Question for people who actually work for an insurance company?

I understand the basics of insurance. Deductible, then coinsurance/copays until you meet your out of pocket max. I have insurance through my employer.

My question is out of genuine curiosity on how claims process/order. I'm sure it'll all turn out fine when things process, but Im curious!

I've always been a healthy person so I've never even gotten close to my deductible ($1600) (out of pocket is $4k with 10% coins). This year has been not so great health wise haha. I've had several procedures and they have required me to prepay before being performed based on my remaining deductible.

First procedure I had to prepay $700 due to not being at my deductible. I prepaid. Got procedure done. Took about two months for the claim to process and pay. Turned out I only actually owed $500. (Got a refund from doc).

Had some labs and appts for other doctors, those didn't require prepay, but processed quickly, ~$200 each x3. So according to my insurance I'm at $1100, only $500 more til my deductible.

I had a second procedure done. I was required to pay $500 up front as that what was estimated to be left of my deductible. Got procedure done. Claim is processing with my insurance. I see total charges are $3k which in theory is irrelevant since I should hopefully only owe deductible and maybe some coinsurance?

I had an appt last week that required a prepay of $223. Since that last claim is still pending with insurance, I'm certain that's why they still required me to prepay. That claim is already in process by insurance and was only $300.

So question number 1, will insurance wait to process claim #2 until claim #1 is done?

And my next question is, I have another procedure next month, will I just keep having to pay my "remaining deductible" until insurance finishes processing claim #1?

I've got a spreadsheet going to keep track of all the payments I've made vs where I'm at with my deductible, so I'll know when to ask for refunds from the hospital(s). Just curious how many times I may have to pay this last remaining $500 on my ghost deductible 😅.

Bonus question, if a procedure gets denied as non-covered, does it still count towards my out of pocket costs or nah?

submitted by /u/verana04
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