When your doctor says you need an operation, there are a hundred details you must address before you can be sidelined for awhile to undergo the procedure and recover. As you get ready for surgery, make sure you have all the bases covered with your insurance company. Knowing what your financial responsibilities will be can help ensure you won’t have any surprises afterwards. The following steps will help you be prepared:
Read your benefits plan or visit with your human resources department as soon as you know you need surgery. Learn the answers to the following:
- What are your deductibles or co-payments for my particular surgery?
- If you are admitted to the hospital, what does your insurance cover?
- If you want a private room, who will responsible for the cost difference between it and a semi-private room?
- Is a pre-certification required? Most insurance companies require physicians to obtain a pre-certification before the surgery and will send you a letter stating that the surgery has been approved. Be sure to have a copy of the letter before the surgery. Your insurance company may refuse to pay non-emergency surgical expenses if no pre-certification was obtained.
- If you have a health care plan that requires you to use a network of physicians, will you be covered if your doctor uses an out-of-network anesthesiologist? Surgeons usually choose these specialists, so it’s important to know if you will be covered if an out-of-network physician is caring for you.
- How does the insurance company handle longer hospital stays if there are complications?
- If you are having outpatient surgery, is the surgical facility in your insurance plan’s provider network? It is possible to have an in-network surgeon who uses an out-of-network surgical facility. Your share of the medical costs may be more if this is so.
When you meet with your physician at your pre-operative appointment, be sure to find out:
- Have you filed for a pre-certification?
- What other medical personnel will be included in my care?
- How do you charge for follow-up appointments? Doctors’ fees for post-operative appointments may be covered in their surgical fees, but not always.
- Do you expect any complications? What would they mean for my recovery?
When you go to the hospital, be prepared to pay at least part of your expenses upfront. If you are responsible for a high deductible and can’t pay all of it, work out a payment arrangement with the hospital before the surgery.
When you leave the hospital, be sure to ask for a detailed bill. Although hospitals provide this information to insurance companies, they generally won’t give a bill to patients unless they request it. You can refer to the bill later if you need to discuss unpaid costs with your insurance company.
Within a few weeks after your surgery, the insurance company will send you an Explanation of Benefits (EOB) for charges levied by your doctor, the hospital, the laboratory and any other medical personnel who were involved in your care. The EOB will show how much you were charged, what the insurance company paid and what portion is your responsibility, if any. Denied expenses will also be listed, along with the reason the expenses are not being covered. Call your insurance company right away if you don’t understand or agree with the information on the EOB.
Learn everything you can before having surgery. It could save your pocketbook!