The Lightbulb Turned On Today

[Back~To~Amy 307]

So, I originally thought my insurance would pay 100% of my WLS since my sinus surgery on April 11th will cover my deductible and, I expect, all of my out of pocket for the year. Then, I was told it will only cover 50% after I meet my deductible and that there is no out of pocket maximum. I'm still waiting on final confirmation of this but I suspect this is the case. Oh, and if I go with insurance, I have to have it at a Center of Excellence. Only hospitals qualify as a Center of Excellence. My doctor does the majority of his surgeries at at "outpatient" surgery center where you can stay confined for up to two days to help cut costs. If I have to have it at a hospital, my fees would greatly go up. The office told me I'd be better off paying their cash price ($12,200.00) then to file insurance because my 50% would definitely exceed the cash price being that the hospital fees are quite hefty. I kinda got it in my head that I'd be paying cash for the procedure but was still holding out hope I had better benefits than having to pay 50% of the bill.

Then today it happened. The lightbulb in my head turned on. I shouldn't have to pay 50% of the total bill. I should only have to pay 50% of the amount of approved charges by my insurance, right? Well, I called my surgeon's office and they were closed. Patience is not my strong point, so I decided to call another local doctor. The insurance girl there confirmed my thoughts. She told me my 50% of the physician's approved charges would only be around $500 to $600! OMG! That is great! Now, I know the hospital charges will be higher than the doctor's and thus a higher approved amount but it still shouldn't total their cash price of $11,900.00. The lady at the doctor's office didn't think so either but told me I'd need to call the hospital to verify. Unfortunately, they were closed for the weekend so the wait contines. One thing I do know though is insurance companies pay WAY under what doctors and hospitals bill. My sinus surgery physician's fee is over $11,000 but the approved amount is only a little over $2,000. It appears it will be that way with the WLS surgeon based on my conversation with a WLS office today. Therefore, I assume the hospital approved fees will be the same way. I can't wait to find out! So much so, I almost wish it was Monday now. See, I told you patience isn't my strong point. I'm just hoping I get to keep more of my money in my bank than I originally thought.

Woo Hoo! (I hope)

[AliveAgain 283]

Be careful, as my surgeon had a lot of "uncovered" fees that really added up after the portion that my insurance would cover. And I have really good insurance, low deductible and out of pocket. Also, the estimate the hospital provided was a fraction of what it actually came to. I think the final bill to the insurance company was close to $130,000 for a 34-hour stay with no complications. Thankfully, I only had to pay a small fraction of that after all was settled and done (I was covered at 90%). They also quoted me around $15,000 for an overnight stay, and I paid cash of the anticipated co-pay to get the 20% discount.

Good luck! I hope it works out in your favor!

[Lisa's Hope 421]

Be careful, as my surgeon had a lot of "uncovered" fees that really added up after the portion that my insurance would cover. And I have really good insurance, low deductible and out of pocket. Also, the estimate the hospital provided was a fraction of what it actually came to. I think the final bill to the insurance company was close to $130,000 for a 34-hour stay with no complications. Thankfully, I only had to pay a small fraction of that after all was settled and done (I was covered at 90%). They also quoted me around $15,000 for an overnight stay, and I paid cash of the anticipated co-pay to get the 20% discount.

Good luck! I hope it works out in your favor!

WOW! That is very expensive for Sleeve surgery. I'm a self-pay patient because my insurance WILL NOT cover anything to do with WLS. Makes me livid especially with the monthly premium my husbands employer has to pay for it. My surgery cost which includes everything, pre op testing, hospital stay up to two days, and post op visits with the surgeon for 1 year is 16,620.00. I will be having my surgery in St. Louis Des Peres Hospital which is a bariatric "center of excellence" hospital in St. Louis, Missouri. I wouldn't have ever been able to afford it if the hospital bill was 130,000. Maybe it depends on what part of the country you live.

[Lisa's Hope 421]

So, I originally thought my insurance would pay 100% of my WLS since my sinus surgery on April 11th will cover my deductible and, I expect, all of my out of pocket for the year. Then, I was told it will only cover 50% after I meet my deductible and that there is no out of pocket maximum. I'm still waiting on final confirmation of this but I suspect this is the case. Oh, and if I go with insurance, I have to have it at a Center of Excellence. Only hospitals qualify as a Center of Excellence. My doctor does the majority of his surgeries at at "outpatient" surgery center where you can stay confined for up to two days to help cut costs. If I have to have it at a hospital, my fees would greatly go up. The office told me I'd be better off paying their cash price ($12,200.00) then to file insurance because my 50% would definitely exceed the cash price being that the hospital fees are quite hefty. I kinda got it in my head that I'd be paying cash for the procedure but was still holding out hope I had better benefits than having to pay 50% of the bill.

Then today it happened. The lightbulb in my head turned on. I shouldn't have to pay 50% of the total bill. I should only have to pay 50% of the amount of approved charges by my insurance, right? Well, I called my surgeon's office and they were closed. Patience is not my strong point, so I decided to call another local doctor. The insurance girl there confirmed my thoughts. She told me my 50% of the physician's approved charges would only be around $500 to $600! OMG! That is great! Now, I know the hospital charges will be higher than the doctor's and thus a higher approved amount but it still shouldn't total their cash price of $11,900.00. The lady at the doctor's office didn't think so either but told me I'd need to call the hospital to verify. Unfortunately, they were closed for the weekend so the wait contines. One thing I do know though is insurance companies pay WAY under what doctors and hospitals bill. My sinus surgery physician's fee is over $11,000 but the approved amount is only a little over $2,000. It appears it will be that way with the WLS surgeon based on my conversation with a WLS office today. Therefore, I assume the hospital approved fees will be the same way. I can't wait to find out! So much so, I almost wish it was Monday now. See, I told you patience isn't my strong point. I'm just hoping I get to keep more of my money in my bank than I originally thought.

Woo Hoo! (I hope)

Hi Amy,

I'm an insurance biller and you are correct. You should only have to pay the 50 percent of the approved charges that the hospital accepts from the insurance company providing the hospital is an in network provider.

Good luck! My insurance doesn't pay anything

[2bsmallagain 156]

I would ask for an itemized estimate of any out of pocket expenses after the expected amount the insurance should pay. Surely the doctors office has done this enough to be able to tell you what your benefits will probably cover and how much you should have to pay out of pocket.

[BeautyVGSJourney 99]

Good luck! my insurance will not cover anything either, but after much research I decided to go to Mexico with dr. Ponce de leon, the whole thing will be less than ~$6,000 and he is a great surgeon, has more experience than most of the ones here in the USA. There are many other Mexican doctors (and from other parts of the world) who have much more experience because both the bypass and sleeve were very slow in being approved in the USA. My doctor actually did a free surgery for someone in canada, this show it and part of the surgery.

http://www.globalnews.ca/video/weight+times/video.html?v=2191228745#video

[cookies 56]

I'm self-pay, but I would say if you have the option of having the surgery through your insurance, I'd grab it, even if it's a bit more.

The advantage is that if there are any complications, these charges would be covered by your insurance as well. I've got the money set aside for my surgery, but if anything goes wrong... I'm going to be in big trouble because my insurance will pay nothing on anything that arises from the surgery since it's not covered.

[AliveAgain 283]

Oh, I only paid about $6000 total out-of-pocket (mostly uncovered expenses with my surgeon). And I know the way hospitals bill insurance is totally inflated. So they billed $130,000 -- had I paid privately it would have been more like $20,000 I'm sure. But I had only a $250 co-pay and a $1500 OOP maximum. It's just amazing to see $25,000 just for the medicine. And of course, the anesthesiologist bills separately, as do labs/radiology technicians.

[fattymcfatterson 107]

SO is the 50% specific to bariatric surgery? My experience is call 10 times, talk to 10 different people, and request it in writing. I had to go through my HR dept to get the actual detail of what is covered for bariatric. But i had also been told different things over the last 6 months every time i called my insurance. Make sure the 50% is also for an "in network" provider. And if you end up finding you have an oop maximum, you can knock a huge chunk off of that without any oop by going to a sleep study thru Dr. David Kim. THey took the amount my insurance paid as payment in full and I got out of $1700 of oop expenses. Would have been more if it was the FIRST thing I had done this year but I had some female stuff to take care of so I got stuck with that oop. Now I am home free the rest of this year. Keep us posted. I really hope you received wrong info and this will be all covered for you.

[Amanda 3.0 140]

I would definitely go the insurance route. You really do have to read your policy to see what is covered and what is not.

If insurance is paying at 50%, then yes, the doctor and hospital will bill whatever they please, but will have to settle for the contracted amount.

I do see a problem with not having the surgery at a Center of Excellence. I am guessing that your surgeon does his procedures at a surgery center for which he is an owner or part owner. So yes, it is in his best interest if you have your procedure there but is it better for you? It just sounds like maybe more money in his pocket. Some of these surgeons are owners or part owners in the sleep study centers, surgery centers, etc. and they might require procedures that benefit their bottom line.

As for the actual amounts paid, I am sure those are all over the place. My surgeon billed ~$16,000 for the surgery but received a little over $2,000 between me and insurance. The hospital billed ~$30,000 for three days but received around $20,000 from insurance (I was already at out of pocket max).

Good luck to you. I would definitely try to go the insurance route and check out the plan documents with my own eyes.

[Back~To~Amy 307]

Thanks for all the advice and suggestions.

Emlefe--I won't have to pay 50% of the total bill and it sounds like the prices you are giving me that the providers gave you are total charges and not the approved amount by the insurance company. At least, I hope so. Anyway, I only pay 50% of the amount approved by my insurance company and they reduce the total amount of the bill quite significantly. Like I said they are only giving an approved amount of about $2000 for charges of over $11,000 by my ENT. They did the same huge cut back on the facility charges too. I just don't remember what they were to post here. I'm hoping I have the same luck. BTW, If you don't mind me asking, how did you end up paying the majority of $6,000 to your surgeon if you only had to pay 10%? That would mean your insurance company's approved amount would have been nearly $60,000 thus making his total actual charges probably over $100,000. Thanks for the things to consider though especially about the other charges such as anesthetist, lab, etc.

Lisa'sHope--yes, the facility is in network.

2bsmallagain-thanks for the advice. I will definitely have my i's dotted and t's crossed before I proceed with WLS.

Cookies--Your comment about having complications covered by insurance is on my list of questions to ask. I believe though they will be covered. However, I am checking on it.

fattymcfatterson--yes, 50% of approved amount is for bariatric surgery and yes, that is the amount for an in network provider. Other non-bariatric surgery is covered at 80% in network. I'm still waiting on the final word of my coverage from the "bariatric department" about my coverage. However, the manager at BCBS who is over our insurance company read right from our company's page about bariatric surgery and the information I've given is what I got from her. Also, I don't have an out of pocket maximum for bariatrics according to this supervisor. Here's hoping she was wrong and I have better coverage! However, I am prepared to pay the cash price if I have to. I AM GOING TO HAVE THIS SURERY....one way or another!

Amanda-My doctor is actually the Medical Director over the WLS at the hospital on the Center of Excellence list. He doesn't have any ownership in the surgery center he uses. It is inside a full-fledged hospital but just not a hospital on the list. He uses it when possible to save on costs. Thus, passing the savings onto the patients. The other thing I love about him is if you pay cash, it is the total amount for EVERYTHING. All preop, surgery, hospital charges, other provider charges and all post of visits for the rest of your life. I will have to take that into consideration when deciding if insurance or cash pay is the best option for me.

[AliveAgain 283]

BTW, If you don't mind me asking, how did you end up paying the majority of $6,000 to your surgeon if you only had to pay 10%?

My surgeon had a non-insurance fee that covers services insurance does not allow at all. Basically, I pre-paid for the next five years of services from him and his office. Office visits, dietician, registered nurse, supplement discounts, support groups, cookbooks, etc. So even if I lost my health insurance tomorrow, I can go in or call for checkups anytime I want and it's covered 100%. I can call the dietician on his staff every day of the week for the next five years, get meal plans, etc. Between that and my deductible and the out-of-pocket maximum, it all came to about $6K for me. He billed $18.5K to insurance of which $3000 was allowed, and my 10% was already part of that pre-payment I mentioned before. Then the hospital billed $107,198 of which $6200 was covered by insurance, and since I prepaid at the hospital I got an additional 20% off my 10% co-pay. The rest was made up of all the pre-testing stuff like the GI series, labs (excised stomach and liver biopsy), and the anesthesiologist fees (they billed $2400 and $1400 was covered).

I'm not sure how much value there will be in those "uncovered" fees that I pre-paid, the next five years will tell. But I do like that I can call and speak to someone at anytime, with any problem and get tons of support. His dietician is very nice and she helps me a lot with what and how to eat. It's also nice to have easy access to great supplements, some of which were included for free as part of my fee.

[Back~To~Amy 307]

Emlefe----thank you , thank you, thank you for taking the time on your latest response and for the very detailed information you provided me. If my fees were to be similar to yours, it would still be cheaper for me to file insurance. However, you bring up a thought for me to check into. The cash price covers all follow up care (and I believe the nutritionist) for life. I'm pretty sure if you use insurance follow visits come at a cost. This year they would be free being that my sinus surgery should get me to my 2012 out of pocket maximum or very, very close to it. However, they would be free starting in 2013 so I would need to take that into consideration too. I'm definitely being careful and am going to make a mindful decision.

As far as all the extras you paid for, I think that was a very wise decision on your part. Who knows if you will get dollar for dollar of your money's worth, but I think you were very smart in doing it. It looks like you got peace of mind in paying for the extras with your surgeon and that is certainly, as they say, worth it's weight in gold.

Thanks again! I really do appreciate it. BTW, your profile pic is beautiful girl!

[AliveAgain 283]

Thank you for compliment! It's the best picture I've taken in years, and it was done using Photo Booth on a raining, boring day! HA!

[Failure 32]

Is it possible to get financed like with CareCredit for example if the surgeon you are using accepts that or another financing company for an out of pocket expense you are responsible for if you have insurance that would pay only a percentage?