I’m about 40% of the way through my planned surgical journey and feel like I’ve gotten enough experience that I can share some things and hopefully help others when they are thinking about and planning their own surgical transition.
One thing I have learned that I think it’s important to tell people is about insurance. Lots of people I know who have health insurance are worried about whether their insurance covers some specific procedure or another they want or need. This is always important to find out, but there’s an additional layer you should be aware of. Some doctors are “in-network” with a provider, but an awful lot (maybe most) are “out of network”. This means that while the insurance covers “the procedure”… it probably won’t cover much of the surgical fees.
To be more precise, surgery can be broken down into facility fees (hospital or surgical center costs) and surgical fees (what the surgeon and anesthesiologist cost). Usually a hospital will be “in-network”, but often the doctor will not be. When this happens and the insurance “overs” the procedure, the insurance company will have a schedule of fees it is willing to pay for various surgical services. They will pay a percentage of the fee they decide the procedure should cost, regardless of the surgeon’s fee. You get to make up the difference.
Here’s an example: Surgery is $20,000.00. Hospital cost: $10,000.00. Surgeon fee: $10,000.00. Insurance “covers” surgery. Hospital is “in-network” and insurance covers 80%… so you pay $2,000.00 to the hospital. Surgeon is “out of network” and insurance says the procedure “should” cost $2,000.00. They pay 80% of that, or $1,600.00… that means you pay the surgeon $8,400.00. Your total cost for the “covered” surgery is $10,400.00 out of the $20,000.00 total cost.
You see how this works. Be certain if your insurance “covers” a procedure that you know not only what is covered and at what percent, but what is “in-network” versus “out of network” and what the schedule of fees they “expect” a procedure (or breakdown of any services) to cost.
Finally, don’t forget to get as much as you can “pre-authorized”. If you do not, you end up fighting after the fact for reimbursement. I should add that pre-authorization will not guarantee you won’t be fighting for a reimbursement… but not having something pre-authorized guarantees you will have to fight for your money.
