Be aware of doing expensive procedures out of network

I just recently found out that when going out of network with health insurance, the amount you get back is set at Medicare rates, which is extremely low. I just recently wanted to have surgery done by an out of network doctor, and I would only get $3,000 back from $23,000. It used to be reasonable and customary rate, which still was low, but when it was determined we would get screwed by the lower rates, they did an overhaul of how it works and now it is worse. I did a search of this online and there is a lot of info on it and I verified this with my insurance, BC/BS. Just make sure you find out exactly how much you would get back before going out of network. Now I have no choice and have to use an in network doctor and my surgery is postponed, as I have to start my dr consults all over again. I finally decided on the dr I want to use for my surgery and now I can't use him, as it will cost me $20,000 even after my insurance reimburses me.

Message edited 7/1/2013 9:42:59 AM.

Re: Be aware of doing expensive procedures out of network

Not always. Did you try to negotiate with the dr? My DD had surgery recently with a dr out of network bc he is the best. We asked him directly not the office staff. He was happy to negotiate and accept what other companies pay him. He said that they do it all the time. Then the hospital etc were all in network. I know many other people who had done the same. Many drs do not take insurance or are willing to negotiate their rates.

Do you have an out of pocket max? Most plans with deductibles or copayments have one. Once you reach the amount they pay the rest.

Be aware of doing expensive procedures out of network

"Most plans with deductibles or copayments have one. Once you reach the amount they pay the rest."

I wish that was true, but it isn't. They only pay what they consider to be fair out of pocket which is quite different from the actual out of pocket costs. I just went through a year of cancer treatments and learned that the hard way. I hit the deductible immediately and hadn't reached the out of pocket max 12 months later because of how they figure their costs. I had to pay the difference on many bills " out of pocket" as the insurance wouldn't cover it, nor would it credit me for having to pay it.

Like the OP, I had to make doctor choices based on in and out of network. While some of the surgery by an out of network doctor - tops in her field - would have been partially covered, the way they break an operation down into codes meant that the the first coded procedure would have been paid at 80%, but the other codes would have only been covered at 40%.

Message edited 7/2/2013 1:08:53 AM.

Re: Be aware of doing expensive procedures out of network

Re: Be aware of doing expensive procedures out of network

Posted by NervousNell

Posted by Lillykat

Not always. Did you try to negotiate with the dr? My DD had surgery recently with a dr out of network bc he is the best. We asked him directly not the office staff. He was happy to negotiate and accept what other companies pay him. He said that they do it all the time. Then the hospital etc were all in network. I know many other people who had done the same. Many drs do not take insurance or are willing to negotiate their rates.

Do you have an out of pocket max? Most plans with deductibles or copayments have one. Once you reach the amount they pay the rest.

I agree with this. I went to the ER (at in in network hosptial mind you) and wound up being admitted and needing surgery to remove my gallbladder. The surgeon on call did the surgery. He was the only surgeon there at the time.
We ended up getting a bill because he was not in network- the hosptial was, he personally was not.
I ended up with a bill for $11,000
I called the office and they ended up accepting whatever my insurance paid for out of network.
We never heard another word about it

Re: Be aware of doing expensive procedures out of network

Well I just had a 10k deductible plan and hit both the deductible in network and out. Paid the coinsurance until out of network until I hit out of pocket max. They paid 100% after. I frequently go OON bc I am very picky about drs and use some who don't take insurance. I have also done that in the past with other plans and companies. My drs have always accepted what insurance pays them. One time I had an issue. I appealed and it was resolved.

Have you tried appealing?

Re: Be aware of doing expensive procedures out of network

Be aware of doing expensive procedures out of network

My plan only pays OON doctors what is reasonable and customary which is way less than they charge - and top doctors in Manhattan don't negotiate. They figure if you want them, you pay for them, otherwise go to someone else. Many do not take any insurance at all.

Just be clear about what is and is not covered.

Re: Be aware of doing expensive procedures out of network

Re: Be aware of doing expensive procedures out of network

Thanks for all the responses.

I am wondering, if a dr that is out of network and is going to cost a lot out of pocket, considers if you spent out of pocket a lot of money at their office in the past.

Message edited 7/5/2013 7:58:10 AM.

Be aware of doing expensive procedures out of network

Wih our medical plans I have noticed oon providers have double the deductible amount... I avoid them completely now.

Re: Be aware of doing expensive procedures out of network