The Life of a Claim: Navigating High Deductible Health Plans

Navigating health insurance can feel like decoding a secret language—especially when you’re trying to help your team make sense of their employee benefits. That’s why we created the Benefits Architecture series—to help employers and employees better understand their benefits and how they work in the real world.

Recently, we explored the life of a medical claim, from the moment an employee enters the ER to the time the claim is paid—and examined how that journey plays out under fully insured and self-funded models. In this edition, we continue the story with that same medical event—an emergency appendectomy—and take a closer look at how a claim moves through the system under a High Deductible Health Plan (HDHP): what gets billed, what’s covered, and what your employees are responsible for.

Whether you’re an employer with a large workforce or a smaller organization focused on cost control, understanding how HDHPs function in real life can reduce confusion, prevent surprise bills, and help your employees make more informed decisions about their healthcare coverage.

Behind the scenes.

When a patient (your employee) arrives at the emergency room with intense stomach pain, hospital charges begin. An emergency room facility fee, physician evaluation, and lab work are some of the initial costs involved with an ER visit. Under an HDHP, these costs are the responsibility of the patient until the deductible is met.

As care is continued and imaging is ordered—often a CT scan to confirm appendicitis—the charges continue. The use of the scanner and the radiologist’s interpretation of that scan are often billed separately and are counted toward the deductible. In most cases, these initial services alone can bring the patient close to meeting their deductible.

While the clinical team takes care of the patient, the administrative team works in the background just as fast. They will verify insurance eligibility and review the plan. In some cases, prior authorization may be required. For example, some plans need authorization for inpatient admissions or advanced imaging like CT scans. Prior authorization isn’t needed in emergencies, but the hospital or surgical team may submit the authorization retroactively—meaning approval is requested after the procedure has already been done.

Once appendicitis is confirmed, emergency surgery is scheduled. The appendectomy can include additional fees such as surgeon and anesthesiologist fees, hospital charges for the operating room and facility charges for hospitalization during recovery. By this point, the deductible has typically been met—but the employee’s out-of-pocket responsibility isn’t over. After the deductible, coinsurance usually applies.

How a $30,000 surgery can look with an HDHP.

Here’s how a typical appendectomy might play out for an employee under an HDHP with a deductible, coinsurance, and out-of-pocket maximum structure:

• The employee pays 100% of costs until the deductible is met.
• After meeting the deductible, coinsurance applies (commonly 20% for the employee and 80% for the plan).
• As costs rise, the employee’s 20% coinsurance continues to add up.
• Once the employee hits their out-of-pocket maximum, the plan covers 100% of eligible expenses for the rest of the year.

Let’s say the emergency appendectomy cost $30,000–including the emergency visit, imaging, surgery, and hospitalization. Here’s how the breakdown might look based on a standard plan with a $3,000 deductible, 80/20 coinsurance, and a $6,000 out-of-pocket maximum:

• Deductible ($3,000): the patient pays the first $3,000 out of pocket. This could include emergency room facility fee, physician evaluation, labs, use of the CT scan and radiologist interpretation of the scan.
• Coinsurance (20% after deductible): After meeting the deductible, the remaining allowed amount is $27,000. The patient would pay 20% of that amount ($5,400), and insurance pays the other 80% ($21,600).
• Out-of-Pocket Maximum ($6,000 cap): Although the total share would be $3,000 + $5,400 = $8,400, the out-of-pocket maximum limits the patient’s total payment to $6,000. Insurance would then cover the remaining $24,000.

Medical charges can add up quickly, and patient responsibilities can be difficult to understand. That’s why it’s important to break down real-life scenarios such as an appendectomy. Understanding how a claim is processed can help both large and small employers evaluate which plan options best suit their organization and their people.

If you have questions about your current program, reach out to your consultant today, or feel free to contact us. We are always ready to answer your questions.

What happens after an emergency?

After the appendectomy, the patient should receive an Explanation of Benefits (EOB) from the health plan. It shows the total charges, how much insurance covered, and what the patient owes. At the same time, separate bills may arrive from the hospital, the radiologist, and the surgeon.

For employees, terms like “allowed amount,” “coinsurance,” or “out-of-pocket maximum” can be overwhelming—especially while recovering from surgery. That’s why consistent communication about how their benefits program works is essential—not just during open enrollment, but throughout the year. Partnering with a knowledgeable, trusted benefits consultant can help ensure your employees understand their coverage and feel supported when they need it most.

If employees have questions about their deductible, coinsurance, or out-of-pocket maximum, they can always refer to their Summary of Benefits and Coverage (SBC), which should be provided to them during open enrollment. This document outlines exactly how the plan works and what they may owe.

Build a strategy that works for your people.

Understanding the journey—from surgery to claim—is key to building a smarter, more supportive benefits strategy. That’s why we created Benefits Architecture. Because your plan is about more than managing costs—it’s about supporting your people with the most comprehensive plan for your organization.

Don’t wait another day, let’s talk about your benefits program!

Cost figures, coverage details, and plan design elements presented in this blog are for illustrative purposes only and do not reflect any specific insurance policy or provider. Actual costs will vary based on your organization’s health plan, the insurance carrier, provider contracts, and the specifics of each medical situation. Employers and employees should refer to their official plan documents or speak with their broker or benefits consultant for guidance if needed.