Insurance incorrectly showing my out-of-pocket maximum has been met

Summary: Insurance is saying I’ve met my out of pocket maximum, but I don’t think I have.

I know this is all very confusing, I can provide clarification as needed.

Age: 30

State: Oregon

Gross Income: $65,000 ————————————————————————— Situation:

I’ve had a lot of medical and mental health visits this year. In March of this year, I started attending an in-network intensive outpatient program for mental health. Prior to starting treatment, both the facility and myself called insurance several times to confirm costs. On these calls, insurance told the facility and myself that treatment would be covered at 100%, even though it was the beginning of the year and I hadn’t had any medical care up to that point.

In June, I started receiving bills from that facility, which was surprising to both the facility and myself. The facility didn’t understand why insurance wasn’t covering at 100% like they said they would. After several calls with insurance, it was determined that insurance had mis-quoted the facility and myself back in March. Instead of 100% coverage, it was actually 70% covered with 30% coinsurance until my in-network out-of-pocket max was met.

After telling insurance I would be getting Oregon’s financial regulation department involved since the March calls were recorded (for quality & training purposes), insurance said they would re-process the claims, covering everything at 100%, as a one-time exception due to the March misquoting. And they have done that (well, almost, there are still 2 claims that need to be fixed. I need to call them to get that started. They should have done to on their own quite honestly, I shouldn’t have to remind them. They total about $3000). Since things are being covered at 100%, there are no out-of-pocket expenses for this treatment.

Side note: I’ve also had about 2 months worth of out-of-network in-patient care this year. My out-of-network care facility does not participate in balance billing, and I was assured any costs insurance does not cover will not be passed onto me (i.e., they will accept the allowed amount by insurance and that’s it). They have honored this. My out-of-network facility has been very accommodating and only had me pay my out-of-network deductible of $2500, and waived another $7000 so I could meet my out-of-network maximum of $9500 and the facility could begin collecting from insurance.

————————————————————————— Problem:

I’m operating with the understanding that in-network and out-of-network are completely separate from each other.

So here’s the confusing part. My insurance portal, as well as my most recent EOB processed last week, show that I’ve met my out of pocket maximums for both in-network ($5000) and out-of-network ($9500). The out-of-network maximum makes sense.

But the math is not adding up for in-network. To date, the only things I’ve paid towards in-network out-of-pocket for this year are a handful of PCP visits, therapy visits, and prescriptions – totaling about $1000 in total. Recall that insurance is still re-processing another $3000 for 2 claims from the misquoting debacle. Eventually that $3000 should be changed to $0. But right now, $1000 + $3000 = $4000 out-of-pocket.

I’m not sure where they are getting that I’ve met my $5000 out-of-pocket maximum.

————————————————————————— Questions:

Since I have an EOB noting that my maximum has been met, can I go to in-network providers and expect not to pay anything? If/when the $3000 claims are re-processed, will insurance end up taking payment away from any provider I may see between and 12/31/2024, in turn having the provider bill me 30% co-insurance? Is the EOB enough to protect me from in-network bills for the rest of the year? I’ve got a few EOBs that say this, not just one.

Do I even bother reminding insurance to re-process the $3000 in misquoted claims? Isn’t that their job to have remembered? Seems I have no motive to remind them, as it will result in my maximum showing as not yet met. Oddly enough, the facility hasn’t billed me for the $3000. They told me back in June they had turned off billing statements for my account because insurance should be covering everything. I think they may have forgotten to turn it back on.