If our insurance reaches its max payout during a procedure, can the provider come after us for the billed amount or are they limited to amount allowed?

My wife had Surgery on her ACL and Meniscus. It was an in-network provider. The billed amount was $32,000. The amount allowed was $8,200 and our insurance reached its maximum annual payout and will only pay $3,000. Can the provider come after us for the billed amount or do they have to stick to the amount allowed on the EOB?

Asked on March 24, 2012 under Insurance Law, Michigan

Answers:

FreeAdvice Contributing Attorney / FreeAdvice Contributing Attorney

Answered 8 years ago | Contributor

The best way to answer your question with respect to your medical insurance policy is for you to carefully read its terms and conditions with respect to maximum payout for health care providers. Different policies have different terms and conditions with respect to the health care provider seeking reimbursement to health care providers when the maximum payout is reached.

I suggest that you consult with a representative of your insurance carrier to assist you further concerning your question.


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