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The news that you need surgery is likely to raise immediate concerns: Will the operation work? How much pain will I take? How long will it take to recover?

Cost concerns are likely to arise. If you have health insurance, you want to know how much surgery you expect your plan to cover.

The good news is that most plans cover a large portion of the surgical costs for procedures that are considered medically necessary - that is, surgery to save your life, improve your health, or prevent potential illness. This gradient can extend from appendectomy to cardiac bypass, but it can also include procedures such as rhinoplasty (rhinoplasty) if it is to correct a breathing problem.

Although most plastic surgeries are not covered by insurance, some procedures are considered medically necessary when performed in conjunction with other medical treatment. A good example of this is breast implants during or after breast cancer surgery.

Coverage varies by insurance company

Every health plan is different. To learn more about the financial ramifications of surgery, your task is divided into two parts:

• Ask your surgeon for details of the typical costs of your procedure and what preparation, care, and supplies will be required. Keep in mind that hospitals and doctors are sometimes unable to provide accurate estimates because they don't necessarily know what they will face after the procedure begins. But the more questions you ask, the more information you have.
• Read the summary you received when you signed up for your plan. 2 In this booklet, insurers generally list covered and excluded costs of care. Contact your health insurance company if you do not have this information.
• Find out what your insurance companies require in terms of prior authorization and / or referral from your primary care provider. The details vary from plan to plan, but you will likely need one or both to cover your next surgery.
  

Other items increase the cost

The financial cost of surgery extends beyond the cost of a single procedure.
Other costs may include:

• Preoperative tests, such as blood tests and x-rays, that help your doctor prepare for surgery and / or ensure that you are fit to perform it
•  Use of the operating room or preparation for surgery, which costs per hour or per procedure.
• Assistant surgeons or surgical assistants (including doctors and / or nurses) who assist in the operating room.
• Blood, plasma, or other biological support you may need to keep your condition stable.
• Anesthesia, intravenous medications and / or doctors who provide them.
• The surgeon's fee, which is generally independent of the actual fee for the surgery. Depending on the circumstances, there may also be an assistant surgeon who submits an additional bill.
• Durable medical equipment. This includes things like crutches or braces that may be needed after surgery.
• Recovery room or area where you are receiving postoperative care.
• Your hospital stay if you need hospital care.
• A skilled nursing facility charges a fee if you need intensive rehabilitation care after you leave the hospital but before you go home.

Part-time nursing care or treatment that you may need during your recovery at home.
Depending on your insurance, each of these items can have different levels of coverage. It helps to know what to exclude.

Certain services related to surgery (anesthesia and hospital stay, for example) are more likely to be covered than others (such as a home daycare if you need help with daily living during your recovery).

 

Understand your insurance plan network

Also, it is important that you understand if all of the caregivers involved in your care are part of your insurance company's network. You may have chosen a hospital and surgeon that are in your plan, but other providers may be involved in the surgery. Associate surgeons, radiologists, anesthesiologists, and permanent medical equipment providers are some examples of service providers that may not be in your plan's network, even though they provide care at a hospital that is in your network and work with your doctor. - network surgeon.

In some cases, you may not even be aware of the involvement of an out-of-network provider, for example, if the treatment was provided while you were under anesthesia. But that won't necessarily prevent you from getting stuck on an out-of-network bill, in addition to the in-network charges you were expecting.

Some states have enacted laws or regulations to protect patients from sudden balance bills in such cases (for example, when a patient receives treatment at an in-network hospital, but some participating caregivers are out-of-network ).

The federal government has put in place some additional protections (as of 2018) for plans sold on health insurance exchanges. For these plans, insurance companies must calculate the out-of-network charges for ancillary service providers at an in-network facility for the in-network out-of-network patient limit (unless the insurance company provide proper notification to patient, prior to operation, out-of-network costs may be incurred and will not be counted). From the patient's cap inside the pocket mesh). But plans that never cover out-of-network care are not subject to this rule. Therefore, if you have an HMO or EPO that does not cover out-of-network care, an out-of-network provider within an out-of-pocket network will not charge you the amount you pay for additional services.

Although insurance companies have to calculate out-of-network costs for the in-network out-of-pocket limit in these situations, the patient is still responsible for the costs and can still be billed to an out-of-network account. Network provider unless the state intervenes to block it. Although many states have taken steps to protect patients from sudden balance bills, 9 states do not have regulatory authority over group self-insured plans as they are regulated at the federal level. So even in states with strong protections for unexpected bills, the protection is not universal.

Since the rules vary depending on where you live and the type of health coverage you have, it is advisable to double and triple check the network status of each person who may be involved in surgery in your best interest to sit down with someone from the billing department and ask a lot of questions. Learn about the network status of service providers who may be involved in your backstage surgery (for example, a radiologist who will read your checks, a laboratory that will treat your tests, an anesthesiologist, a provider of permanent medical equipment, etc. ). Get written confirmation that these providers are connected to the network. If not, ask the hospital if you can use a network provider.

If this is not possible, you may consider switching to another hospital and / or surgeon to avoid an out-of-network bill.

If it appears that there are no options for full in-network surgery in your area, you can contact your insurance company, prior to surgery, to see if they will work on a temporary in-network arrangement with participating service providers. in your surgery. 

When the invoice arrives

Even with this knowledge, understanding the hospital bill can be difficult. Formats will vary, but you can expect to see:

• The total cost
•  Total insurance payments, if your plan reviews the rates before receiving the invoice
• Total insurance settlement: the amount deducted by the hospital under its contract with the insurance company.
• Total discounts for patients, optional discount that the hospital can extend to the patient (consult the hospital employment office)
• The total amount owed by the patient
  

Please note that you may receive more than one bill, as the different caregivers involved in your care may be billed separately. In each case, you should also receive an Explanation of Benefits (EOB) from your insurance company, explaining how the insurance company handled the bill. Don't pay a bill until you are sure you understand it and make sure your insurance company actually processes it.