Understanding Health Plan Coverage: How Much Will Surgery Cost with Insurance?

insurance claim

For those in need of surgery, peace of mind often comes from knowing that they have health insurance to help cover costs. However, no two insurance plans are the same, and unfortunately, out-of-pocket costs can vary greatly, depending on the health plan provider.



So how much will surgery cost with insurance coverage?

Even though every plan is different, there are things you can do to educate yourself…So, let’s take a look at this pre-surgery “homework” together! We’ll review key industry terms, discover how to calculate costs and understand options to help pay for services not covered by insurance.

Step 1: Review Plan Benefits

Insurance coverage is an agreement between yourself and the insurance company that outlines the benefits and services covered by your insurance provider. Some companies are more widely utilized than others, and participation may vary greatly state to state or by region of the country.

Items and services that the insurance plan pays for are considered “covered services” and can be found in the Summary of Benefits and Coverage (which you should have received upon enrollment).

Terms and Important Items

The Summary of Benefits and Coverage (SBC) is chock-full of key terms, and some of the most important (when considering the impact on your wallet) are listed below:

  • Copayment (Copay)

A fixed amount paid for medical services, usually a standard amount for office visits, therapy sessions, etc.

  • Deductible

The amount of money due from the patient before the insurance company will cover costs for health-related services. (Copays and various other payments often DO NOT count toward a deductible).

For example, if your deductible is $2500, you will be required to pay that $2500 out-of-pocket (within the calendar year) before insurance coverage will assist in paying for medical services.

  • Coinsurance

The percentage of costs you must pay (each benefit period) for covered services even after your deductible is met.

For example, if you have an 80/20 plan, you will pay 20% of the costs of services  (after your deductible is met) until the out-of-pocket maximum limit is met.

  • Out-Of-Pocket Maximum (OOPM)

The maximum amount an insured person will pay each benefit period (from deductibles, coinsurances and services). Once this amount is reached, medical costs are paid at 100% by the insurance company.

In-Network vs. Out-of-Network

Now that you have an idea of key health insurance terms, you also need to do some research on your plan’s provider network.

What’s a provider network?

Essentially, it’s a group of providers who are contracted with your particular insurance plan.

Why does your insurance plan direct you toward in-network providers as opposed to out-of-network providers?

In-network physicians, offices, labs, etc. provide care to insured patients at a discounted rate (a rate negotiated by your plan that’s considered “payment in full”).

Why Does In-Network vs. Out-of-Network Matter?

Short answer: you pay less for copays, coinsurance and your out-of-pocket maximum if you stay in-network.

While some insurance plans will still cover a smaller percentage of the costs for out-of-network providers, most HMOs will not pay a penny for the care you receive from an out-of-network provider.

Step 2: Make Sure Your Surgery is “Medically Necessary”

Just because you’ve been dealing with pain for months or have had several appointments with your primary care doctor and/or specialists DOES NOT mean that your insurance plan considers your surgery “medically necessary.”

And, if your procedure isn’t considered medically necessary, then your insurance WILL NOT PAY!

Cases abound where a patient’s physician decides that a procedure is needed, yet the insurance company doesn’t feel the same.

Moral of the story: make sure you understand your insurance coverage.

What Happens If Care Isn’t Covered?

If your claim is denied, then you will be responsible for the entire bill.

With any insurance plan, you have the right to appeal any denial, but each company’s appeal process is different, so make sure you understand your insurance plan’s process. Your physician may also be able to advocate on your behalf to try and get the procedure approved.

Step 3: Calculate Costs

Your surgeon or primary care physician might be able to give you some insight into the overall general costs associated with your impending surgery, but there are numerous “add-on” surgical costs that can inflate the price.

Here are some additional items not usually factored into normal surgery costs:

  • Pre-Op Testing
  • Anesthesia
  • Additional Hospitalization Costs
  • Surgeon Fees

Additionally, be sure to have a good understanding of whether your procedure will be inpatient (usually requiring hospitalization of at least 24-hours) or outpatient (non-invasive procedures where patients are able to return home same-day).

Inpatient care tends to be more involved and more costly, billed in two parts (facility fee and surgeon fee).

Once you know some of the details of your surgery, reach out to your insurance plan with your SBC in-hand and ask for a price estimate for your procedure. They may even have an online cost estimator tool available for quick and easy use.

Step 4: Paying for Surgery

Once you have an idea of how much your surgery may cost with insurance coverage, the final step is to have a plan in place to pay the costs you will be personally responsible for. Planning appropriately can significantly reduce stress and anxiety before and after surgery!

Once the bills start arriving in the mail, confusion may set it, so be sure to review ALL bills carefully. Layouts vary, but most include the following line items:

  • Insurance Payment (if your insurance received the charges before your bill was sent out)
  • Insurance Adjustment Amount (the contracted rate negotiated by your insurance plan)
  • Discounts (if applicable)
  • Total Charges
  • Total Amount Due From Patient

Depending on your hospital or surgical hospital of choice, you may be able to set up a payment plan (a formal repayment agreement) for costs not covered by insurance. With this option, monthly installments are established and a payment plan will not negatively impact your credit score.

Other options commonly used to help pay for medical procedures include using money from checking or savings accounts, utilizing home equity lines of credit, crowdfunding (i.e. GoFundMe) and seeking assistance from nonprofit organizations that provide financial assistance.

Surgery Isn’t One Size Fits All

Unfortunately, no two surgeries are alike, and that includes the price!

The key to a good surgical experience relies heavily on your involvement in the process – so be sure to ask questions, get a good understanding of the procedure, reach out to your insurance plan and compare pricing for various facilities!

Know what you’re up against by educating yourself on the most important parts of the process:

  1. Understand key terms and important items.
  2. Make sure your surgery will be covered by your insurance plan.
  3. Anticipate general costs.
  4. Have a plan in place for the payment of the costs you will be responsible for.

Even though surgery costs with insurance coverage are significantly lower than surgery without insurance, you owe it to yourself to investigate all of your options. Contact different facilities and see how pricing fluctuates.

More importantly, be sure to review facilities for patient satisfaction and infection rates. Remember, not all hospitals and surgical hospitals are the same.

For more information on the diagnostic and surgical procedures offered at Edgewood Surgical Hospital and Lawrence County Surgery Center, contact us today!