Currently live in the US. Need surgery out-of-state where my insurance considers those providers/facilities out-of-network.
Confused about how my benefits, what insurance pays, what surgeon + facility fees are there, and so forth. Here's what I have gathered.
My Insurance:
- Out-Of-Network Deductible $3,000 (I believe I have only met about $150 OON deductible toward my plan)
- Out-Of-Network Out-Of-Pocket $10,000
- Surgery benefit 50% after deductible, up to max of plan allowed
- Anesthesia benefit 50% after deductible, up to max of plan allowed
My Surgeon (in other state, out-of-network):
- Has upfront early cash payment discount of $8,000 that I have to pay first
- Will bill insurance estimated $34,000 based on insurance procedure code
Surgery Center / Anesthesia (in other state, out-of-network):
- Estimated cost that I will have to pay to facility is ~$3,019.24 upfront
- They calculated the deductible of $2,838.49 with anesthesia of $180.75 as of 3/13/24. Total cost is $ 3019.24 (2838.49 DED + 180.75 ANES).
What my surgeon's team had e-mailed me:Your insurance carrier may only cover a % based on the allowable amount (aka-allowable payment per procedure code), once you have satisfied your deductible and out of pocket amount has been met. Your insurance carrier will be billed the full amount for the procedures, however the $8,000 quoted is the early cash payment discount for our services.
You will receive an EOB informing you which procedure(s) were billed and the amount your insurance was invoiced, and of that amount, what they(insurance) agreed to pay. It will then state that the patient(you) will be responsible for paying the balance. (This EOB on the claim that will state that you owe the balance of what they [insurance] didn’t pay to the provider.)
We will submit the surgical claim to your insurance for the full estimated billed amounts, and will appeal if the payment is below the billed amount. If your insurance reimburse the fulled billed charges for the procedure, only then will we refund you the upfront money paid.
As you know, we are an Out-of-Network facility, Thereby your insurance company will send their payment portion for our services to you and not our office. Although this should not happen. Upon receiving check(s) from them, we ask that you please notify us.
So what I gathered is:
I would have to pay upfront $8,000 of my own money to the surgeon and ~$3,019 upfront to the facility.
The surgeon would then try to send the bill of $34,000 to my insurance. My insurance will probably not cover much of it. Where my confusion is, would I then be responsible for the rest? For example, if I pay $8,000 to surgeon directly, would my insurance then try to bill me for the $26,000?
Or is pretty much my max is $8,000 for the surgery no matter what? Because the surgeon will "try to appeal for the full amount"? But most likely, I believe it would fail and the insurance would deny it. Am I in a similar position for the surgery center?
This is my first time having surgery and trying to do it out-of-state/network, so it's very confusing trying to get a proper estimate from all the people involved (my insurance, my surgeon, the surgeon center/anesthesiology). Quite frustrating since I didn't want any surprises and just wanted some concrete billing estimates. Not sure why it has to be this difficult. For example,. there is a big difference between paying a total of ~$11,000 versus something like $50,000 so I just wanted to make sure I knew what I was getting myself into.
What am I not understanding or missing?
Thoughts?
original posted by msgidol to r/personalfinance on Sat, 16 Mar 2024 11:34:05 GMT.