Surgery Costs With Health Insurance

Surgeries are never fun–and neither are the medical bills that come with them. Every insurance plan covers surgery costs differently, which can make it difficult to know how much your procedure will cost ahead of time. However, with a little digging, you can usually find out whether or not your insurance will cover a procedure and what you should expect to pay.

Step 1: Find Your SBC

All insurance plans have a Summary of Benefits and Coverage (SBC). This document explains which services your plan covers and how your insurer will help pay for each of these services. You can find yours by Googling “[Your Plan Name] SBC.” When reviewing your SBC, here are a few helpful terms to keep on hand:

  • Out-of-Pocket Maximum (OOPM): this is the MOST you can pay on covered medical services in a year.

  • Deductible: the amount of money you have to pay before your insurance kicks in.
    Example: Let’s say your insurance covers 100% of your surgery after you hit your $4,000 deductible. If you were to get your appendix removed for $33,000, you would pay the full $4,000, and your insurance would pay the remaining $29,000.  

  • Coinsurance: a fixed percentage of medical bills you’re required to pay after you hit your deductible.

    Example: Let’s say you need open heart surgery, and your insurer bills 20% coinsurance for surgeries. You also have an out-of-pocket max of $7,500. If your surgery costs and you’ve already met your $6,000 deductible, your coinsurance (which in full totals $8,000 for the surgery) would be capped at $1,500 because of your out-of-pocket max.

Step 2: Determine if Your Procedure is Inpatient or Outpatient

Healthcare providers categorize surgeries as either inpatient or outpatient care:

  • Outpatient care: a medical service that does not require you to stay at a facility more than 24 hours. This includes routine checkups, services, and even surgical procedures  that allow you to leave on the same day.

  • Inpatient care: any medical service that requires admission into a hospital. This usually involves serious ailments and trauma that require one or more days of overnight stay at a hospital.

Whether or not you’re receiving inpatient or outpatient care matters because they’re treated differently by your insurance when it comes to determining surgery costs. Since outpatient care tends to be less involved and uses fewer resources, it is usually less expensive than inpatient care.

Inpatient care is billed in two parts:

  1. the facility fee (e.g. costs for staying in a hospital room each night)

  2. the surgeon or physician fee

Generally, your health plan will have copays for inpatient care on a per stay or per day basis.

Ultimately, how your procedure is classified is up to your doctor. A good rule-of-thumb, though, is the “24-hour rule.” If you’re in the hospital for more than 24 hours, you’ll be classified as an inpatient. Even visits to the ER always start as outpatient until the doctor decides you’ll need to stay longer than 24 hours.

You don’t usually get to choose between inpatient and outpatient care, but you can always ask your doctor if it’s a possibility.

Step 3: Do the Math

Once you’ve determined whether or not your procedure is inpatient or outpatient, you can head to your Summary of Benefits and get an idea of how your insurance will bill you for your surgery costs. Outpatient care and hospital stays are listed as their own categories with details.

Most importantly? Communicate with your doctor! They can help you make sure you get your procedure at an in-network facility and understand what type of care you’ll need. From there, you can contact your insurance company and get a price estimate for your surgery. In fact, many insurers have cost estimator tools right on their websites.

The Exception: Bariatric Surgery

Bariatric surgery is a type of procedure that results in weight loss. Examples include a gastric bypass or adjustable gastric band. Because this form of surgery has a more extensive approval process, it can be difficult to get your insurer to pay for the procedure.

To be eligible for bariatric surgery, you’ll need to prove that the procedure is medically necessary. Being overweight doesn’t automatically make you eligible; you need to demonstrate that other methods, including a medically supervised weight loss program, have been ineffective. The approval process can take anywhere from one month to a full year, and it usually requires you to:

  • Have your physician confirm that your body mass index (BMI) is:

    • Over 40 or

    • Over 35 with complications like coronary heart disease or diabetes

  • Complete a medically supervised diet program of 3-7 consecutive months

  • Schedule a consultation with your bariatric surgeon

  • Schedule a consultation with your primary care doctor to get a medical clearance letter

  • Schedule a psychiatric evaluation to obtain a mental health clearance letter

  • Schedule a nutritional evaluation with a registered dietitian

  • Send all your documentation to the insurer along with a detailed history of your obesity-related health issues and treatment attempts

  • Wait for approval or denial from your insurer

  • Schedule your procedure (if approved) or appeal your denial

If you are considering bariatric surgery, this resource can help you find insurance plans that will cover the surgery costs.

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Aly KellerComment