Things to understand about your health insurance:

How do I know if I have a really good health insurance policy?

There are many health insurance carriers and each carrier has a variety of plans available in the healthcare market. An overall indicator of a good policy is comprehensive coverage with low out of pocket costs. Many plans are inclusive of wellness and preventive services. Also, plans which reimburse providers adequately or reasonable and customary when utilizing in and out of network coverage without exclusions rank highest among health insurance plans.

Why are so many great doctors not ‘in network’ with my insurance?

Highly specialized and notable physicians can choose to not participate in health insurance networks. Premier physicians render healthcare services that often exceed conventional practices. These physicians often do not receive adequate recognition or compensation for their services. For this reason, many choose to not participate in health insurance networks.

What is an EOB?

An EOB or Explanation of Benefits is a written correspondence from health insurance companies to providers and patients. Claim details including but not limited to date of service, billed procedures, billed amount, paid amount and patient responsibility (i.e. deductibles, and coinsurances).

Will my insurance premium go up if I utilize my health insurance?

This is a common belief, but not true. Many complex factors contribute to the ever-increasing insurance coverage premiums. Premiums will increase whether or not you use your coverage.

Will I be required to pay my deductible in full before the insurance company contributes?

All patients are contractually obligated to pay their deductible in full. Deductibles need to be exhausted before the carrier starts to make payments toward eligible services.

How do I know if there is a daily cap for insurance reimbursement?

Most carriers provide online access to plan benefits and coverage limitations. You can find information on Daily Cap Limits here. You can also call the number on the back of your card, and speak with a representative in the benefits department. Tell them the type of procedure and place of service you wish to learn about.

What does ‘out-of-network’ - ONN- benefits mean?

Out of Network, or OON is the terminology used for healthcare providers that choose not to participate in a carrier’s network. When a provider is contracted or In-Network, he or she is bound by the terms and conditions set forth by the carrier. The in-network provider agrees to accept the payment determined by the carrier.

Why do I have such limited choice of in-network Surgeons?

Many doctors believe in providing great care to their patients which involves spending the appropriate amount of time per case. Sometimes up to an hour. In order to do that they have to generate enough income per case which is not possible given the reimbursement of many insurances. For this reason, many providers can not afford to become in-network and choose to accept payment directly from the patient or on an out of network basis For this reason you have a much better choice of out-of-network providers.

Will my health insurance cover the cost of my surgical procedure?

Every insurance company is different and every plan is different. Check your plan benefits documents, check for any exclusions. Call the number on the back of your card and tell them what procedure you are considering. Some surgeries require prior authorization, in that case, your surgeon must obtain the authorization to ensure coverage. Always check with your carrier to be absolutely sure.

Why was I reimbursed such a small amount for my out-of-network Surgeon’s fees?

When a provider submits an OON claim the allowed amount is not easily determined at the time of claim processing.  The insurance company may underpay the claim. It is the patient and the provider’s responsibility to speak to a claims specialist to review and reprocess the claim. This often results in an additional payment. 

How long does it take for an insurance company to pay for my procedure?

Claims processing timeframes vary from carrier to carrier. On average, an insurance company will complete processing a claim within 30-45 business days.

Why did I receive a check for my Surgeon and Facility fees?

Insurance companies are not particularly keen on encouraging their customers to utilize their out of network benefits. In efforts to make the out of network experience cumbersome, they will sometimes process the claim payments directly to the patient and not the provider.

What does it mean if my Surgeon is out of network?

When an OON surgeon provides services, they will be utilizing your OON benefits. This means the claim will be subject to the OON deductible and coinsurances.

My deductible is very large. Will I be responsible for the entire amount before my insurance company contributes?

It is typical for carriers to provide payment for services once the deductible has been satisfied.

Do I have any options if I am unable to pay my out-of-pocket responsibility?

Many providers will offer many options based on the needs of their patients.  Payment plans, and settlement offers are examples of providers working with patients.  Depending on your situation, you may even apply for financial hardship.

What do I do when my Surgeon or Facility sends me a large bill?

Many patients mistake and EOB or explanation of benefits for a statement.  An EOB is the carrier’s communication to you. Always call the physician or facility, and ask them what your responsibility is.  Many providers may choose not to balance bill their patients. It’s best to confirm your balance before making any payments.

Things to consider when planning an elective Surgery:

Is it safe to have Plastic Surgery in a doctor’s office?

Yes, it is extremely safe to have surgery including plastic surgery outside the hospital, in a private surgery setting. 

However you should ensure that your surgeons is board-certified and only works with board-certified anesthesiologists. 

You should also ensure that the surgeon’s office/facility is accredited as proof of adherence to the highest clinical standards including staff and equipment necessary to perform outpatient elective surgery.  

These exclusive environments have several advantages for patients including limiting exposure to infections, privacy for patients, and having the same team of experts work together on a daily basis which increases safety, efficiency and personalized care to each patient.

Will the Ambulatory Surgery Center send me a large bill?

You will have to consider what your deductible and coinsurance is.  If you have a high deductible that has not been met, it will be your responsibility to pay this amount. However, the discussion of out of pocket expenses will happen before your surgery, so that you have an idea of what your expenses will be.

What if I need to spend the night under observation after my surgery?

For certain procedures, your surgeon might suggest that you spend the night with a nurse for observation and monitoring.

We have 2 excellent options in that case: either an overnight stay in a private setting at the facility where your surgery was performed or at a hotel nearby with which we have developed strong personal relationships.

PreferredMD has access to top-notch licensed RNs, you will be in great hands.

What can I ask the Anesthesiologist to ensure I get the best care?

Your board-certified anesthesiologist will review your medical chart including your history, physical exams, labs, and any other pertinent clinical data.

Your anesthesiologist will always call you the day before surgery to go over the medical information personally with you.

Please share with him/her your medical issues, past surgeries and your experience with previous anesthetics, medications, and possible allergies.
You will also discuss the timing of any medication to take before surgery and NPO status.

Your anesthesiologist will tailor a personal plan for you to create the safest perioperative environment with the lowest possible side effects including for instance specifics anesthesia techniques reducing the risk of postoperative nausea.

On the day of surgery, you will meet with the surgeon of course and the anesthesiologist in-person to review what was discussed over the phone and answer any last-minute questions.

Your surgical team will also always ensure you have an escort to take you home after the surgery.