Question:
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According to my insurance (First Health Network - PPO)I will be responsible for 20% of the usual and customary fee for my surgeon. Can anyone give me a ballpark figure? I haven't read to much about costs on this site? Thanks, Gina — ftworthgirl (posted on June 8, 2003)
June 8, 2003
since you have a PPO, odds are there is a maximum yearly out of pocket you
have to pay. Your 20% can't exceed that amount. U&A varies by
company.
— [Deactivated Member]
June 8, 2003
As long as your surgeon is "In Network", you won't have to pay
any more than you out of pocket maximum. However, if your surgeon is
"out of network", you will be responsible for the 20% of Usual
and Customary (U&C) up to your out of pocket maximum PLUS whatever the
difference is between U&C and what is billed.
— Carolyn M.
June 8, 2003
I had surgery at a Bariatric Treatment Center in Michigan. Last week while
speaking with them, I asked about my bills from the surgery. I was told my
surgeons bill was about $8700.00 and the hospitalization was $48000.00 (I
was in the hospital 75 hours and the surgery was uneventful). I'm not sure
about the surgeon, but I know the hospital cost is much higher than most if
not all others(that's why BCBS PPO has pulled their contract with BTC).
— colleenkenn
June 8, 2003
Just my two cents worth. I went out of network and my insurance said I
would be responsible for 40% of reasonable and customary fees. I had to
remit my out of pocket maximum to the hospital prior to surgery. I had Lap
RNY on 4/22 and my hospital remitted all of my money but 30.00. They
accepted the resonable and customary! Yea. You just can't tell what they
are going to do and NO ONE will tell you in the insurance business what
resonable and customary is. Good Luck!!
— Barbara S.
June 9, 2003
You can ask your insurance company the usual and customary allowance for
this procedure - the CPT codes are on this website somewhere I think - and
they can give you an idea. I think my insurance allows around $2000.
— bethybb
June 10, 2003
Gina,
The Usual and Customary is industry set standards. It can vary from company
to company, but mostly it varies from city to city. The insurance companies
look at what the average is being charged by providers (doctors, hospitals)
in certain areas(usually zip code based) and they come up with a figure
from there. If you go to a doctor that is in the First Health network (he
has a contract with that insurance and he will only be paid the allowable
amount for that procedure) you will probably be charged the 20% of the
contracted rate, which is considerably lower than the U&C. If you go
out of network, which I'm assuming you are since you asked about U&C,
then you will be charged according to the U&C rate. This rate is
programed in the insurance companies claim paying system and the Customer
Service Rep you speak with on the phone cannot tell you what it is. You can
try to speak with a Manager or Supervisor in the claims department, but
that may not be of help either. Your best bet is to find out what the
doctor charges for the procedure and calculate from there. Keep in mind you
will have additional charges...assistant surgeon, anethesiologist,
hospital, etc. I know this may not be the specific dollar amount you want
to hear, but insurance companies don't want you to know the figures for
their own gain.
— Robin J.
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