Question about insurance and financing

[Kelly G 31]

Hi everyone

So I went to the seminar today and got a breakdown of the costs. Then I called my insurance provider (BCBS of Michigan) to ask what "tier" this surgery would fall under (I get my insurance through my provider, which is a hospital, so more of my insurance pays for services done at the hospital where I work, and pays for less for services done at other hospitals).

I won't bore you with the details, but BCBS says that the surgery will cost my $400 dedictible and after that co-insurance will kick in. I will be responsible for up to $3000 maximum before BCBS will kick in and pay for the rest. But according to the packet I got at my seminar, it says that the hospital requires the payment of all dedictibles and co-insurances to be paid in full prior to the surgery taking place. And the practice that does the surgery also requires $1000 to be paid 2 wks pre-op that covers all pre-surgery testing (psychological evals, dietician and exercise physiologist appointments) and post-operative visits for one year (2 wks post op, 6 wks post op, 3 months, 6 months, 9 months, 12 months).

Has anyone had to do this before? If so, have you been able to finance that co-insurance/deductible portion through a third party? Does financing that money mess up the insurance at all?

Thanks for any and all input in advance!!

Kelly

[makemyownluck 785]

Is the surgeon/hospital you are going to part of your bcbs network? If so, then you shouldn't have to pay anything up front - that's part of their contract with bcbs to be a provider in their network.

I'd contact my insurance to verify the providers you chose are in network and will be paid at the highest available level for the surgery. If not, you might need to start shopping around for a different surgeon. Or try to work something out with them about the pre-payments.

I have bcbs (but in IL) and I didn't have to pay anything up front.

[Kelly G 31]

Thanks for replying, MMOL!

I work at a hospital, which makes my insurance really wonky. I technically have 3 "tiers" of "in-network" insurance. Tier 1 includes the hospital I work at (so surgeries that happen at the hospital where I work gets more coverage from my insurance), tier 2 includes some doctors who don't work at the hospital where I work, but are in the area, and teir 3 covers any doctor or hospital services that accept blue care network insurance. So the surgeon I would like to do my sleeve is in the blue care network, but he doesn't work at the hospital where I work. So I will get coverage, but not as much as if he worked and performed the surgery where I work. Does that make sense? Of course it doesn't, it's health insurance, haha.

So I've already checked with my insurance company, and they say that the surgeon and the hospital where I'd like to have it done are both "in network" as far as accepting blue care network insurance. However on the sheet I got at the seminar today, it says (and I quote), "Saint Mary's will require payment in full prior to surgery for any coinsurance or deductibles." So even though Saint Mary's is "in network" and accepts my insurance, I am reading that quote to mean that they require me to pay the consurance amount and deductible amount BEFORE I get the surgery...which confuses me!

[Nuchnuch 120]

I have BCBST and the doctor's office made me pay $1,500.00 which is supposed to be things which the insurance company won't pay and then the hospital made me pay the $500.00 they figured that the insurance wouldn't pay.

That was all paid prior to surgery.

[Kelly G 31]

That is similar to what I am talking about, nuchnuch. The surgeon's office wants $1000 before the surgery which is supposed to cover things the insurance company won't cover (the pre-surgery testing, surgeon consult, psych eval and post-op check ups for 2 wks, 6 wks, 3 month, 6 month and 1 yr). But what confuses me is the surgeon's office also telling me that the hospital where the surgery is performed is going to want my insurance deductible and co-insurance money before the surgery as well. I have just never heard of that and was wondering if anyone else had experienced that...

[Nuchnuch 120]

Yes, I had knee surgery at this same hospital and they did the same thing then...they wanted to make sure they get what they think the insurance won't pay.

I went through Tennova which is affiliated with St. Mary's so may be why they ar the same.

[Kelly G 31]

Huh - did they require you to pay the co-insurance as well? That's a lot of money to expect up front before a surgery. Between the surgeon's office and the hospital (deductible+co-insurance) they are going to want $4500! I don't have that kind of money laying around. The surgeon's office offers financing, but I'm not sure if that is to cover the whole $4500 I'd need, or only the $1000 the surgeon's office wants...

[makemyownluck 785]

I totally get what you're saying about the tiers. I work in health insurance, and I actually understand their wonky rules! lol

But part of the benefit of having insurance is so that the bills go to them first. Here's the problem with paying up front:

You give X amount of dollars to the hospital when you have the surgery.

The bills come into the insurance company and you don't know what's going to be paid first - so that by the time that claim from the hospital is processed, the insurance has already applied other things to your deductible, and now you're the one stuck trying to figure out the mess after the fact. Having worked in insurance, I know there are a lot of instances like these where the hospital required payment up front, then DIDN'T include the patient payment on the bill when they submitted to insurance. So now, the hospital has been OVERPAID, and YOU have to go back and try to fix all of it.

Also, I'm assuming you've met part of that deductible already, right? And with the pre-op testing and visits, that should gobble up a lot of that deductible as well. I have a $1500 deductible and I met all of that long before I made it to surgery...

[Kelly G 31]

That's exactly what I'm afraid will happen, MMOL! But if they MAKE me do it...I don't see a way around it. Can I call the hospital and tell them I don't want to pay up front? LOL

I suppose I could do some research. The hospital I work at is (relatively) small and they don't perform any bariatric surgeries here except lap band (which I DON'T want). And when I went to my PCP he said that he sends ALL of his bariatric patients to this practice because they're so good. I don't know that if I tell them I can't afford their up front costs if he will refer me to some place else. But I'm guessing that most other places will operate similarly, since it would take place at the same hospital...

Well here's where I get confused with the deductibles and whatnot. As of now, the only doctors I've ever seen are "Metro" doctors, so they all fall under tier 1 of my insurance. And they've all been simple office visits with a $10 co-pay. This will be my first time going to a "tier 3" doctor that has a different "set" amounts of deductibles, co-insurances, etc. But I don't think I've met my annual deductible yet. I get so confused with insurance.

For example. My tier 1 deductible per year is $100. My tier 1 co-insurance maximum per year is $1000. I have only seen tier 1 doctors and paid my tier 1 co-pays of $10 per visit. Question one: Do the office co-pays go toward my deductible? Otherwise I have had some expenses go toward the deductible (chest x-ray cost, etc)

My tier 3 deductible is $400/year. My tier 3 co-insurance maximum per year is $3000. If I've paid some expenses toward the tier 1 deductible, does that also lessen my tier 3 deductible or are they separate?

So like, say for example that in seeing my tier 1 doctor I paid $150 for something that went toward my tier 1 annual deductible. Does that mean if I go to my tier 3 doctor and get a bill for $500 that I am working with a $400 deductible fresh because it's tier 3, or that I'm working with a $250 remaining deductible ($400 tier 3 deductible minus $150 paid toward my tier 1 deductible).

Does that even make sense? I feel like I'm talking in another language, haha.

[chinamama 104]

One thing to remember that any preop tests you need you can request them to be done at your hospital. Even if they usually do them in house. Might save you a few dollars.

[makemyownluck 785]

That's exactly what I'm afraid will happen' date=' MMOL! But if they MAKE me do it...I don't see a way around it. Can I call the hospital and tell them I don't want to pay up front? LOL

I suppose I could do some research. The hospital I work at is (relatively) small and they don't perform any bariatric surgeries here except lap band (which I DON'T want). And when I went to my PCP he said that he sends ALL of his bariatric patients to this practice because they're so good. I don't know that if I tell them I can't afford their up front costs if he will refer me to some place else. But I'm guessing that most other places will operate similarly, since it would take place at the same hospital...

Well here's where I get confused with the deductibles and whatnot. As of now, the only doctors I've ever seen are "Metro" doctors, so they all fall under tier 1 of my insurance. And they've all been simple office visits with a 10 co-pay. This will be my first time going to a "tier 3" doctor that has a different "set" amounts of deductibles, co-insurances, etc. But I don't think I've met my annual deductible yet. I get so confused with insurance.

For example. My tier 1 deductible per year is 100. My tier 1 co-insurance maximum per year is 1000. I have only seen tier 1 doctors and paid my tier 1 co-pays of 10 per visit. Question one: Do the office co-pays go toward my deductible? Otherwise I have had some expenses go toward the deductible (chest x-ray cost, etc)

My tier 3 deductible is 400/year. My tier 3 co-insurance maximum per year is 3000. If I've paid some expenses toward the tier 1 deductible, does that also lessen my tier 3 deductible or are they separate?

So like, say for example that in seeing my tier 1 doctor I paid 150 for something that went toward my tier 1 annual deductible. Does that mean if I go to my tier 3 doctor and get a bill for 500 that I am working with a 400 deductible fresh because it's tier 3, or that I'm working with a 250 remaining deductible (400 tier 3 deductible minus 150 paid toward my tier 1 deductible).

Does that even make sense? I feel like I'm talking in another language, haha.[/quote']

These are all really well thought out questions. I'd write down every question you can think of and call the insurance company and ask all of them til you know for sure how your benefits work. When I had a plan with copays, they did NOT apply to the deductible, but there are many plans that DO apply copay to the deductible.

When you figure out the benefits, maybe ask the hospital if they can let you do installments so you won't have as much $ hanging out there while the bills are being processed. Also verify w your insurance if contracted providers are "allowed" to request money up front. If they aren't, tell the provider you spoke w your insurance and they advised not to pay up front. You'd be amazed how that actually works (in IL it does, anyway).

Best of luck, insurance can be the highest hurdle to jump in this process! Let us k ow how it goes for ya!