Help Me Understand My Situation
Background: I have an EPO plan through my employer that covers all in network services. I do not need a referral to see a specialist. I have a $300 deductible and a $3,000 out of pocket maximum. My insurance has an app that allows me to track my spending toward both my deductible and my OOP Max.
I recently suffered from a knee injury (patellar dislocation—ow). I found a orthopaedic specialist practice in network and made an appointment. I have not seen a doctor this year until this, so this is the first time I am using my insurance this plan year.
My first appointment, I was charged $150 at check in to see the doctor because I “have a deductible that has not been met yet.” Okay. This was for the office visit and x-rays of my knee. The doctor wanted me to get an MRI at the lab across the hall, and sent a request to my insurance to get that approved. It was and I went for the MRI—this was a $30 co-pay. Cool. The following day, I went back to the doctor to review the MRI results. This time I was charged $75 due to not meeting my deductible yet. Okay again. So at this point I’ve paid $255 out of pocket.
Today I log into my insurance app to check on my claims and I see that I’ve met $90 of my $3000 OOP Max. But have not met any of my deductible. I thought this was weird so I started looking at my individual claims. The MRI claim was straightforward—all I owed was the $30 copay. But the two ortho claims both say that my only responsibility is a $30 copay for each of them. That makes the $90 OOP Max amount make sense because copays don’t count toward deductible. But what about the other $165 I paid at the office for each of those two visits? Shouldn’t that go toward my deductible then? I don’t understand why that’s not reflected in my spending then. And if they don’t go towards deductible, shouldn’t the office be refunding me?
This is my first time really dealing with insurance/doctors on my own, because I don’t see doctors often (I know I should). And I don’t want to go throwing a fit over something until I truly understand what is going on. Can anyone help me figure it out?
