Your risks, the recovery time and how bad it will hurt— all important issues to bring up before going under the knife. But if that’s all you ask about, unexpected medical bills may leave you with a rude awakening once the anesthesia wears off.
Navigating the health care industry can be tricky, particularly in the case of surgery, which often includes numerous providers, several treatments and procedures, not to mention a hospital stay. Understanding what questions to ask, of whom to ask them and how to handle the responses can save you money and spare you a headache, allowing you to focus your attention where it’s needed— on your health and recovery.
You’ll have to do the work
“I believe the biggest misconception that patients have regarding insurance and surgery is that ‘someone’ is looking out for their financial interests and there is only one bill for services rendered,” says Claire Freeman, a patient advocate and medical billing expert in Chino Hills, Calif.
“Usually, there is no ‘someone’ to look out for the patient’s financial interests,” she says, “and in fact, the system is built on the presumption that the patient will make their decisions accordingly.”
Going into surgery without this knowledge can leave you with a stack of bills afterward.
Mitigate the risk of unexpected costs by asking the right questions:
1. Is this covered by my insurance?
The question of insurance coverage is deceptively simple. Because surgery involves multiple separate costs— for the surgeon, the operating room, anesthesia and numerous other details related to your hospital stay— you can’t expect a clear single answer for this one.
Talk to your provider.
Talk to your doctor about exactly what the surgery will involve. Is it a single operation, or will they be doing multiple procedures while you’re under anesthesia? Ask what happens if they get inside and must change their course of action— discovering, for instance, that the MRIs beforehand didn’t tell the whole story, which isn’t an unheard of circumstance, Freeman says.
Make sure you know what procedures they plan on billing the insurance company for, how long your anticipated hospital stay will be, and what the possibilities are if something unexpected occurs while you’re “under.”
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Talk to your insurance carrier.
Your insurance provider is the gatekeeper between you and the lowest final costs. They will determine what’s covered and how much you pay out of pocket for services rendered. After talking with your doctor, you should have a complete and accurate picture of everything that your medical team wants to accomplish during surgery and in the days following. Talk to the insurance representative about it all. Ask if the procedure requires pre-authorization, a sort of preapproval for pricey procedures, and make sure all aspects of the surgery, including your hospital stay and any post-surgical rehabilitation, are covered.
2. Are all of my providers in-network?
Insurance companies contract with certain medical providers to offer lower-cost services to insured patients. When you go outside this “network” of contracted providers, your medical services may be covered, but you’ll likely pay a much larger share of the cost.
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“Just because a doctor ‘takes’ your insurance does not mean he is in-network,” says Martine Brousse, founder of AdviMed, a patient advocacy and medical account management company. “Also, just because he wants to perform a service at a specific hospital does not mean it’s in your best interest.”
It’s your job to ensure the hospital you’re treated at and all of your providers are considered in-network. This gets tricky when some providers under the same roof are in-network and others are not. Check to make sure your surgeon, the hospital and anesthesiologist are all in-network. Freeman also recommends asking whether your surgeon will use an assistant. If so, you’ll need to check that person’s network status too.
3. What is my share of the costs?
Insured patients are picking up more of their own health care costs in the form of higher deductibles and coinsurance, so you will have some cost-sharing responsibilities when it’s all said and done. The key is to get a good idea of what you’ll owe so your balances aren’t a shock.
Typically, surgery costs go toward your deductible, with the insurance company picking up more of the costs once this limit is reached. For instance, if you have a $2,000 deductible and 20 percent coinsurance, you will pay $2,000, and 20 percent of the charges on top of that after meeting that threshold. But not everything is subject to the deductible. For some services, like seeing your doctor at a regular appointment, you pay a copay.
READ MORE: Copay vs. Coinsurance: This Guide Can Help
The best person to help you get a handle on your cost-sharing responsibilities is the hospital or surgeon’s billing department. Using information from your insurance policy, they should be able to help you come up with an approximate estimate.
Ask questions and keep records
Throughout the pre-surgery prep, take notes, ask for things in writing and keep copies of all your communications with hospital, doctor and insurance representatives. Billing errors are common, and even if you’re diligent about asking the right questions, you could end up with a surprise bill. Documenting your efforts may help bolster your case in the event of a problem later.
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