Not in Network ?

[Veggestyle 0]

Quick question...I just found out that the hospital I am planning to have my surgery is "not in my network." What does that mean for me?

[mousecrazy 2]

It may not mean too much. The hospital I had my surgery in was not in network, and somewhere in "paperwork land" I was only charged what I would have been charged if it had been in the network. Ask the office staff at your surgeon's office...they know how to handle this stuff with the super-special world of insurance!

[Veggestyle 0]

Thank you for the advice! I appreciate it!

[JMO 0]

the worst that it could mean is you have to pay a little more.. but its no biggie!! good luck

[Mvpo8961 1]

I have to respectfully disagree with JMO. My insurance states in our booklet that if we go to an out of network facility (when the services are available in an in network facility) we pay a 2000 dollar penalty and are responsible for 75% of the charges. This is for either a hospital or outpatient surgery facility.

Now the hospital that I had my surgery charged 48,000. My in network negotiated price was 16,000.

Had I gone outside the network I could have potentially been responsible for 38,000 assuming the out of network facility charged the same charges as my hospital charged.

That's a pretty good chunk of change.

Some facilities will only charge what a contract price would be whether you are in or out of network. Still if your insurance makes you pay a percentage of that fee it can still be pretty steep. In my case it would have been 75% of 16,000 plus the 2,000 dollar penalty making my out of pocket 14,000.

You definitely need to know the requirements for your monetary responsibility in regards to YOUR insurance.

Myra

[Alexandra 55]

Everything depends on the kind of policy you are covered under. I have an HMO, which means if some provider is not in my network I get $0 coverage. Period. I must stay in my network to get ANY benefits at all. (Luckily, it's a huge network.)

Veggestyle, you may have out-of-network benefits but before you proceed it's imperative that you find out what they are. And even if you do have them, it is true that you won't get the benefit of negotiated rates. That means you will be responsible for the difference between what your carrier covers and what the hospital bills--could be many tens of thousands of dollars.

Stay in-network, if you can!!

[Bettina 0]

Yes definitely stay in network if you can....hosp stays are a HUGE expense if they are out of network!! But check with insurance, because sometimes if the doc is covered and that is the only hospital he works out of....they may take the amt that your insurance would provide if it were in network...that actually happened to me...yay! Hospitals don't have to solicit for patients that's why they don't join networks....whereas a private doctor is competing with other doctors..so they hop on that network bandwagon as to lower the prices ---after all, lower amt of money they recieve is better than getting no money at all!

Let us know how it went!!!

[mousecrazy 2]

Definitely check it out, that's only prudent. I am just letting you know how it worked out for me. I was not asked to pay anything I wouldn't have paid for an in-network facility. Also, it was out-patient.

[Mvpo8961 1]

mousecrazy like the new avatar.

M

[mousecrazy 2]

Thanks for noticing the new avatar...thought it was about time (the other one was taken in November!)

Congrats on your great progress with the weight loss!

[Veggestyle 0]

I spoke with my insurance company again yesterday...I have a feeling I will be talking with them quite a lot! I was told that whether or not the hospital is "in-network" if the procedure is considering "out-patient" it will be covered 100%!!! The difference lies in if for some reason I have to say at the hospital at soon the "out-patient" procedures becomes an "in-patient" procedures, my insurance will only cover 65% as opposed to 80% if it were in network. At this point, my hospital considers the lapband to be an "out-patient." I guess I just better make sure I get to go home!

[mousecrazy 2]

When you talk to anyone, jot down the name and date. I kept a little folder with notes, names, etc as I went...everything went smoothly for me, but just in case, I kept good info. It's just a good idea anyway. Have you chosen a surgeon? If so, his or her office will handle a lot of stuff with your insurance for you.

[Bettina 0]

I spoke with my insurance company again yesterday...I have a feeling I will be talking with them quite a lot! I was told that whether or not the hospital is "in-network" if the procedure is considering "out-patient" it will be covered 100%!!! The difference lies in if for some reason I have to say at the hospital at soon the "out-patient" procedures becomes an "in-patient" procedures, my insurance will only cover 65% as opposed to 80% if it were in network. At this point, my hospital considers the lapband to be an "out-patient." I guess I just better make sure I get to go home!

Isn't your lapbanding considered an overnight stay??? My doc insists you stay overnight to make sure everything is okay.

[Veggestyle 0]

The surgeon does not require an overnight stay. They check for certain things, such as your ability to walk and go to the bathroom, once you are able to do that you can leave. So really it depends on your body after the surgery.

[Bettina 0]

The surgeon does not require an overnight stay. They check for certain things, such as your ability to walk and go to the bathroom, once you are able to do that you can leave. So really it depends on your body after the surgery.

ummm okay but what about the upper GI that they do before they send you home to see how your stomach handles how you are swallowing? I am sure they want to make sure you can at least handle Water before you leave. (just curious)