Insurance And Surgery: Who Contacts Whom?

When it comes to surgery, it is important to understand your insurance coverage to avoid unexpected costs. While hospitals generally accept most major insurance plans, it is advisable to verify this beforehand. The billing process can be complex, with separate charges for the surgeon, facility, and other providers. Patients are typically responsible for deductibles, copayments, and coinsurance, which vary depending on the insurance plan and procedure. To estimate costs, patients should contact their insurance company and medical providers, who can provide procedural codes and cost estimates. Understanding billing protections, such as the No Surprises Act, can also help prevent unexpected charges.

Hospitals may request upfront payment before surgery

However, this is not always the case. Depending on the patient's health plan, credit history, medical needs, and choice of hospital, the patient may be asked to pay some or all of their deductible upfront. In the case of an emergency, hospitals are required by law to assess and stabilize the patient, and upfront payment cannot be requested. For pre-scheduled surgeries, upfront payment may be requested, but it is not always required.

If a patient is asked to pay upfront, they can ask the hospital for an estimate of what they will owe. It is important to note that negotiated medical costs tend to be lower than retail costs. Patients should also be aware of their rights and understand their health plan's contract with the hospital to ensure they do not pay more than the negotiated price.

In some cases, hospitals may offer prompt-pay" discounts for patients who pay their share of the bill in full in advance. Hospitals may also partner with companies that offer low or no-interest medical loans, which can be a better option than putting the payment on a high-interest credit card. Patients should also check with their insurance company to see if they have any advice regarding contract rules and state regulations related to medical billing practices.

It is recommended that patients discuss the timing of payment with the hospital's billing office well in advance of their surgery. This will help patients avoid the stress of finding out close to their surgery date that the hospital wants them to pay a large deductible immediately. Patients should also familiarize themselves with the specifics of their insurance plan's coverage to avoid unexpected bills.

Patients should familiarise themselves with their insurance plan's coverage

Secondly, patients should understand their insurance plan's specific coverage for surgical procedures. Certain services associated with surgery, such as anaesthesia and hospital stays, are more likely to be covered than others, such as at-home custodial care during recovery. Patients should review the Summary of Benefits and Coverage provided by their insurance company, which outlines covered and excluded costs. Contacting the insurance company directly can help clarify coverage details and estimate potential out-of-pocket expenses.

Additionally, patients should be aware of their insurance plan's requirements for prior authorisation or referrals from their primary care provider. Different plans have varying specifications for coverage approval. Understanding these requirements beforehand can help ensure that the surgery is covered by the patient's insurance plan.

Moreover, patients should know their financial responsibilities, such as deductibles, copayments, and coinsurance. Hospitals may request upfront payment or a portion of the deductible before providing high-cost care. Patients should inquire about the facility's policies and billing practices to avoid last-minute financial surprises. Understanding cost-sharing arrangements and negotiating with the insurance company can help patients estimate their financial obligations.

Lastly, patients should be aware of their rights and protections under relevant laws, such as the No Surprises Act. This Act protects patients from surprise balance billing in hospitals and ambulatory surgery centres. Knowing these rights can help patients challenge insurance denials and unexpected charges. If issues arise, patients can seek guidance from insurance denial lawyers to navigate the appeals process and ensure they receive the coverage they deserve.

Hospitals must adhere to the No Surprises Act

The No Surprises Act protects patients from surprise balance billing if they are treated at a hospital, hospital outpatient clinic, or ambulatory surgery center, which covers most places where surgeries are performed. Balance billing refers to when an out-of-network provider or facility bills you for the difference between the billed charge and the amount your health plan paid. This can occur when your health plan does not cover the entire out-of-network cost, leaving you with higher costs than if you had received care from an in-network provider or facility.

The Act also bans surprise bills for most emergency services, even if they are received out-of-network and without prior authorization. It prohibits out-of-network cost-sharing for most emergency services and some non-emergency services, ensuring that patients are not charged more than in-network cost-sharing for these services. Additionally, it bans out-of-network charges and balance bills for certain additional services, such as anesthesiology or radiology, provided by out-of-network providers as part of a patient's visit to an in-network facility.

To comply with the No Surprises Act, healthcare providers and facilities must provide patients with an easy-to-understand notice explaining their billing protections and their right to waive billing protections. Patients must receive notice of and consent to being balance billed by an out-of-network provider, and providers cannot coerce consent. However, they can refuse to provide services if the patient does not agree to receive a balance bill.

It is important to note that the No Surprises Act does not replace existing state surprise billing laws but instead creates a "floor" for consumer protections. As long as a state's surprise billing law provides at least the same level of consumer protection, the state law will generally apply.

Patients should check if their insurance covers their chosen surgeon and facility

Patients should be aware that hospitals may request upfront payment before receiving high-cost care, and it is beneficial to understand the billing practices of the hospital and insurance company beforehand. It is important to check if your insurance covers your chosen surgeon and facility, as well as any other medical providers involved in your care, such as assistant surgeons, radiologists, and anesthesiologists.

Firstly, patients should familiarize themselves with the specifics of their insurance plan's coverage. This includes understanding the covered and excluded costs for care, as well as any prior authorization or referral requirements from the primary care provider. Patients can refer to the Summary of Benefits and Coverage provided by their insurance company or contact the insurer directly to clarify.

Secondly, patients should verify that their chosen surgeon and facility are part of their insurance plan's provider network. This is crucial because using out-of-network providers may result in higher out-of-pocket expenses. The No Surprises Act, which took effect in 2022, offers billing protections for patients treated at in-network hospitals, hospital outpatient clinics, or ambulatory surgery centers. However, some out-of-network providers may ask patients to waive these protections and consent to receive a balance bill, which includes charges not covered by insurance.

Lastly, patients should work with their service providers and insurance company to determine an estimated cost for the surgery. While it is challenging to confirm the exact amount covered by insurance before the claim is processed, obtaining a "`typical cost` estimate" can provide a ballpark figure. This estimate should consider the potential for additional services or procedures that may be required during surgery, which can impact the final cost.

By proactively checking their insurance coverage, patients can make informed decisions about their surgical care and avoid unexpected financial burdens.

Patients may receive multiple bills for surgery

Furthermore, if the patient has been admitted as an inpatient, they will receive bills from non-employed physicians who provided care during their stay. In some cases, patients may also be billed separately for services provided by the Emergency Department (ED) physician if they were seen in an emergency setting. It is important to note that ground ambulance services are generally not covered by billing protections in the No Surprises Act and may result in out-of-network charges.

The complexity of medical billing can be challenging to understand, and patients are advised to familiarize themselves with their insurance plan's coverage to avoid unexpected costs. Patients can refer to the Summary of Benefits and Coverage provided by their insurance company to understand the covered and excluded costs for care. Additionally, patients can contact their insurance company to clarify their plan's specifics, including prior authorization requirements and the need for referrals from their primary care provider.

To prepare for potential out-of-pocket expenses, patients may consider enrolling in a high-deductible health plan (HDHP) if offered by their employer or when purchasing individual insurance. This allows for the use of pre-tax money to pay medical bills, resulting in potential savings. However, hospitals and medical providers may request upfront payment of a portion of the deductible before providing high-cost care, and patients should inquire about the facility's policies and billing practices in advance.

Frequently asked questions