We have a pretty pricey insurance plan: family of 4, 36k/year. When my wife had a gall bladder attack and had to get it removed, the insurance company quickly paid the surgeon's bill, and followup doctor visits.
But the insurance company denied the anesthesiologist bill, the hospital surgery room rental bill, and the hospital recovery room bill all as "medically unnecessary", also known as: they won't be covering it.
We tried talking to the original doctor and surgeon but of course they got paid and their offices said the rest of this wasn't their concern. We weren't really sure who we should be talking to to help us show the insurance company that anesthesia is fucking necessary when someone cuts you open.
After about 8 months of stress it was all eventually resolved for a fraction of the original price. In those 8 months though everyone who wasn't getting paid were sending us notices about how we didn't pay yet and how we could set up a payment plan. We talked to hospital billing and they said they usually just drop bills insurance doesn't cover. Usually. And that we shouldn't worry since this happens all the time and that it usually isn't resolved until lawyers get involved.
the usual "gotcha" that people mention is going in for a planned procedure and accidentally receiving care from an out-of-network physician. this makes your out of pocket max irrelevant. I've never had this happen to me and I have no idea how often it actually occurs (outliers are always the loudest on the internet), but it still worries me.
They’ll put a note in your file.
If someone else gets swapped in when your in the table, call back and bitch to them. I’ve had that eliminate the out of network charge.
Is it still a massive pain in the ass we shouldn’t have to deal with? Yes.
I've never been to a doctor without a ridiculous "outlier" scenario following the visit for months.