Possible surgery in my future. How to avoid out of network providers

[emzhengjiu]

I guess the title says it all. I will likely have to have surgery this year or early next year. I'm worried about out of network providers being used while I'm in the hospital. Is there any way I can ensure only in network providers are used? I don't have other adults who can stay in the hospital with me to double check. Suggestions so that I'm not hit with surprise and high bills.

[Susan C.]

My information is dated, that has happened to us, I appealed, and it was paid as in network. Our doctor and the hospital were in network, and I argued that we had no control over who came to treat. I do see plans now that say no matter what, out of network is not covered... but not all insurance companies are like this. That was a huge deciding factor in picking our insurance.

[JumpyTheFrog]

There is some all expenses included surgical center in Oklahoma that clearly posts prices on their website. Maybe a place like that would work.

 

ETA: article http://kfor.com/2013/07/08/okc-hospital-posting-surgery-prices-online/

 

Price list

http://surgerycenterok.com/pricing/

[G5052]

Not really. Know the hospital's policies, and of course check ahead of time with your insurance.

 

A family member had surgery just before Christmas with an anesthesiologist who was not on our plan. We had to have a certain surgeon and his availability meant only that hospital or a wait of many more weeks. But I knew that I could challenge it because our insurance allows you to do that with an out-of-network anesthesiologist if you truly had no other options. We didn't, and I did eventually get in-network costs on that one. But the first bill was a goody!

 

If your surgery can be done at an outpatient facility owned by the practice, your costs will nearly always be less. A family member had surgery at one that is literally next to the hospital last week, and even in-network, we probably saved $500+.

[Nart]

Check out the anesthesiologist before surgery. My son had ear tubes inserted along with his tonsils and adenoids out at one surgical center where the anesthesiologist was in network. A year later his ENT doctor recommended another ear tube surgery but mentioned that she switched surgical centers. That surgical center wasn't in network so the ENT told us she could perform the surgery at a hospital where she also performs surgeries. I called the hospital and it was in network, then I asked about the anesthesiologist. Lo and behold after numerous phone calls there was NO in network anesthesiologist who worked at that hospital. We would have has to pay and when I called the billing office of the anesthesiologist they told me they billed by the minute and it was thousands for a simple ear tube surgery ( it is a really quick surgery around 15 minutes). I was told by a hospital administrator that more anesthesiologist are opting to not be in network simply because they can then charge what they want and don't have to negotiate with insurance companies. We could have filed appeals with our insurance company but decided not to go ahead with the surgery for another reason.

[Alisa in Florida]

You might want to check with your insurance company. With mine, as long as the surgery was in an in-network facility, they considered all of the providers to be in network, as well. I've had 3 surgeries in the last 2 years and none of the anesthesiologists were in network, but the insurance company processed them as in network.

 

I was never able to find out who the anesthesiologist would be until the morning of surgery. Too late to do anything about it at that point.

[FaithManor]

Hmmmm, with ours, if we go to an in-network hospital and are admitted, we can't be billed out of network for anyone who sees us because once you are in the hospital system, you don't have any control of who works on you. The rules apply only for non-hospitalizations in which we are making our own appointments.

 

Ds once had an out of network doc, but it was an emergency surgery at an in-network hospital so fully covered.

 

I would call and ask a manager - don't settle for a customer service rep - of your insurance company, get that person's name and position in the company, and ask for a follow up email which you then never delete. This way if they say it's covered, they can't back track later, or they can try, but you have verifiable communication otherwise.

[emzhengjiu]

Hmmmm, with ours, if we go to an in-network hospital and are admitted, we can't be billed out of network for anyone who sees us because once you are in the hospital system, you don't have any control of who works on you. The rules apply only for non-hospitalizations in which we are making our own appointments.

 

Ds once had an out of network doc, but it was an emergency surgery at an in-network hospital so fully covered.

 

I would call and ask a manager - don't settle for a customer service rep - of your insurance company, get that person's name and position in the company, and ask for a follow up email which you then never delete. This way if they say it's covered, they can't back track later, or they can try, but you have verifiable communication otherwise.

I will call back and insist on talking with a manager. That's a great point! When I called the first time, I was told it was my responsibility to make sure that all labs, physicians, etc. were in network. That's almost impossible when you are hospitalized! We have a broken system, but at least the total out of pocket is capped. Still for me as a single mom, that cap looms large.

[emzhengjiu]

Actually, are the out of network costs capped? That's another question for a manager and a close review of my plan details.

 

ETA: It's harder to deal with insurance than the illness!

[SparklyUnicorn]

Yeah this is the kind of stuff that needs to be fixed through legislation.  People get burned by this a lot. 

 

 

[SparklyUnicorn]

You could probably at least check the major stuff.  Anesthesia, surgeons, imaging, and respiratory therapists. 

 

This is why that whole "consumer driven" health insurance plans are bogus.  Consumers don't have much power in some instances.  And a lot of insurance companies as well as providers are not forthcoming with information such as cost.  Which is mind boggling.  That's like going to a furniture store and them not telling you up front what a set of furniture will cost.  That you'll only know once it is in your house.  But that is really how they roll. 

 

 

[Sandragood1]

FaithManor is right. I had surgery in April at an in network facility with an in network surgeon. The anasthesiologist was out of network. Insurance denied to cover it initially. But the surgery center told me what to do. Call insurance and say I did my best to be in network by picking a facility and doctor that are in network. I had no control over the anesthesiologist but "I did my due diligence" to be in network. They had to cover it.

 

If your insurance has this coverage (Section 5, Amendment 5,.. Something like that..) they must treat it as in network. The hospital may be more forthcoming with data than your insurance company. Mine was.