Surprise from in-network specialist

I have a Nevada HMO plan from Health Plan of Nevada, a UnitedHealthcare subsidiary. My in-network primary care provider referred me to a specialist (a dermatologist), and I believe that referral was approved by my HMO, and that the specialist is, naturally, also in-network.

I see on my card “Specialist: $60”, and when I went to the specialist, I paid the receptionist $60 on the day of my visit (in early June, 2022). Now, I see on my HMO’s website: “Amount billed: $302.65” and “Your cost share: $224.82”. I am nowhere near my deductible — I’m several thousands of dollars short of it.

So, where did the $224.82 come from? From my card, I’d have guessed my total cost would be $60. If I am responsible for the total bill, I would expect my total cost would be $302.65. I tried calling my HMO, and the person I spoke with was unable to provide an explanation of where that figure came from.

Any ideas on what might be going on? I am not concerned about the price and I don’t plan on fighting over it, but I am concerned that if something really, really expensive happens, I might totally mis-estimate my costs. So, I thought I should take the time now to learn the rules behind the billing procedures.

There is unfortunately no “click here for an EOB” for that claim; that button is on most other claims, and I don’t know why it’s missing for that one.

So, my theories thus far:

The claim is still being negotiated between the doctor’s office and insurance, and that this is why there is no EOB yet.

The doctor’s office did a procedure over and above what insurance was expecting, and insurance rejected that part of the claim. This is why I seem to be responsible for some, but not all, of the cost, and why my responsibility exceeds the amount shown on my card. I am guessing the doctor’s office is trying to appeal that rejection.

If I wait long enough, I’ll be able to see the final result and the EOB on my HMO’s website.

If I see things I don’t expect on the EOB, I should try to find a different doctor’s office. My impression at the visit was that they just did a routine skin exam, so I have no idea what the extras might be.

Any thoughts? And can anyone provide a reference on the details of how a HMO claim gets processed? I have a feeling the devil is in the details, and I’d rather get to know the devil before I really need to.