If you’re scheduled for surgery you likely have many concerns and questions about the procedure itself. On top of that, you may also be worried about the costs. So-called “surprise bills” can occur when you inadvertently get care from an out-of-network provider, and they can add up quickly. Several states have passed laws to address this problem, at least in some circumstances. But there are some questions you can ask ahead of time to raise the odds you won’t find an unpleasant surprise in your mailbox.
“What are the details of my insurance policy?”
Most people know the bare bones of their health insurance policy. But before planned surgery you should have a conversation with your benefits manager to make sure you understand the nitty-gritty details of your deductible and co-insurance responsibilities.
Pay particular attention to your out-of-network benefit, advises Katalin Goencz, co-president of the Alliance of Claim Assistance Professionals. Someone may be reassured to see that their policy covers 80% of out-of-network care, for example, and opt for a provider who’s not in-network.
But that doesn’t mean the insurer will pick up the tab for 80% of your bill. They’ll pay 80% of some maximum allowed amount, which could be based on their in-network reimbursement rate, what Medicare charges, or something else altogether, says Goencz. So the insurer’s share of the costs may be much less than you’d thought. And what’s more, the provider can bill you for the difference between what they charged and what your insurer paid — and your costs don’t count toward deductible or your out-of-pocket maximum.
“What exactly will my surgery entail, in insurance-speak?”
To get a ballpark estimate of what you’ll be facing, tell the insurance or billing coordinator at the surgical practice that you’re scheduled for ABC procedure with X surgeon at Y hospital on Z day, says Goencz. Current Procedural Terminology codes, commonly known as CPT codes, are what a provider uses to identify procedures and services when they bill insurers. Ask what CPT codes the office anticipates using to bill for your procedure. Then call the insurer to see if you can get an estimate for those codes. Not every insurer will do it, says Goencz, but some will.
“Are my providers in my insurance network?”
If you want to stay in-network to save money, start by verifying that the facility and primary surgeon are in your insurance plan’s network. Make sure they’re in the provider directory, and double-check with the insurance coordinator or office manager at the surgical practice to make sure the information is current.
Be sure you have the exact name of the plan, and take particular care if you have a plan purchased on the insurance exchanges set up by the Affordable Care Act, since they often have narrower networks than similar-sounding non-exchange plans.
But unfortunately you can do your best due diligence with your surgeon and facility and still be surprised by bills from out-of-network providers you may not even have known you used, such as anesthesiologists, pathologists, surgical assistants, and radiologists, says Karen Pollitz, a senior fellow at the Kaiser Family Foundation.
If you’re not in a state with consumer protections on this front, “tell your primary surgeon you only want in-network providers,” says Betsy Imholz, special projects director at Consumers Union, which advocates for stricter consumer protections against surprise bills.
You can ask ahead of time which medical professionals are likely to be included in your procedure, and see if they’re in-network. And once you’re in the hospital, ask to have a note put in your chart or at your bedside to request in-network providers only. If you’re surprised by a bill anyway, try appealing to your insurer or the provider.