I have scheduled 3 surgeries on my legs (2 on 1, 1 on the other) The first is scheduled for tomorrow. I let the surgeons receptionist know that my insurance has 3 levels,
1 for inner network (since I work at a hospital, anything that goes through this hospital is covered 100% )
2nd level- in network level for services not offered at my hospital (comparable to what everyone elses insurance pays)
level 3- for in network but services my hospital provides or out of network procedures (1000 deductible---insane!)
So the procedure I have to get is 3 parts and the 1st is covered at my hospital (i had it done on my left leg and there is one general surgeon not specializing in this who works at the hospital who can do the next part so I called his office like I was told by the dr who finished the first part and I was told by his staff that once the first part is done by someone else he won't look at you and that its not his speciality and that he does the second part but its more invasive then the other dr does)
so I have to go in network but not throught the hospital (the 2nd level). I was worried about it getting denied at the 2nd level, and the doctors office said they submitted it and it was all approoved with nothing due at time of service and that its all good and I spoke to the insurance reps at my hospital and they said I can submit extra forms to get the procedure included in the 2nd level but they won't know until after the surgery goes through if its approoved. Now I'm torn my leg hurts very badly but I don't want to take the risk of it not being covered in the second tier and going to the 1000 deductible which I in no way can afford.
I called my insurance company and they said theres no way to know until after the procedures researched so I could get hit with the 1000 if its denied
so what would you do?
i hope that made sense somewhat. I'm working on 2 hours of sleep
what i'm most concerned about is the first procedure is tomorrow and then the 2nd and 3rd are in a month so what happens if it is the 1000 deductible and then i cant pay it off will they cancel the 2nd and 3rd procedure until i can pay it? and since insurance requires the procedures to be done within a certain time frame what if I cant pay it by that timreframe and then canteer get the 2nd and 3rd part?
marda I did talk to the billing office but I think theyre unaware of my complicated insurance and to them it was approoved and looks like i have no dedcutible, i'm worried that aftyer the 1st procedure my 2nd two won't be done unless i can pay the 1000 up front for the first
I think $1000 is a deal. Our deductible is $10,000 BEFORE our insurance pays anything.
When it comes to health and safety. DON'T skimp and pinch pennies. It's not worth it.... YOUR health is more important.
Well you leg hurts, so sounds like either way you need to do the surgery and in the long run $1000 is nothing. So go sleep and have surgery tomorrow! And then be happy that things will get better. You can't live off of what if's...
Some of us have to pay $3000 up front J. to go be seen for anything to meet our deductable every year. You are lucky to have the insurance you have! Sounds like a pretty awesome plan to M..
I'm an insurance agent. My opinion is that none of this matters. If the surgery is necessary, then you do whatever you need to. And by the way, a 1000 deductible is nothing. Mine is considered "low" and its $3000. And thats J. for my kids. Hubby and I can't even afford it for ourselves. J. my opinion...good luck.
We have a $3,000 deductible. I remember very clearly being unable to afford treatment, but hurting and having to do something.
I would go to the BEST surgeon. I would appeal three times in order to get it paid for. Often the first claim is denied.
I don't blame doctors for not working on you after others may have messed it up. One of the ways doctors avoid lawsuits and raising our rates is to prevent unfair lawsuits.
I have gone out of network and made payments. There is no interest if you make arrangements and pay the minimum each month. Don't put it on credit card or a medical loan.
I would take care of my legs-no matter what the cost
This happened to M. with respect to the ultrasound we had done at 20 weeks. The insurance company "authorized" it because my older child was born via emergency c-section, but in the end didn't approve the coverage because it came back that everything was fine. Um... the only way to know that everything was fine was to do the ultrasound. I was not thrilled with the $500 bill that ensued, but as it was explained to M. the insurance company can "authorize" a procedure, but decide in the end that it wasn't medically necessary.
Personally, knowing that we weren't going to have the same issue the second time was worth the $500. If your quality of life will substantially improve, have the surgery. Work with the billing department AHEAD of time to work-out a payment plan and see if you are eligible for any discounts.
My mother had spinal surgery several years ago, which was not "elective", but the insurance company wanted her to have at least another year of PT before having surgery. The PT hadn't worked, the surgeon wrote a letter stating that she could be paralyzed and the therapy notes all indicated that she was a compliant patient who was "not responding" to PT. Bottom line, she was in excrutiating pain and immobile for most of the day. They elected to pay for the surgery out-of-pocket ($40,000), but in working with the surgeon's office they were able to negotiate a much better rate ($20,000) as long as they paid for it in cash. The doctor's office may work with you, so don't give up yet!
You need to ask the doctor's business office that will be doing the surgery. Only they will know if they'll do the surgery even if you aren't able to pay the deductible fully first. I suggest that what the doctor does or doesn't do is unrelated to whether or not you pay a lump sum. You can arrange for payments in advance or after the surgery.
I wonder why you haven't talked with the business offices. They should be able to tell you before the surgery what the charges will be, whether or not it's covered at which level. I've had several surgeries and always knew ahead of time what was and what was not covered by M. insurance.
The receptionist cannot tell you about the billing. Only the business office can do that.
After your SWH They will not require you to pay the deductible up front! The surgeries will be done whether or not you've already paid the deductible for the first. Think about it. Billing is done in a 30 day cycle and then you have 30 days to either pay the bill in full or make arrangements to make payments. Actually you have much longer. So they will do the next surgery before you'll have had time to even be aware of the cost for the first surgery.
You need the surgery. Are you saying you will choose to not have the surgery if you have to pay $1000 deductible? That is J. so foolish. You need the surgery. The doctor will NOT not perform the second surgery because of money. It J. doesn't work that way.
Please find a way to let go of your worries. It will work out in the end and your body does not need the extra stress of worry. It will work out! Tell yourself that over and over.
As others have said, $1000 deductible is not such a bad number. The deductible could be much higher. And you can pay it off in payments. $50/month and it's gone in less than 2 years. As long as you're paying every month the business office will leave you along. Miss payments and they will be calling you.
I J. find it hard to believe that the doctor would preform the procedure without having definite payment arrangements made. What if he does the procedure and it's not covered and drops to the 3rd level and you don't have the money to pay him? Usually, you have to pay for this type of thing in advance or have advance authorization.
But in any case, you don't say what's wrong with your leg, what benefit you can expect from the surgery, etc., so it's hard to know what I would do. Without full information, I can't say what I would do.
After reading your SWH, I think I would put off the entire procedure until you have all of the information you need about the insurance.
they wont care if the #1 is paid for before #2 or #3. get what you need done and make pmts if it is not covered. as much as they would love to have all money at once they wil;l take pmts and usually not charge interest. do what needs to be done and worry when its time to worry no sense in wasting your energy on what may or may not happen.
I wonder if "we won't know until after the surgery if we can approve this or not" might be insurance-speak for "it depends upon how talented the billing clerk at the doctor's office is?" I would speak with the billing people at the surgeon's office and see if they can give you any suggestions. I'm not saying that they would do anything shady to get it covered, BUT I do know that a lot of good doctors have billing people who know how to get services covered under many different insurance policies. As long as you've made them aware of what the insurance company is telling you, then they can take proactive steps to help you make sure it's covered/coded properly/etc. Good luck. That whole situation sounds kind of crazy!
It makes sense... so basically you have to either deal with the pain or take a gamble, b/c neither the insurance company or the hospital can guarantee that it will be covered by the 2nd level.
I would go ahead and have the surgery. It's a lot of money, but it's something that needs to be done. If it's denied, hopefully you can contact the hospital's patient reps to barter with your insurance company and make adjustments for you, or work out a payment plan as a last resort.
So if a train leaves Chicago going 35 MPH and a train leaves St Louis....
Have I ever mentioned I hate word problems? :p
Are they doing both parts at the same time within the same procedure?
Why don't you PM M. all the gory details and I will ask one of our coders before they leave. :) They should have the answer if it is an insurance we are familiar with.
I do insurance for a living and what the insurance company is saying is that they won't be able to determine coverage until after the dr's billing office submits the claim. Drs will call asking about different benefits and we are able to quote how payments would be made however without the actual cpt procedure codes and diagnosis it's hard to determine exactly what is being done and why.
In your case I would ask the dr's office to do something called a predetermination of benefits. What this does is put the diagnosis in writing and give the insurance company the procedure codes that will be billed.
From what I'm gathering it appears that you may be having varicose vein issues. Because they can be painful requiring treatment or J. cosmetic a predetermination might be the way to go. Also if anything is denied have the dr's office submit an appeal with surgical notes.
You were in a hospital, but I'm assuming you haven't worked in insurance before? A 1,000 deductible is VERY low, and incredibly ideal. You should be thanking your lucky starts for that!! Second, there is NO way to know what the insurance will cover before the procedure...because, the insurance company doens't know exactly what they will be billed for. You didn't specify...does the Level 2 coverage say you should have 100% covered? If so, since it's in network, but not through the hospital...you will not actually get 100% covered. Insurance has an "allowable amount." Until they get the bill, you have no way of knowing what the allowable amount is. Say your surgery cost $4000. Their allowable amount could be 2000, and they will pay 100% of that, but you are responsible for the other 2000...which will be billed to you. (That you can usually make payments on.) So, nothing is due at service, because they have to bill the procedure. But at second level, you will owe something. Does that make sense? You won't get denied the second level. What will happen, is you will have the procedure, they will bill the insurance company, and the insurance company will pay 100% of their allowable amount, and the rest is on you.
Either way, you need the surgery right? I mean, you have to get the others once you get the first. Your office should have (and they might have, that might be how they know) sent in the codes and got some information on billing before hand. That can give them a pretty good idea of what is covered, and they are probably going on that. However, until that bill gets sent...they can't know 100%. They can only have a solid idea.
Health care madness. Stop the insanity!
Good luck with your procedures.
