent money and breast cancer hits. DH is self employed and I provide our health insurance.

Can I be refused treatment? What are my rights regarding the out of pocket maximum? How do others deal with this? Can I ask that I expect that my treatment to be done this calendar year because if I'm broke now, I certainly won't have another $11,000 plus in 2018.

Beatmon

Number 1 have you called your insurance company about the things they say aren't covered? Is it something you actually received or could it be something that was miscoded by the hospital so insurance refused it? There are so many mistakes made in billing. My husband was once billed hundreds of dollars for a procedure that was miscoded and charged out as disinfection of supplies.

Contact the Social Worker at your oncologist office or at the chemo unit. They can help figure out and also there are low interest loans available for medical expenses at some hospitals. ( of course I know you don't want more debt in loans)

Also I just rec'd in the mail today a coupon from Genentech Patient assistance ....go to their website and fill outapp. This is what it read:

You are eligible for a benefit up to $25,000 effectivev07/24/17. The copay assistance card covers all but $25 per treatment of the patient's out of pocket cost specific to Genentech cancer therapy up to maximum benefit per 12 month period.

I have no idea how to use it but I'm going to find out. It is certainly worth looking into it for you since with your her2+ Herceptin is protocol.

I'm so sorry that you are going through the financial worry on you of the cancer worries. I am lucky in that I took out Aflac in 2009....it really eases finances.

Good luck and please let us know how you are doing. Other ladies that know more about ways to get help will probably add their ideas

rdeesides

ToughCookie- I'm afraid I am in a similar situation. I am going to talk to the social worker at the hospital, but my backup plan is to take money out of my 401k, even though you are never supposed to do that. I'm trying not to stress out about it now though. Money concerns are the last thing we need right now.

Rebekah

Jackster51

No advice, but so so sorry our "Health Ins" industry puts us in this position. I hope you find a solution that allows you to concentrate on yourself and your recovery. Big Hugs.

ChiSandy

Before I retired from actively practicing law, I did a lot of probate/estate administration work. Hospitals & medical service providers would routinely file creditors’ claims for “expenses of last illness,” which take priority over other claims against the estate. At every creditors’ claim hearing at which a hospital’s claim was filed, I’d conference with the provider’s lawyer in an empty jury room and go over every item on their bill. I was usually able to get half of the items tossed out.

Know that in order to make up for the fact that insurers, Medicare & Medicaid reimburse so inadequately, hospitals routinely overcharge—especially for tests done with expensive machines which costs need to be amortized and tangible “things” (like meds & supplies) that get reimbursed at a higher rate than “services” (i.e., the people who administer them). Hence the $15 box of tissues, $25 pair of nonskid socks (once billed to a decedent who’d been a double amputee), and $20 aspirin.

Go over every item with a fine tooth comb and negotiate! Hospitals are betting you won’t. And as a last resort, their social workers can help set up long-term repayment plans.

edwards750

I agree with ChiSandy. Go over every item on the bills. I used to work at Federal Express and they offered a bonus for every "mistake" ala overcharge on medical bills specifically hospital bills that we all know typically cover multiple pages of charges. The hospitals are betting most people won't do that.

I'm guessing most of us have discovered errors. I sure have. We should all expect every charge to be explained and verified. It's criminal to me how they charge you for drugs and services they know full well you didn't receive. Don't take no or some vague response for an answer.

Case in point my husband was in the trauma unit at a local hospital and we received mountainous bills as you would expect. We were being charged for multiple doctors who were out of network. I challenged every one of them. One doctor, would you believe, called me at home and said he would split the cost. That was nice of him to call but I said no we weren't paying anything and we didn't. The charge was deleted. Keep in mind we amassed over $300k in medical charges. It was beyond overwhelming. After the dust settled we still owed over 50k.

I was the lone breadwinner at the time and for 8 months so it might as well have been 50 million. They ended up writing off the balance. The hospital still received over $250k in insurance payments.

We have BC/BS insurance with $5k deductible. We reached that deductible in 2 months when I was DX. I paid the bills in installments. Maybe you can arrange that as well.

It is apparent they go after those of us with insurance to offset those without. The costs are staggering but don't let them intimidate you. You do what you can that's all you can do. It didn't bother me for a nano second to tell them I would pay monthly and what I could pay.

You certainly don't need or deserve more stress. You have enough to worry about.

Good luck!

Diane

candles1

So sorry you're in this tough spot.

All I can add to the great advice above is, you absolutely should ask your providers if they can try to complete your treatment within your "insurance year."

I had to deal with some waiting over the course of my treatment, but when my doc explained that she had to fit in people whose insurance was rolling over at year end (mine wasn't), I totally understood. I was happy to let others in that situation "cut in line" so to speak. So, I do think good docs are sensitive to that.

Lula73

out of pocket maximum usually means that the insurance company picks up everything over that amount. Have you been paying the bills as they come from the hospital or waiting til they've been adjudicated through your insurance company? I don't pay anything g until adjudication and I've received the Explanation of Benefits from the insurance. When they adjudicate the amount they've charged will change to the insurance negotiated rate then subtract the coverage amount and you're left with the patient responsibility amount. Ex: office visit charge = $200, insurance negotiated rate = $100, insurance covers 80% = $80, leaving patient responsibility = $20.

If you haven't been waiting for the insurance adjudication before paying you will need to match up your bills, how much you've paid to each provider, and the explanation of benefits from insurance for each visit and see where you might have overpaid to get a refund. Insurance can't keep keep up with what you've been paying toward your out of pocket maximum and deductible if you don't let them adjudicate first.

I deal with insurance stuff all day at work. Feel free to ask questions here or PM me

Trvler

DO NOT TAKE MONEY OUT OF 401K!! That money is protected in the event of a bankruptcy. Do not touch it!

Icietla

Have you looked into Hardship Deferments that might delay for a time your payment obligations on the Student Loans?

edwards750

I second what Lula posted. BC told me not to pay anything until we got the EOB. You might be surprised, or not, to know how these hospitals and doctors offices tell you what you owe only to find out later it's not correct. It's usually less.They push so hard for their $ on the front end they try to manipulate you into paying then. The ones that really anger me are the ones who agreed contractually to an approved charge and then try to charge you the maximum.

Lesson learned for me. I check everything on the bill. We pay ours from a my chart account online.

Diane

sbelizabeth

Before my mastectomy the surgery center office called and demanded a credit card pre-payment. I said this hadn't happened when I had the lumpectomy. The caller said they gave you a break last time. I was furious. I said I don't need a "break" I need a mastectomy, so bill me like last time. I was so peeved I wrote a nasty letter to the CEO.

I avoid pre-payments like the plague, because they're so frequently wrong. "We'll refund whatever you overpaid." Uh-huh. After many months and lots of phone calls. When my EOB arrives I check everything and THEN pay.

Magnolia83

I echo the idea to talk to your hospital's billing department and social worker. If you just have to cover your maximum, you can have the hospital put you on a payment plan that you can afford. I literally called up my hospital after my mastectomy bill and said "I can afford $150 a month" and they were like, "Okay". I thought it would be harder than that, LOL. I think I owed $7,000 or so. Anyway, they did not charge interest on the payments and when I had more money I paid more. I ended up getting a small inheritance from a relative and was able to pay the remainder off after a few months.

Also PLEASE research financial resources for cancer patients in your local area! There are usually charitable organizations that can help, you just have to find them and apply (the oncology social worker should be able to direct you to some of these resources as well)...for instance I was able to receive grocery and gas cards when I was going through chemo which really helped (I was commuting nearly an hour each way for work each day...had to work to keep insurance...so the gas cards saved me a bundle). GOOD LUCK!

cive

Many states are covering breast cancer screening and treatment by way of the Medicaid expansion for those people making 2 times or less of the federal poverty rate.

edwards750

Good for you Magnolia. If they had said no then what would they have done - repossess your MX? Seriously? Of course they don't have to accept your payment but then what? Sue you? Not saying they shouldn't be paid in a timely manner but let's get real how many people can write them a check and be done with it? How many of these people working for insurance companies could fork over that kind of money?

We all know there are literally hundreds and hundreds of women facing astronomical bills from BC. It took us 3 years to settle the total bill. We have BC/BS and a flex plan but we exhausted the flex plan in the early going. I'm sure they would have done the full court press had we not had insurance coverage.

It's appalling how many women are turned away from treatments because they can't afford it.

Diane

sbelizabeth

"Reposses your MX." OK, that made me snort my iced tea out my nose. Hahaha...

Paying a hospital bill out of pocket can always be negotiated. The accounts receivable dept can reduce the amount and will agree to take a very low monthly payment. It still sucks but arrangements can be made.

ChiSandy

Seconding the advice not to fork over one red cent till you get your insurer’s EOBs. My bills can look scary, but the EOBs’ bottom lines are always “amount you may owe: $0.” Haven’t had any non-drug co-pays since I went on BCBS Medicare Part B supplement. And in the months before that, when still on United’s PPO, after the EOBs I didn’t have any remaining balances over $200—and darn few of them.

MelDent

Hi-

Just going over finances with my husband.

2 years ago, I had to have brain surgery. Out of pocket it was $7,000. That was our OOP max. We set up a payment plan with the hospital at that time. We're still paying on it. 3,000 to go. As long as we're consistently paying $200/month (or more), they don't care how long it takes.

Now with cancer, we have a $4,000 oop max. I'm at a different hospital for tx and they have the same policy. As long as we consistently make payments, it doesn't matter how long it takes.

We are putting pre-tax money into an HSA account and using that, so it's going to take a while- There is a limit to how much we can put into that account.

I have found this to always be the case with hospitals/doctor's offices. I hope that helps.

drsharon

I'm in a similar situation. Always had good health. Self employed with a doctorate and student loans. My deductible was $7000 year which was quickly $14000 overnight because of my diagnosis and treatment spanni fall into winter. Hospital said not to let costs effect my treatments decision. That there is funding. After radiation over, funding declined. I refused chemo and as far as I know I'm cancer free post surgery. I will do anything to avoid getting it again. I don't trust the system and the money they make from chemo. Good luck to you! Apply for help but if you have an income/double income, there's no way out unless you can do your own fundraising. I was embarrassed to ask friends and social media for money.

chronicpain

In addition to all the useful charity and fee negotiation exploration suggestion above, if you are truly out of all assets beyond $200O or so in the bank, a house, and car, and have low income, you can apply for Medicaid (welfare insurance safety net) or taxpayer subsidized insurance price support under Obamacare even if your income is a little higher than usual. Procedures vary from state to state.You can get a "Medicaid pending" number to get treatment going, you can get emergency waivers, you can go to the county hospital or university hospital where the uninsured and foreigners go, there are many options.

You can look closer at what other assets you have to sell (jewelry, second home like a cabin, land, designer clothing you can sell on ebay), and what living expenses you can cut back on. You can charge on credit cards if credit is good, borrow from friends, look to your church, borrow from parents who often have assets, other family, charity organizations, take out personal loans, set up a GofundMe, to tied you over, set up a paymentschedule.

There is no shame in asking for help, if you do not have enough saved to make payments right now

I am optimistic you will find something that works.

calidancer

Curious if anyone has had any luck disputing charges? The hospital charged $8100 for one implant for my revision. Insurance paid about half of the total charges so that means I'm paying about $800 for the implant which I imagine is what it did actually cost?

Doesn't it seem crazy that cancer patients are paying more than augmentation patients? If you add up the implant, the cost of the OR and recovery room, which is billed on time alone, you are already at more than an augmentation which would take roughly the same time. It's FRAUD!

I got no where with insurance, my surgeons patient coordinator, or the hospital billing department. Other than an offer of a payment plan.

So frustrating! I feel like the hospital just charges whatever they want! But we are real people who have to pay the coinsurance. And year after year it's really a tremendous amount of money for something that is supposed to be covered by federal law!

edwards750

You do have to go over your bills and EOBs with a fine tooth comb. A lot of doctors and hospitals overcharge when they are required to bill only the allowable amount dictated by the network they are a part of. They agreed to it so don’t let them tell you any different.

We have had to appeal charges and fortunately won those cases. Squeaky wheel...Do not pay anything to the doctors office or hospital until you get the EOB from your insurance company no matter what they say. We have BC/BS and a rep told me that very thing. You can access it online now which is convenient.

The last thing you need is more stress. If it ends up a payment plan so be it. We did that with one BC bill. Took us several years to pay it off bit it’s paid in full.

Good luck!

Diane