Insurance Will Only Pay For 80% If They Approve

[difa 114]

Most insurance has an agreed amt that the doc and hospital can contractually charge and on top of that ins will pay a portion and you pay the rest. Cash payets at my docs office pay 12k out of pocket. His price agreed with my insurace is around 16-18k. Ill pay 250 deductible and then 15%.

[difa 114]

Most insurance has an agreed amt that the doc and hospital can contractually charge and on top of that ins will pay a portion and you pay the rest. Cash payets at my docs office pay 12k out of pocket. His price agreed with my insurace is around 16-18k. Ill pay 250 deductible and then 15%.

[Krystyneh 55]

Well my $250 program fee covers 100% complete access to remedyehr.com or something like that for a website plus being able to contact their nutritionists through their personal phone lines. I'm not 100% positive with everything. I live in Vermont and my insurance is Wellmark BCBS of Iowa but its a PPO insurance and I'm going to Dartmouth Hitchcock Medical Center in Hanover NH. They've never worked with this insurance before but they take BCBS and they cover 80% of it but dont hospitals do the surgery then bill the insurance? Because the woman I talked to said that she would bill the insurance then I'd get the remaining balance on my bill. I always thought that they can't bill the insurance company until after surgery just incase they have to do something extra or am I wrong? Do they bill before or after surgery?

[goddesscordelia 30]

Do it, borrow it- it's totally worth it- I paid for 10% so your 20% sounds pretty good!

-Cordelia, banded 1/08

[goddesscordelia 30]

That's 100%

-Cordelia, banded 1/08

[Krystyneh 55]

Well I'd be saving to pay my part but my question is due they bill they insurance before or after? She said she would bill my insurance and after they pay their 80% that I'd have to pay the rest of the bill unless I have another insurance also. I'm praying they bill afterwards because then I'd set up a payment plan.

[difa 114]

Yes they bill you after....even though the insurance pays 80-85% there are other factors like deductoble you might have already met and max out of pocket

[Krystyneh 55]

Oh well my deductible is $100 and I dont have a maximum out of pocket

[Krystyneh 55]

Okay so the woman did call me back today and she said that the $11,000 IS AFTER my insurance pays their 80% but what I don't understand is one of my friend's sister is going for gastric bypass and her surgery is $26,000 TOTAL WTF it doesn't make sense to me at all

[MikeinMD 9]

That makes no sense to me. Is this person from the insurance company or the doctor's office?

[difa 114]

that can't be right. That means the doctor giving you the band is charging almost $100,000 for the surgery. Something is not correct. Most surgeries are $11,000 - $18,000.

[Krystyneh 55]

That makes no sense to me. Is this person from the insurance company or the doctor's office?

She's with the surgeon's office and it doesn't make sense to me either...it's sooo messed up so guess what...it looks like I'll be doing a payment arrangement. Gastric Bypass is only $26,000 total and my parents joked that I should just go for that lol I want lap band tho

[Krystyneh 55]

that can't be right. That means the doctor giving you the band is charging almost $100,000 for the surgery. Something is not correct. Most surgeries are $11,000 - $18,000.

yeah see that's what I thought...it doesn't make sense at all but that's what she said. I just don't understand it.

[MikeinMD 9]

Is this surgeon within your insurance company's network? I would call your insurance company and ask them about options. Maybe a different surgeon if this one is so expensive?

[NWgirl 574]

I would say that they are screwing you over. Insurance has an allowed amount that they contractually pay- My surgeon and the hospital billed total about $20k and my insurance only paid about $15k. Of that allowed amount (15k), I owed $800. I also did not have to pay a "program" fee. I went with a center of excellence location, and would suggest that you look for another surgeon who will not screw you over. You could SELF PAY for $11k in many places.