My insurance is Amerihealth NJ I have a total deductible of $1,550. My question is after going to all the specialist for pre op appointments what if I only accumulate maybe $600 in their fees. Will the surgeon or my insurance just bill me for the balance of my deduct. I know was I reach full out of pocket cost $1,550 my insurance covers 100%. Anyone knows

My insurance is Amerihealth NJ I have a total deductible of $1,550. My question is after going to all the specialist for pre op appointments what if I only accumulate maybe $600 in their fees. Will the surgeon or my insurance just bill me for the balance of my deduct. I know was I reach full out of pocket cost $1,550 my insurance covers 100%. Anyone knows

MsJoy,

You need to review your policy to determine both your deductible and MOOP (Maximum Out-of-Pocket). Typically the surgeon will request their fees up front. They will be able to tell you based upon their contract with your insurance how much that will be. I'm going to give you a general scenario, you will need to change the numbers to reflect your plan.

Deductible $3000. MOOP $6000. Co-insurance 20%. Remaining Deductible $2914

Office visits $140 - Surgeon Office visit - Behavioral Health consult - $140

Surgery cost $2400 - Surgeon Surgery cost $10,000 - Hospital

Pre-clearance testing - $500

Now because my deductible hasn't been met, the costs of the consults and any pre-clearance requirements (i.e. X-rays, ultrasounds, EKGs, EGDs, etc.) are my responsibility. The costs paid count towards my deductible. Once I've reached my deductible, the insurance will pay 80% of costs until I reach my MOOP. Once I reach my MOOP, then remaining COVERED costs will be paid at 100%. This is why it's very important that you know these amounts.

So after paying for my pre-op testing and consults, I have only $2134 left remaining towards my deductible ($2914 - $780). The surgeon will collect their $2400 fee from me prior to surgery thus bringing my deductible down to $0. My MOOP has also been reduced by $266 bringing the remaining balance to $2734. My insurance will now kick-in 80% of my hospital costs. I am responsible for 20% of costs up to my remaining MOOP balance of $2734. So the insurance pays $8000 (80% of $10,000) and then I'm responsible for the remaining $2000. I still have not met my MOOP yet, so I will be responsible for paying for any additional medical treatment that year up to $266.

Again, these are only estimates just to give you an idea of the process. Your amounts will differ, but the process is the same. Keep in mind, the billed rates are always more than what the actual insurance company pays anyway. You are only responsible for the negotiated rates if you're going to an in-network provider. That's the perk of staying in-network. Since amounts that will be given to you by the hospital and surgeon are only estimates, it's important that you keep track of costs by reviewing ALL of your EOB statements from your insurance company. They will detail what was billed, if it was covered, the negotiated amount, the amount paid by insurance and your responsibility. Because there are a lot of moving parts involved with surgical estimates the amounts can and often do change. Additional tests and procedures will reduce the remaining amount of your deductible thereby also reducing your out-of-pocket to the surgeon and hospital.

In regards to the hospital, it is important that you know how to negotiate. Remember, claims aren't aren't necessarily sent automatically. So it's possible that your deductible might not reflect your actual amount remaining because the imaging center hasn't submitted a claim, etc. the hospital will always try to collect any remaining deductible and a portion of your co-pay. When you register for your surgery and meet with the financial counselor you should have all of your paperwork with you -- especially if your remaining amounts aren't updated online yet. Remember, that's all they have to work with. They can't tell that you already paid the surgeon or that the claim for your EGD hasn't been received yet. Try to negotiate to pay at least half of your remaining balance (unless you're prepared to pay the entire balance) and set-up a payment plan you can afford for the rest.

Does this help? I know it's probably more than what you're looking for, but I figured it might help. Let me know if you have any questions.

Ally

Thank you Ally that's very in formative though I'll admit I'm still bewildered. I know my insurance said my out of pocket cost is a total of $1,550 once that's met they pay 100%...Guess I'm just going to have to go through the insurance process to get a full understanding of it. Did my research and ask my Dr which insurance would be best to work with which is why I choose Amerihealth. I will read and re read your post until I under better.

Thank you Ally that's very in formative though I'll admit I'm still bewildered. I know my insurance said my out of pocket cost is a total of $1,550 once that's met they pay 100%...Guess I'm just going to have to go through the insurance process to get a full understanding of it. Did my research and ask my Dr which insurance would be best to work with which is why I choose Amerihealth. I will read and re read your post until I under better.

Ha the process is purposely bewildering. : )

I would try to go on the insurance website and research information on your own. Knowledge is always power and it helps you hold onto your money.

Best wishes to ya!

Ally