How Much of Your Surgery Will Health Insurance Cover?

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The news that you need surgery is likely to elicit immediate worries: Will the operation work? How much pain will I endure? How long will it take to recover?

Concerns about costs are likely to follow close behind. If you have health insurance, you'll want to know how much of the surgery you can expect your plan to cover.

The good news is that most plans cover a major portion of surgical costs for procedures deemed medically necessary—that is, surgery to save your life, improve your health, or avert possible illness. This can run the gamut from an appendectomy to a heart bypass, but it may also include procedures such as rhinoplasty (a nose job) if it's to correct a breathing problem.

Although most cosmetic surgery is not covered by insurance, certain operations are typically deemed medically necessary when they're done in conjunction with other medical treatment. A prime example is breast implants done during or after breast cancer surgery.

Coverage Varies by Insurer

Each health plan is different. To best educate yourself about the financial ramifications of your surgery, your homework is two-pronged:

  • Ask your surgeon for a breakdown of what your procedure normally costs and what preparation, care, and supplies will be necessary. Note that hospitals and doctors sometimes can't provide accurate estimates, because they don't necessarily know what they'll encounter after they begin the procedure. But the more questions you ask, the more information you'll have.
  • Read the summary you received when you enrolled in your plan. Inside this booklet, insurance companies typically list covered and excluded costs for care. Contact your health insurance company if you do not have this information.
  • Find out what is required by your insurers in terms of prior authorization and/or a referral from your primary care provider. The specifics vary from one plan to another, but you'll likely need one or both of those in order to have coverage for your upcoming surgery.

Other Items Add to the Cost

The financial toll of surgery extends beyond the cost of an individual procedure. Other costs can include:

  • Pre-operative tests, such as blood work and x-rays, that help your doctor prepare for surgery and/or ensure your fitness for it.
  • Use of the operating room or setting for the surgery, which has a per-hour or per-procedure cost.
  • Co-surgeons or surgical assistants (including doctors and/or nurses) who help in the operating room.
  • Blood, plasma, or other biological support you may need to keep your condition stable.
  • Anesthesia, intravenous medication, and/or the doctor(s) needed to provide it.
  • The surgeon's fee, which typically is separate from the fee for the actual surgery. Depending on the circumstances, there may also be an assistant surgeon who sends an additional bill.
  • Durable medical equipment. This includes things like crutches or braces that might be necessary after your surgery.
  • The recovery room or area in which you are cared for following the surgery.
  • Your hospital stay if you require inpatient care.
  • Skilled nursing facility charges if you require extensive rehabilitative care after leaving the hospital but before returning home.
  • Part-time nursing care or therapy you may need during your recovery at home.

Depending on your insurance, each of these items may have different coverage levels. It is useful to familiarize yourself with what may be excluded.

Certain services associated with surgery (anesthesia and hospital stay, for example) are more likely to be covered than others (such as at-home custodial care if you need assistance with daily living during your recovery).

Understand Your Insurance Plan's Network

In addition, it's important to understand whether all of the providers involved in your care are part of your insurer's network. You may have picked a hospital and surgeon that are in-network with your plan, but there are likely to be other providers involved in your surgery. Assistant surgeons, radiologists, anesthesiologists, and durable medical equipment suppliers are a few examples of providers who might not be in your plan's network, despite the fact that they're providing care at a hospital that is in your network and working with your in-network surgeon.

In some cases, you might not even be aware that an out-of-network provider was involved—if the treatment is provided while you're under anesthesia, for example. But that won't necessarily prevent you from being stuck with an out-of-network bill, in addition to the in-network charges that you were expecting.

Some states have enacted legislation or regulations to protect patients from surprise balance billing in situations like this (i.e., where the patient receives treatment at an in-network hospital, but some of the providers involved in the care are out-of-network).

And the federal government implemented some additional protections (as of 2018) for plans that are sold in the health insurance exchanges. For these plans, insurance companies are required to count out-of-network charges from ancillary providers at an in-network facility towards the patient's in-network out-of-pocket limit (unless the insurance company provides adequate notice to the patient, in advance of the surgery, that out-of-network costs may be incurred and will not be counted towards the patient's in-network out-of-pocket cap). But plans that don't cover out-of-network care at all are not subject to this rule. So if you have an HMO or EPO that doesn't cover out-of-network care, the amount you're billed for ancillary services by an out-of-network provider won't count towards your in-network out-of-pocket cap.

And even though insurers have to count the out-of-network costs towards the in-network out-of-pocket cap in these situations, the patient is still responsible for the costs, and can still be balance billed by the out-of-network provider unless the state has stepped in to prohibit this. Although numerous states have taken action to protect patients from surprise balance billing, states do not have regulatory authority over self-insured group plans, since those are regulated at the federal level instead. So even in states with strong surprise balance billing protections, the protections are not all-encompassing.

Since the rules vary depending on where you live and the type of health coverage you have, it's wise to double and triple check the network status of everyone who might be involved in the surgery. It's in your best interest to sit down with someone from the billing department and ask lots of questions. Find out about the network status of the providers who may be involved in your surgery behind the scenes (eg, the radiologist who will read your scans, the lab that will process your tests, the anesthesiologist, the durable medical equipment provider, etc.). Get confirmation in writing that these providers are in-network. If they're not, ask the hospital if an in-network provider can be used instead.

If that's not possible, you may consider switching to a different hospital and/or surgeon, in order to avoid an out-of-network bill.

If it turns out that there are no options for a fully in-network surgery in your area, you can reach out to your insurance company—before the surgery—to see if they'll work out a temporary in-network arrangement with the providers who will be involved in your surgery. 

When the Bill Arrives

Even with this knowledge, understanding your hospital bill can be challenging. Formats will vary, but you can expect to see:

  • Total charges
  • Total insurance payment, if your plan has reviewed the charges before you received the bill
  • Total insurance adjustment — the amount discounted by the hospital under its contract with the insurer
  • Total patient discounts, an optional discount the hospital may extend to a patient (check with the hospital's business office)
  • Total amount due from the patient

Note that you may receive more than one bill, since the various providers involved in your care may bill separately. In each case, you should also receive an explanation of benefits (EOB) from your insurance company, showing how the bill was processed by the insurer. Don't pay a bill until you're sure you understand it and are certain that your insurer has already processed it.

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Article Sources
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