Hello everyone I was approved this Monday for surgery through BCBS NJ. My surgeon is out of network with a 70/30 percentage. My max out of pocket is 2000. My surgeon office called and gave me my date but has not mention any amounts I have to pay she always said it could be NO MORE then 2000. My question is has anyone had similar situation when did u have to pay and how much? THANKS

First, congratulations on your approval! A few things:

Are you sure your max out of pocket is $2K when you are going out of network? Often times, there is a seperate OOP Max for out of network.

By going out of network, you are responsible for any charges above the insurance allowance. So, if your provider charges $10K and insurance allows $8K ... you are on the hook for 30% of the $8K plus the additional $2K not allowed. Make sense? (Don't panic too much here, some providers will "waive" the amount above allowance, but be sure to check beforehand so you don't have any surprises!)

I just called the doctor office and they said i will not know how much I will pay untill after surgery! I'm still confused don't want to owe more then I can afford to pay back. The person I spoke to was the front desk will call back ro speak to my coordinator... Thanks so much for your response!

:-)

If you don't get a good answer, try this.

Ask them for the procedure codes and charges they will be billing.

Call your insurance company with that information. They can do a preliminary payment estimate based on charges, allowed and anticipated billed amount. It won't be 100% exact (since claims may come in between now and surgery), but it will be fairly close. Be sure they know the provider is out of network.

Then, call back to your surgeons office to see if they will waive any balance above the insurance allowance. If they agree, ask them to put it in writing!

Ok will try! Thanks a ton! :-)

I just called the doctor office and they said i will not know how much I will pay untill after surgery! I'm still confused don't want to owe more then I can afford to pay back. The person I spoke to was the front desk will call back ro speak to my coordinator... Thanks so much for your response!

:-)

I was worried about the same thing. I called the hospital that I was having my surgery at and spoke with a financial advisor. She called my insurance and called me back with my grand total. I have BCBS of Tx. and because I had met my deductible for the year, AND paid in some of my out of pocket for the year, I only had to pay $1448. Because my out of pocket is also $2000. If you have not met your deductible (if NJ is anything like Tx) You will be responsible to the hospital for %20 AND to your Doctor for %20. If you HAVE met your deductible, you will only have to pay the $2000. I suggest calling your insurance, and if they don't help, call the hospital and ask for the financial office. Someone should be able to tell you.

If your plan pays for out of network 70/30% then you will only have to pay 30% of the allowable. Not above the allowable. Even though the doctor is out of network the insurance still will only approve a certain amount. If you did NOT have any out of network benefits it would be different. But since they are telling you they will cover 70% of it, you will only be responsible for the 30%. The best bet is to find out the procedure codes from your doc and call BCBS and ask them what the allowable is. They can give you an estimate. Plus if your plan states no matter what you are only responsible for a certain amount before they cover 100%, the the $2000 could be true. Just depends on how good your plan is.

I have BCBS of TX and I have to pay my $500 deductible and up to $2000 out of pocket for co insurance. Since my deductible is almost meant I only have to may $2030 to the hospital, because my co insurance is 20% of the allowable. Then my insurance will pay 100%. The doctor will be afterwards if needed.

Hope that helps.

If your plan pays for out of network 70/30% then you will only have to pay 30% of the allowable. Not above the allowable. Even though the doctor is out of network the insurance still will only approve a certain amount. If you did NOT have any out of network benefits it would be different. But since they are telling you they will cover 70% of it, you will only be responsible for the 30%. The best bet is to find out the procedure codes from your doc and call BCBS and ask them what the allowable is. They can give you an estimate. Plus if your plan states no matter what you are only responsible for a certain amount before they cover 100%, the the $2000 could be true. Just depends on how good your plan is.

I have BCBS of TX and I have to pay my $500 deductible and up to $2000 out of pocket for co insurance. Since my deductible is almost meant I only have to may $2030 to the hospital, because my co insurance is 20% of the allowable. Then my insurance will pay 100%. The doctor will be afterwards if needed.

Hope that helps.

I work in the health insurance industry and what I've highlighted above is not accurate. Since the surgeon is out of network, he does not have to write off the difference in allowance and billed. He can expect to be paid what he billed.

I do agree that calling and finding out the amounts is the best way to give yourself some peace of mind about the amount you owe. Best of luck!