Insurance Will Only Pay For 80% If They Approve

[Krystyneh 55]

Okay so if I understand what the woman told me is that my insurance, if they approve me for lap band surgery, will pay 80% of the surgery and then I'll be left having to pay $11,000. Now I'm waiting on a settlement from the lawyer so that should be about $12,000 but I really don't want to have to pay that much. What are other options? I'm also not sure if $11,000 is what I'd be left paying or if she meant that they will pay 80% of $11,000. I'm waiting for the woman to call me back to tell me exactly because if all I'm left owing is $2,200 then okay that's a little easier to deal with. What are other options for me though? I know a lot of people say Care Credit but I already have a credit card through them and I still haven't been able to pay off $1,000 in the last year and now I'm up to owing them $2,250 because of how high the APR% is GRRR. I'm getting so frustrated because I finally am in the process of doing everything. I could have told my husband not to insure our daughter and I under his insurance and kept my state insurance where they would have paid 100% of the surgery but I don't feel right to do that to the state. Someone else in the state of Vermont needs state insurance more then I do. I guess I'm just going to have to start saving up and if I have to wait until next year to get surgery then that's what I'm going to have to do. GRRR why does it have to be sooo frustrating. But seriously is there any other choices? I know that my surgery has to be paid IN FULL by the day that I have surgery.

[difa 114]

My insurance pays 85% of the procedure but how I figured it out it was around 2000 after they pay what they pay. I have an FSA that will cover that amount.

[hopingtobebandedsoon 89]

Yeh if u have insurance that pays 80% i dont think theres anyway u would have to pay that much.... I work for an insurance company...call your insurance and ask them what your yearly out of pocket is!! If they something like 5000 or even less then thats all the OOP you would pay...i think u may be understanding it wrong..im curious to know what u find out!

[Shannon28 26]

11,000 seems like a lot. The total of my surgery was around 19,000 but my insurance paid 80% of that. I ended up paying a little over 5000 out of pocket but thats because I was required to pay a 1000 program fee at the place I will be getting fills. And then there was another 250 fee from my insurance, so "technically" I paid a little over 20% for the entire surgery. I had to pay in full also and boy was that rough! None of that 5,000 included the pre-op testing or diet. Hope you find out soon, but I really don't think it would cost that much. Good luck!

[NWgirl 574]

My insurance covered at 80% too, but the catch is that it is 80% up to the out-of-pocket max for the year. My Out of pocket max is $3000 and my deductible was $2500. I racked up around $2000 with just pre-op tests and owed about $800 for the actual surgery.

As for the IN FULL, I had to put down a $100 deposit for the hospital to get my date scheduled, and have yet to receive the bill for surgery. I just wonder how you could be expected to pay in full when they would not know exactly what you owe towards OOP because some claims may not have come in by surgery date?

[difa 114]

My surgeon told me the cost with insurance or if i was a cash payer.

If my surgery was 20000, the most I'd have to pay is $3,000 after the $250 program fee.

Though if I remember correctly I think the cost is like $16k-18k for the lap band surgery with my doctor. Luckily i was told that since I have an FSA that they will allow me to pay for the program fee after the surgery. I have paid $10.00 for the psych eval and that's it....so far. I have $2500 in my fsa...I think my wife had to pay around 1600 - 1900 to the hospital that the procedure was in (same insurance as mine). Mine should be cheaper since my procedure will be at the outpatient building versus the hospital.

[Krystyneh 55]

My deductible is $100 a year but out of pocket doesn't have a maximum there. I'm just hoping I don't have to pay more then $3,000 for the remaining balance but I should find out Monday by the woman. I just want to figure it out before I even get a surgery date lol

[MikeinMD 9]

Also remember that you should only have to pay 20% of the insurance approved amount. If the total is $25000 but your insurance will only allow the doctor and hospital to charge $15000, you would have to pay 20% of $15000 or $3000.

[Krystyneh 55]

Oh okay cool then that doesn't sound so bad lol I was freaking out about $11,000 and I only have to pay 20%

[29Ladybug 37]

Wow I guess thought that I was paying to much, my out-of pocket will be $440.00 and this will cover my fills and visits. I pray that your cost will go down:-)

Sent from my iPad using LapBandTalk

[Krystyneh 55]

Thanks I hope I dont have to pay too much because I already just paid $250 for the program fee

[Krystyneh 55]

Well where I'm going I heard that everything has to be paid upfront but I thought that was just if u self paid but idk lol I guess I'll figure this whole process out sooner or later

[Britneygirl 65]

Well where I'm going I heard that everything has to be paid upfront but I thought that was just if u self paid but idk lol I guess I'll figure this whole process out sooner or later

I would be careful w those program fees. In my opinion that s just a sneaky way for drs offices to get more money from those of us who hav insurance and don't have to pay anything. My office required a $1200 program fee that they demand before they scheduled my surgery. I didn't have it and I made a big complaint to the office manager and asked why I had to pay that much and I ended up having it waived (they never mentioned it again.) so ask questions before u pay that. I think drs know how bad people want this surgery so they capitalize on it. Beware of these fees. U are having a medically necessary surgery. So why "program fees"?

[Britneygirl 65]

Well where I'm going I heard that everything has to be paid upfront but I thought that was just if u self paid but idk lol I guess I'll figure this whole process out sooner or later

I would be careful w those program fees. In my opinion that s just a sneaky way for drs offices to get more money from those of us who hav insurance and don't have to pay anything. My office required a $1200 program fee that they demand before they scheduled my surgery. I didn't have it and I made a big complaint to the office manager and asked why I had to pay that much and I ended up having it waived (they never mentioned it again.) so ask questions before u pay that. I think drs know how bad people want this surgery so they capitalize on it. Beware of these fees. U are having a medically necessary surgery. So why "program fees"?

[Kate rules 43]

I would check with insurance company on what their "allowed amount" is for the surgery and fees. They have contract rates with hospital. They will pay 80 percent of the allowed amount and that leaves you 20 percent of the allowed amount. My doc and hospital charged 36k for the procedure and 23 hour hospital stay. I think the ins co paid out all of 13k.

Calls ins co with the CPT codes for the procedure, talk to a supervisor, and ask what is allowed amount for procedure. It varies by region.

Keep in mind that if you go to an out of network provider you are responsible for balance because there is no contract rate.