What is not counted towards the maximum out of pocket for health insurance

[Anonymous]

I have a $4,000 max out of pocket with my insurance (Kaiser if that matters). Typically I never come close to it but two months ago I was diagnosed with a kidney stone and had the removal operation last week. Between the initial diagnosis costs (a trip to the hospital for an analysis and scans and bloodwork following two days of deep red urine) and the surgery itself, I've paid just about $4,000 out of pocket, including the $1600 deductible.

I thought I'd now be at the max and that would mean healthcare for the rest of the year is basically free. But the insurance company is telling me that, no, I'm still only $1800 towards the max. I'm currently asking for more information and a detailed breakdown of the services I've received to understand what is counted towards the max and what isn't, as it doesn't make sense to me.

Fortunately I'm not worried about the money, I can easily afford this, but I'd long thought the maximum out of pocket meant exactly that, the most amount you'd ever spend for healthcare in a given year. Crossing fingers the insurance billing department hasn't caught up with the surgery and payment for it, which was just last week, but I'm steeling myself for a lengthy fact finding battle with Kaiser, who is pretty abysmal in giving you information. Can anyone clarify what may actually be going on? Note all services have been with Kaiser and I do not go to anyone outside Kaiser.

[Anonymous]

I don’t know Kaiser specifically, but co-payments are not usually counted towards out of pocket expense total. Are there any expenses you’ve paid that that insurance company might not be aware of? Sometimes the surgery facility will collect the “facility fee” upfront prior to surgery, but the insurance company is not made aware that you paid that fee. The facility fee will count towards your out of pocket expense as long as the payment is the insurance company has confirmation that you paid it.
Ask for the list of payments that the insurance company claims is going towards your out of pocket expenses and see what’s missing.
If $4,000 is your max out of pocket, you should not be paying anything beyond that.

[Anonymous]

I don’t know if it’s relevant for Kaiser, but with PPO type insurance plans, out of network expenses will only count towards your out of pocket up to the reasonable and customary fees for that service/procedure. Is it possible that some of your expenses are considered out of network? Also, all my insurance plans (never had Kaiser though) have always provided a detailed Explanation of Benefits where all of those things are broken down. I would at minimum demand that.

[Anonymous]

It may be a timing issue since it all happened so fast. If so, you should get refund(s). With my non-Kaiser plan, I've paid a provider part of a deductible that I told them I'd already met but they couldn't tell on their computer yet. So I paid and got a refund.

I don't have Kaiser. Can you look at EOBs online? They may not be ready yet.

[Anonymous]

We have a separate drug plan/ drug OOP max in my non-Kaiser insurance.

[Anonymous]

In general look at the EOBs.
But they typically have an allowed amount. That, not the whole amount, applies to the deductible.
So if the doctor charged $2000 and they allow $700, only $700 goes to the deductible. Same idea for out of pocket maximum.