When an elective surgery is in your future it is important to know the ways in which your health insurance company can impact your decisions.
You may in fact have limited choices and out-of-pocket expenses. Research your benefits so that there are no surprises.
Here is a list of common ways in which your health insurance carrier can affect your surgery.
1. You may have limited or no choice of facility where the surgery can be performed.
Often surgeons have practicing privileges at several facilities and may recommend one over another. If the facility is not in network with your insurance carrier then you would be looking at paying out-of-pocket for the procedure.
2. Many health insurance plans require that certain medical treatments such as medication or physical therapy have been tried and failed before approving a surgical option.
It is important that your health care providers document those failures so that the need for surgery is clear. Required failures can be found in the insurance carrier’s benefits descriptions.
3. Not every possible procedure for a condition will be approved. Health insurance carriers generally recognize and approve a standard surgical procedure for a particular condition.
If your surgeon is offering and/or encouraging a new or uncommon procedure the insurance carrier will likely deny coverage without thorough documentation from the physician as to why the standard procedure is not appropriate for you.
4. Most often the health insurance carrier has a contract with the facility and the surgeon so those portions of your bill are covered.
It is not uncommon to find that the anesthesiologist is not contracted with the insurance carrier which can leave you liable for that portion of the bill.
Find out the name of the anesthesiologist and call your insurance company to verify coverage.
5. As with hospitals and physicians, health insurance carriers contract services with medical equipment suppliers, home health agencies, rehabilitation centers, and extended care facilities.
- There may be co-payments for equipment or for each day of service.
- There may be limitations on the number of home health visits allowed for your condition.
- There may be limitations on the number of days allowed in an inpatient rehabilitation center or skilled nursing center.
- There will likely be only a certain number of hospital days covered (based on national averages) for a particular procedure without complications.
It can be challenging to research and obtain all the answers you need from your health insurance carrier.
Start at their website for beneficiaries and read through the coverage details. Call their customer service if you are not finding answers.
The staff at your surgeons’ office can be a valuable resource as they deal with insurance companies every day and likely have worked within the guidelines of your insurance carrier before.
By Anna K. Coss RN, BSN, MSN
Image: ABC News.