Question:
Anyone ever dealt with a PARTIAL Coverage Policy?

I am under an Anthem BC/BS self insure policy (administered by Anthem, but actually underwritten by own company -- an Insurance company). They have gastric bypass as a covered procedure, but only at 50% after $1000 deductible. Has anyone had anything like this? It will only be 50% of the allowable amount, this I know. I am just trying to gauge how much that is going to be. It won't be half of the self pay amount, just the allowable. Any help is appreciated. The whole thing is just kind of crappy, because I will be in the hospital bed doing anything to get out as quickly as possble.    — Ann D. (posted on January 26, 2005)

January 26, 2005
If this policy has in-network doctors and hospitals and you can use them, then you should be able to get darn close to what the costs are likely to be. At least then you would only get hit with the 50% and not UCR charges (above usual, customary and reasonable). I had my surgery in Feb 03 and my total hospital and doc charges was $26,000, which actually was less than the self-pay for my doc. Although the self-pay is based on staying one more day and some other things and if you don't use everything then you get some of your money back. One of the reasons mine was so reasonable is that the hospital I was at had very reasonable charges. The total bill for surgery and 3 days was $13,800. This included 2 staplers they use during surgery that totaled about $2,000. I know if I had it at any other hospital in the area it would have been at least $10,000 higher. The total hospital charges for my LBL was $36,000 and I was in 3 days. Granted the surgery was 8-1/2 hours longer and I got 3 units of blood, but then again they didn't need any specialized one-use staplers. This was done at a hospital in another city. Charging almost 3 times what my WLS was is insane to say the least. <p>I would talk with the hospital and doc and see if they will agree to accept no more than the self-pay amount. Then you would know the maximum and whatever insurance pays it would be taken off of that. In reality it would mean you would end up paying less than 50% because what the bill the insurance is way more than is built into the self pay. Even if they only did this with the hospital portion. That is the charge that is most likely to get out of line. Basically they bill it all out item by item, insurance pays and then they agree to write off the difference between the self-pay and the individual charges. It's worth a discussion. Either way the hospital and other involved are not losing out in any way, because they are agreeing to do it for a max self-pay fee anyway. Good Luck!
   — zoedogcbr

January 26, 2005
If your in a HMO, POS or PPO plan and you use all in network doctors and hospitals (doctors and hospitals in the Anthem network), look to see what the in network out of pocket expense is. That is the maximum amount that you would have to pay out of your pocket before the insurance kicks in at 100%. Check to see if the out of pocket includes your $1000 deductible.
   — Patty H.

January 26, 2005
I just had surgery 12/17 and I have to pay for 20% of EVERYTHING and a $3,000 co-pay, I just got my first bill just from the hospital and that was $31,000 and I was in for three days with no complications. I'm anticipating that I will need to put out about $10-$15,000, but hey it's better than self pay but still sucks when my sister who is on Soc. Sec/Disability didn't put out a cent and I've been with a fortune 500 company for 26 years. I hope your costs aren't too much and good luck with your surgery. (Jennifer, 12/17/04, RNY Lap)
   — jenniferw

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