I am going to start an appeal asap. I Prepaid My Dr knowing that I had a preapproval letter in my hand. Then after the surgery the insurance company denied my Dr and Anesthesiologist claiming they never got the bill, 4 times!!! we have records of electronic filing also. Then after much phone work by me, my Dr insurance person and My human resource people they agreed they needed to pay. Then guess what, Because my Dr is not part of plan, my coverage drops from 100% to 80% coverage. Not to bad right. The customary charge that they allow for lap band surgery is only a little less than $2000.. I get 80% of $2000. Get real, who can schedule surgery for less than that? I cant believe this, they usually pay so well on anything else. Ive lost the need for blood pressure meds, antidepressants and 4 other drugs. I'm saving them money in the long run. Does this make any sense to anyone? O BTW. If I had bypass I would have had 100% coverage on everything, but I would have probably had other health issues stemming from that. Does anyone know how to prescribe schizo drugs to a company?

Our medicare system works like that in Australia. Everyone gets medicare rebates on medical treatments, and then you can opt to have private health insurance as well - which covers hospital costs, extras such as physio, alternative therapies, dental, optical etc. Most of my lapband was covered by Medicare.

But Medicare pays 80% of a "scheduled fee" and there's not a doctor or surgeon in the land who charges the "scheduled fee". They all charge over and above that so I was out of pocket by $3,000 - but with all aftercare free forever - because my surgeon charges the scheduled fee only for all that, and directly bills Medicare instead of me.

Unfortunately, going out of network leaves you unprotected against "balance billing." That's the primary reason to stay in network if you can, all the time. The big unspoken loophole is those "covered charges" which never come close to the actual charges billed by out-of-network doctors. In-network docs are bound by contract to accept whaveter the carriers have negotiated to pay, and forbidden to bill the patients the balance.

It's VERY IMPORTANT to understand our insurance plans clearly before seeking trreatment. I've heard many, many stories of people getting into big trouble going out of network.