Any Self pay folks out there?
I found out some things about my insurance coverage and it doesn't seem so great. I'm almost wondering if self pay is a better way to go.
who has done it? How much does it cost? The bariatric surgeons office said their self pay is: $18,000 for the surgery and that covers 3 mos of after care.
insurance covers $25k towards bariatrics. So basically if there's any after care of anything I'll have to pay out of pocket. The agreement the surgical center has with BCBS is that they'll charge them $27k for the surgery. So that leaves me with $2k to pay..
BUT I have $8,650 worth of copays and deductibles to pay out of pocket, plus the $2k balance from the surgery.
I'm just scared. I don't know what the best choice is!
I would check to see what your out of pocket for in network is. I know if it's a covered benefit, once you are out of pocket max reached, that's it, the rest of the year doesn't cost you anything, that's why I timed my surgery for mid November. My out of pocket for the year is $4k and I think my surgery cost me 1900 or so, and all the follow ups until 12/31 isn't costing me a dine, and I too and Anthem Blue Cross.
Your out of pocket maximum per year is what your co-pays, prescriptions, lab work, etc totals for the calendar year. Whatever you pay out of your pocket except for your insurance premium. I know mine is $4k per year in network/ $8k out of network. So after I hit that $4k during the year, any in network is basically free from your checkbook. I am switching from Anthem to Kaiser on Jan. 1 mostly because I am sick of them changing things left and right as far as who's in network or out and so on, not to mention the $116 a month premium increase that would the case starting Jan 1 as well. I went to Kaiser and got basically the same plan coverage and in some cir****tances a bit better coverage in some areas for actually about $100 less a month than I am paying now. That said, I spoke to my current surgeon about the transition to Kaiser if he knew any WLS surgeon at Kaiser that he would recommend because most doctors in a certain specialty usually come across each other at some point at meetings, fellowships, etc. My current surgeon said there was no need, just inform my new primary care doctor when I get to Kaiser of what I had done in November, had his staff pdf me a copy of my entire chart with him including copies of all the labs and so on and that my follow ups can be done with the PCP instead of a WLS doctor. Any future blood work is just cbc panels which can coincide with your yearly physical so it won't matter. You see advertisements on here for WLS surgery for 12k or so, find out what your out of network deductible is and see what the price difference is. Might be worth going that route. I would definitely call your insurance company and speak to their pre-procedure or whatever term they specifically use and get some answers and make sure you note down who you speak to, their extension and the date and time you speak to them in case there is a he said she said issue later.
Co-pays are part of that out of pocket total, it's not 8850, then an additional 2500, then another 2k. Take a look through your plan's specifics, I would also recommend being it's the usual open enrollment to choose a different plan, if you can afford it, even one that's a little more expensive would be better for a year if you are going to pursue the surgery. I knew I was going to be having a couple surgeries between last year, this year and next year and that's why I choose a top shelf plan to get the out of pockets low.
Find out what the contracted price actually is for the whole deal (hospital, surgeon, anesthesia, etc.). $27k may be the charge, but it's almost assuredly not what you and your insurance company will be billed. For example, in the hospital department I work in, one of our procedures has an official charge of $4600. Depending on the insurance company, the amount we actually get paid is $420 to $2700.
Ah, gotcha. Interesting scenario. When I first started the VSG process in 2012, my insurance had an exclusion for all WLS, and the self-pay price then at the Ohio State University Medical Center was $16,800. You might want to make sure before going that route too that any complications would be covered by your insurance if the surgery itself was self-pay. Policies with exclusions exclude care for complications too, so I'm not sure how that would work if it wasn't excluded but wasn't covered by them.
