CPT code and insurance worries. Aetna help???

Marcus C.
on 6/20/13 8:57 am
Hi everyone so I have aetna pos ii insurance. I will be going to an in network hospital and doctor. My insurance has a $10k max coverage for bariatric surgery.

I called aetna with the CPT code for VSG and they're telling me the facility charge for VSG is $1450+- same for the surgeon. For in network. Does this seem right? I mean I know hospitals have negotiated rates but I'm not sure how in/out network works. But this amount seems low.

My concern is after its all done I'm hit with a $30k bill because I'm only allowed a $10k max. Did anyone with aetna have similar coverage...did you happen to see what your negotiated charges were after getting VSG?

Thanks for ya help!
VSG on 06/12/13
I just looked on my UHC site and don't see them yet.

   

Sleeved 6/12/13 - 100 pounds lost to get to goal!

Marcus C.
on 6/20/13 9:19 am
Ok. I know it'll be different for everyone but I'm looking for ballpark figures. Did you have a coverage max
VSG on 06/12/13
no, no coverage max, but I had to be in-network and thus subject to negotiated rates.

   

Sleeved 6/12/13 - 100 pounds lost to get to goal!

lnettles1963
on 6/20/13 11:24 am
VSG on 07/12/13

I have aetna pos 11 also, I do not have a restriction like that, but I did have to choose a Center of Excellence hospital to be considered in network.

It may be a restriction your employer choose.

I would call again and have the Dr office call if they have not already.

Marcus C.
on 6/20/13 12:32 pm
Well the doctors office isn't sure. Their response is they don't know how much anesthesia etc ill need to determine. To put in perspective I was in a car wreck. My hospital bill was $17k. If I go to my aetna claims it says "your aetna member rate for $17k bill is $6500. Your plan pays 6400. You pay. $100". So I guess I'm looking for a ballpark from someone else with a similar/same plan
califsleevin
on 6/20/13 3:12 pm - CA

I am/was covered by an Aetna POS type policy, though without that specific benefit cap.The numbers you list sound plausible, though there will no doubt be a few other misc. charges in there as well, such as the anesthesiologist,, etc. I don't recall what the in-network hospital charges were (it was more than two years ago and has slipped off the EOB listing on their website.) but they were probably in the ballpark of what you were quoted, maybe a bit more since I was in for two days rather than their originally authorized one day.

Another insurance wrinkle that can play into this is the max out of pocket expense on the policy (usually around 5-6k per year.) Though the surgeon was out-of-network, they covered his fee at 100% as we had hit that max out of pocket for the year by the time they got around to paying it. So that's another question that you can ask them, or your doc's insurance coordinator - how that max out of pocket coverage relates to their max bariatric coverage.

Good luck, but it sounds like things will probably be OK with both doc and hospital being in network.

1st support group/seminar - 8/03 (has it been that long?)  

Wife's DS - 5/05 w Dr. Robert Rabkin   VSG on 5/9/11 by Dr. John Rabkin

 

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