So apparently the "max out of pocket" on the cover sheet of your plan is b.s. and only applies in-network. I guess good luck having in-network coverage if you're on a vacation and have an emergency.
Actionable advice: check if your employer-provided healthcare is a self-funded insurance plan or a fully insured plan. And then look up the relevant consumer protections in your state for that type of plan.
Also, in case you're wondering what the hell all those hospital administrators are dong, the answer is "shaking down your employer and screwing you over":
> In a statement, St. David’s HealthCare defended its handling of Calver’s bill and sought to blame the school district and Aetna for offering such a narrow network.
>“While we did everything right in this particular situation, the structure of the patient’s insurance plan as a narrow network product placed a large portion of the financial responsibility directly on the patient because our hospital was not in-network,” the hospital said.
> WellRithms reviewed Calver’s bill in detail at the request of Kaiser Health News and determined that a reasonable reimbursement would have been $26,985. That’s less than half what Aetna paid.
So the last line, "less than half what Aetna paid", does that ostensibly mean the hospital is definitely charging an unreasonable price, and by having been paid twice what is reasonable by Aetna that ostensibly this teacher shouldn't have to pay a dime? It's just a contractual reason he owes this money?
Not ostensibly, but actually.
The article goes on to identify some concrete charges that independent auditors felt were ridiculous, including charging $19k for stents that the hospital most likely purchased for about $2K.
> It's just a contractual reason he owes this money?
The hospital just straight up dropped all but $800 of the charges when they got PR heat.
People in the US are used to their employers purchasing group health plans from insurance companies. In that model, a premium (often part paid by the employer, part by the employee) is paid to an insurance company in return for coverage. When there's a claim, the insurance company pays, out of its own money, and the insurance company's profit comes from taking in more money in premiums than it pays out in claims.
In a self-funded plan, the employer and employees still pay premiums, and all that money goes into a pool which is used to pay the claims. Typically a company is hired to administer the plan, but that company is not an insurer, and that company does not pay claims; the money to pay off claims comes directly out of that pool of premiums.
What this means is that the administrator just pays whatever it's told to pay by the company that hired them to run the plan. It's not the administrator's money being spent, and their profit is in the fees they charge to run the plan, not in denying or underpaying claims.
My very first real job out of school, years and years ago, was a place that did administration for self-funded plans. About once a month we'd get a call from one of our client companies saying "yeah, we know our plan's rules say not to pay that claim, but we want to pay that claim". And we'd say "OK, it's your plan and your money, you make the rules".
The downside is that if the company gets into financial trouble, its contributions to the pool of money that pays claims are often one of the first things to stop happening. I remember pretty clearly one client company that went bankrupt and just stopped paying into its plan, and once the money in the plan's pool ran out there were no more claims paid.
My guess is in a situation like this I'd get the reasonable amounts for services provided from my insurer and use them as a basis to refuse any unreasonable charges.
Another option is maybe to require that language on the "patient responsibility form" to include the blurb about fair prices. For instance:
In the event that my health plan determines a service to be “not payable”, I will be responsible for the complete charge and agree to pay the usual, customary, and reasonable costs of all services provided.
Nothing. That's why everyone always asks for a good and trustworthy mechanic. Or an HVAC repairman.