I am not sure if its worth submitting the out-of-network claim to my insurance.
I got a jaw surgery in November and before the surgery I had to pay estimated amount to my surgeon’s office in order to secure the surgery date. The estimated fee included Surgeon’s fee + Assistant surgeon’s fee. My surgeon is in network but the assistant surgeon is not in network. I did a discounted self pay for the assistant surgeon and no claim was submitted. The assistant surgeon fee was $7,400 and I paid $1,950 as a self pay.
Now that most of the claims have processed I was able to get a refund for to surgeons’s fees as it was covered by insurance. Since the assistant surgeon is out of network and no claim has been submitted I didn’t receive a refund (makes sense).
I already reached my in network OOP max ($3,800) & deductible ($2,800) and out of network deductible ($2,800). I still have $2000 left on my Out of Network OOP max as it is $5,800 for this year.
I called Aetna and was told that I can submit the out of network claim and they will reimburse me 70% of what is deemed the cost? (Not 100% sure if i understood this part) And the 30% will go towards my deductible (I think). I called the surgeon’s office and they informed me that if I submit the claim it will be submitted with the $7,400 and whatever Aetna doesn’t pay I will be responsible. (This is where I am not sure if its worth me submitting the claim in case i end up with more bills)
So is it worth it for me to submit the out of network claim? I was thinking the insurance should know that I paid almost $2k out of pocket already since I still have to pay about $3k more to the hospital as well (this amount is already accounted for in my in network OOP max and part of it is a coinsurance and is still processing because it was submitted incorrectly) I just don’t want to pay extra but I also think I shouldn’t be paying $6K+ for medical expenses this year when my out of pocket max is lower than that.
Please let me know if I can clarify anything else.