In working with patients in surgeon offices as well as physical therapy, we often hear the phrase “oh, I have insurance- it’s covered,” only for the patient to be surprised when they receive a bill.

We know that insurance coverage can be so confusing, and this week we wanted to provide some clarity around how insurance coverage works and give you a worksheet that you can use when preparing for any type of insurance-covered procedure so that you have an idea of what your financial responsibility will be- if any.

Know Your Insurance Plan

One of the best ways to determine whether your surgery will be covered (and how much you will owe) is to get familiar with your insurance plan. Many patients know their insurance company and their copay amount for office visits, but many do not know the details of their plan.

We have some terms for you to help make sense of how your insurance plan works and what numbers you should be familiar with in your own plan.

  • Deductible:  The amount that must be paid out of pocket before benefits kick in
  • Coinsurance: The percentage split that the insurance will pay once you have met your deductible. This means that after they meet their deductible, the insurance pays “X%” of all charges thereafter.
  • Out of Pocket Max: The maximum amount you will pay of your own money before your insurance pays 100% of your covered medical expenses. This typically does not kick in until the deductible and coinsurance have been met.
  • Copay: Not every plan or service has a copay, but some do. The copay is the amount that you must pay at the time of service (before any bill has been sent to insurance). This is above and beyond your deductible and coinsurance. For example- you may have a $50 copay for a specialist visit (which is what a plastic surgeon is classified as). When you check in for that appointment, you will pay the $50. You may still receive a bill for the office visit (your deductible and coinsurance if applicable) after the visit has been sent to insurance for reimbursement depending on your plan.
  • In and Out of Network: Each plan has in and out of network providers. Ideally, if you happen to have a plan that is out of network for a provider you’re going to see, the office will give you the heads up if they are out of network. However, this does not always happen. In network providers have negotiated a lower rate with your insurance by providing services covered under your plan. Out of network providers often charge more and your insurance will cover less of their services because they have not negotiated a rate with your insurance plan.

The best way to avoid higher medical bills for out of network providers is to verify that your provider is in network with your plan before your visit.

Let’s Look at an Example

Let’s use the example of Breast Reduction Surgery and for this example we will say our patient is Mary and she has Blue Cross Blue Shield. Here are her important plan numbers:

Deductible: $500
Coinsurance: 80%
Out of Pocket Max: $1500

Every patient has a deductible. That number will differ from patient to patient. In order for a patient’s benefits to kick in, they typically have to meet their deductible. For example, if you have Blue Cross/Blue Shield and you have an 80/20 plan (which means they pay 80% of your charges and you pay 20%), you’ll have to meet your deductible before they will pay anything toward your medical bills.

In this example, we will say Mary’s deductible is $500.

The out of pocket maximum is the amount that Mary will not exceed to pay out of pocket in a year. In this case, it’s $1500. So once Mary has met her $500 deductible, she’s only responsible for 20% of any charges beyond the $500 up to the $1500 out of pocket maximum.

Once she’s paid $1500 out of her own pocket for that year, she is covered at 100%. 

Get Surgery Prices in Advance

According to an article by Consumer Reports, one of the easiest ways to prevent medical billing errors is to get prices for your medical care ahead of time. While this can be confusing and time consuming, it can remove a lot of stress down the road from surprise medical bills.

Using the example of Mary above, let’s say that her Breast Reduction surgery will cost a total of $1000. (***Please note, this is just an example and is for demonstration purposes only).

So if her surgeon is going to bill $1000 for a service, assuming Mary has not met anything toward her deductible, this is how she will be billed: 

  • The first $500 will satisfy her deductible. The insurance will transfer that amount to her automatically. 
  • The remainder of the charge, $500, will be billed at 20% coinsurance.
    20% of $500 is $100. Add these two together. (The insurance pays the other 80%).
  • Mary’s total responsibility for this charge is $600. Deductible, plus 20% coinsurance after deductible is satisfied.

When making your initial appointment, be sure to get clarity on prices.

Ask If Your Surgeon Takes Insurance

Many plastic surgeons do not accept insurance, therefore it’s important to ask when making your initial appointment if that is a factor. In addition, many procedures may not even be covered by insurance. In this case, you need to find out if the procedure you are seeking is even covered by your insurance company.

Therefore, when calling to make an appointment it’s important to ask, “Do you accept my insurance?” as well as “Is this procedure covered by my insurance.” If your surgeon accepts your insurance and you want to be sure the procedure is covered, be sure to ask the exact procedure code or CPT code so you can verify with your insurance company.

Download Our Free Worksheet

If you are planning any type of breast surgery, you can use our free worksheet to determine what your financial responsibility will be for that procedure.

In order to use the sheet, you will need to get your plan information from your insurance provider and your procedure information from your doctor.

Insurance companies use CPT or procedure codes to bill each service. Once you have the CPT code for your surgery, you can call the insurance company to ask them what your responsibility will be for that code under your particular plan.


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