Understanding your insurance
By, Amanda Wright
The world of health insurance can be daunting, especially if you are considering an elective procedure like bariatric surgery. We get calls every day from prospective patients with questions about where they should start if they are considering a procedure, will their insurance cover the cost and are they going to be financially responsible for anything out of pocket. The answers can vary from patient to patient, it’s important to know your policy so you don’t end up in over your head or with a surprise bill. We’ve compiled a list of the top things you should know about your insurance before proceeding with surgery.
The first place we recommend our patients start is to contact their insurance provider and ask about bariatric coverage for their policy. A single provider can have hundreds of policies that differ depending on the company they contract out to, whether it’s through the affordable care act or what state you reside in. This makes it even more important to know if your individual policy has bariatric coverage, if they have certain health requirements in order to qualify and if there is a bariatric max coverage for your desired procedure. Asking a friend with the same provider that had the surgery is not sufficient.
If you have ever been sick and gone to the doctor, you’ve probably paid a copay to be seen. This is a fixed amount of the total bill that you are responsible for health care services rendered, this splits the cost between you and the provider. Copays are due for every office visit and should be expected to be collected up front. In most cases they do go towards your deducible and out of pocket max but again it depends on your policy and is a good idea to ask your provider.
A deductible is an amount you are required to pay before your insurance will start to cover expenses. Typically policies with a high deductible will have lower monthly payments and policies with a high monthly payment will have lower deductibles. If you are considering surgery in the next year it’s important to weight these options to see what is financially right for you short and long term.
Co-insurance is the amount you are responsible for once your deductible is met; it’s your share of the cost but is not the same as your copay. You cover the full cost until you’ve met your deductible then you cover a percentage of the cost until you reach your out of pocket max. I know this can be confusing, just keep reading and I will provide an example at the end that will hopefully provide some clarity.
Out of pocket maxes can be a savior when proceeding with surgery; this is the maximum amount you will be responsible for out of pocket in a given year for charges submitted through insurance. One thing to note is with family policies there is normally an individual out of pocket max and a family out of pocket max, so just because you reach your individual max you will still be responsible for cost related to other family member’s health care bills until the family out of pocket max is reached.
When considering surgery many patients are not aware it’s billed in three separate bills; the facility, anesthesia and the surgeon. It is possible to have a surgeon in-network, while the facility or anesthesia is out of network and will not be covered by their insurance. It’s important to do your own research and ask questions, if you don’t you can end up with an out of network bill which can be substantial and you will be responsible for it.
There are options for financing elective procedures like bariatric surgery. Care Credit is a great resource for financing healthcare procedures, they offer introductory rates and terms up to 60 months. Many companies offer flex spending accounts which is deducted pre-tax from your check and can help you save money to apply towards surgery related expenses. If your credit score is not the best, our affiliate True Results might be a good option; they can provide in house financing for some of the pre-certifications and testing, as well as the procedure and facility cost.
Patient Sally Sue’s insurance has a $30 PCP copay, $50 specialist copay, $2000 deductible, 20% co-insurance and $3000 out of pocket max (she is the only one on the policy). Sally went to her primary care physician (PCP) to discuss procedure AB, she paid a $30 copay for the office visit. After discussing her options, her PCP thought the procedure was a good idea and she was referred to a specialist. She paid a $50 copay to see the specialist. The specialist told Sally the procedure would cost $7800 (procedure, anesthesia and the surgeon) but before she could proceed she would need clearance from two other specialists for a $50 copay for each visit, an EGD that cost $500 and cardio clearance that cost $400. So this is how it all breaks down:
- $30 in PCP copay
- $150 in Specialist Co-Pays ($50 x 3)
- $500 for EDG
- $400for Cardio Clearance
- $7800 for Procedure AB
- $8880 Total Cost for the above
Sally is solely responsible for the first $2000 to meet her deductible.
Of the remaining $6880, Sally is responsible for her 20% co-insurance or $1376. However, since she has an out of pocket max of $3000, she is only responsible for $1000 to meet this amount and her insurance will cover the remaining $376. Follow up care or testing needed post-surgery would also be covered by her insurance at that point, until her coverage year started over.
*Amounts are figurative and do not relate to any real procedure.
