Question about insurance coverage

[puffynipsman]

Hello doctors,

My current insurance plan covers physician's fees for gyne surgery according to the following:

1. I pay my deductible
2. I pay 50% of the next $2,000
3. I pay 20% of the remaining total, with a maximum of $1,500

It's a bit confusing, and although my potential surgeon and I spoke at length to conclude I do meet all criteria my insurance provider requires to have a gyne procedure covered under their policy, I'm assuming the worst and that I'll have to foot the entire bill myself. That's fine--I want to have this done.

That said, in another thread, someone told me the following: "I want to note one other experience regarding health insurance coverage.  Don't go there!  It's not worth it.  If you pursue it, they will require it to be done in a surgery center and if insurance changes there mind after it is performed, you could be facing a $10k bill instead of $5-6."

Can someone please explain, if insurance denies the claim, how I will be responsible for more than what the surgeon would have charged had insurance not gotten involved? In my case, the surgeon quoted me around $6,000 for the surgery. If insurance denies the claim, why would I have to pay more than that ~$6,000?

Thanks for your help.

[Litlriki]

This is a problem I have to deal with in my institution, since I operate at a hospital.  For "self-pay" patients, they have a fee plan, which is different from the fee plan used to bill insurance companies for covered procedures.  If you're approved by your insurance, there is no guarantee that they will pay--it says that on the letter of prior authorization.  (You'd have to ask them what circumstances would compel them to not pay after saying that they will, but don't expect an answer that's satisfying.)  If you proceed, and they DON'T pay, then you're responsible for the charges, not for the "self-pay" fee.  In my practice, the surgeon's fee is the same, but the hospital and anesthesia charges are higher when insurance is billed. 

I hope that lends some clarity.

Rick Silverman

[puffynipsman]

Thank you Dr. Silverman. In light of your explanation, would it be wiser for me to take the self-pay route, and then submit the bill to the insurance after it's all over? Or is there even less of a chance my insurance would cover the charges that way?

It's sounding like my best option may be to just take the self-pay route and avoid the possibility of additional fees.

[Litlriki]

Your insurance company may or may not allow you to do that.  You should check with them to see if it's possible to get reimbursement.  If the surgeon is a contracted provider for the insurer, it may not be possible, but if the surgeon doesn't take that insurance, it may be possible, in which case they might pay out their allowable for the service.

RS