How many used an out-of-network surgeon?

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loralei
Posts: 12
Joined: Thu May 08, 2014 2:54 am

How many used an out-of-network surgeon?

#1 Post by loralei »

Hello,

I am working with a dentist and now ortho who referred me to a local surgeon. He and the staff seems excellent, and they operate in the hospital system we are familiar with. He is not in my network, so I was wondering what people's experiences have been with out-of-network surgeons. Are you on the hook for pretty much all the surgeon's fees, but the insurance still covers hospital-related expenses for the approved surgery if hospital is in network? I just wanted some idea since I'm shopping around. The only surgeon in-network that comes up is an hour away and has some bad customers reviews on the internet, which has made me anxious. Thanks!

samoorelaw
Posts: 440
Joined: Sun Jul 14, 2013 4:44 pm
Location: Las Vegas, Nevada

Re: How many used an out-of-network surgeon?

#2 Post by samoorelaw »

My surgeon was out of network. My surgeon was amazing and my insurance covered it: the surgeon's fees were discounted approximatey $4,000 under united health care's multiplan network even though it was out of network so I paid significantly less (surgeon's fee was $8,564, and after the discount and my deductible, my end was $3,000). I can't speak to the hospital question because my surgery was performed in my surgeon's office suite, but the anesthesiologist was covered at the in-network rate so I would think the same would be true for the hospital fees.
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sirwired
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Joined: Thu Oct 30, 2008 10:05 am

Re: How many used an out-of-network surgeon?

#3 Post by sirwired »

Consider expanding beyond an hour's drive if it'll mean you find a good one in-network. This is inconvenient and makes for travel costs, but travel costs are usually a LOT cheaper than out-of-network rates.

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kpw818
Posts: 122
Joined: Thu Jun 20, 2013 8:59 pm
Location: Colorado

Re: How many used an out-of-network surgeon?

#4 Post by kpw818 »

I'm likely going out of network for my oral surgeon because there is no one in network in my area (and surrounding, I've looked in Wyoming, New Mexico, Kansas, and Utah, lol). The surgeons listed mostly don't do orthognathic anymore.

I was told I could apply for a gap exception, where they would cover at in network rates. Honestly, 80% coverage doesn't sound that bad on the surgeon's fees, since some insurance plans don't cover it at all. I would rather not pay out of network for a medical procedure that I need, but I don't think out of network would be that bad.
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sirwired
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Re: How many used an out-of-network surgeon?

#5 Post by sirwired »

kpw818 wrote:I'm likely going out of network for my oral surgeon because there is no one in network in my area (and surrounding, I've looked in Wyoming, New Mexico, Kansas, and Utah, lol). The surgeons listed mostly don't do orthognathic anymore.

I was told I could apply for a gap exception, where they would cover at in network rates. Honestly, 80% coverage doesn't sound that bad on the surgeon's fees, since some insurance plans don't cover it at all. I would rather not pay out of network for a medical procedure that I need, but I don't think out of network would be that bad.
Find one in the Denver metro area that will do the work, and pester the insurance co to pay 80% of whatever it is that surgeon wants to charge. If they can't sign up surgeons to work at the rates they'd really prefer to pay, that's their problem, not yours. You DO not want the insurance company merely covering 80% of what they'd pay an in-network surgeon when a doctor not participating in your insurance plan can take you to the cleaners.

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lissybear22
Posts: 35
Joined: Tue Feb 18, 2014 10:03 am

Re: How many used an out-of-network surgeon?

#6 Post by lissybear22 »

I'm using an out-of-network surgeon... the only surgeon in my insurance network has one foot out the door into retirement, and still wires people's mouths shut.... so, I will do what I have to!
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MeyerLemon
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Joined: Thu Apr 17, 2014 3:08 pm

Re: How many used an out-of-network surgeon?

#7 Post by MeyerLemon »

Yep. I'm going to Dr. Arnett in Santa Barbara, and he is out of network for everyone. I have Aetna, and it looks like they are only going to cover about $20k of the $60k it is going to cost! Boo.

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lissybear22
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Re: How many used an out-of-network surgeon?

#8 Post by lissybear22 »

I can relate to that issue. My insurance company will pick up a max of 10k -- and that is only if they come to understand that this procedure is not cosmetic. I am lovely enough. :wink:
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sirwired
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Re: How many used an out-of-network surgeon?

#9 Post by sirwired »

MeyerLemon wrote:Yep. I'm going to Dr. Arnett in Santa Barbara, and he is out of network for everyone. I have Aetna, and it looks like they are only going to cover about $20k of the $60k it is going to cost! Boo.
$60k? Yowza! I think that even at "rack" rates, my LeFort I was only half that.

Really, if I were in your shoes, I'd do a lot of research to find a qualified surgeon that's in-network, even travelling a distance to do so... you can buy a lot of plane tickets and hotel nights for $50k.

I know Arnett is good, but are there no surgeons in-network in the entire country that can do your operation well? Mine was done by an OMFS professor who himself trained under one of the legends in the field, and is in-network for BCBS, Cigna, and probably several others.

tdc10
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Joined: Mon Sep 18, 2017 9:26 pm

Re: How many used an out-of-network surgeon?

#10 Post by tdc10 »

Hi - just my two cents in case it is helpful: I went for multiple consultations, with about half of the surgeons out-of-network (I was willing to pay out of pocket for all of these visits, which were not covered by my insurance). I decided to go with an in-network surgeon - actually located further away than some other in-network and out-of-network surgeons - with whom I was most comfortable with in terms of experience. Idid not feel like there was a massive difference in the backgrounds and skillsets of the in-network vs. out-of-network doctors to justify paying tens of thousands of dollars more for an out-of-network surgeon (I live in an expensive metro area in the U.S.). Additionally, I also considered the fact that the large majority of jaw surgery cases are done by in-network surgeons in this country given the costs, and judging by these forums and my research, the vast majority of these surgeries ultimately have favorable outcomes.

Additionally, I think it's incredibly important to call your insurance company with the exact medical codes for all of the procedures you will be having done (which will need to be pre-authorized). For example, if your plan covers 20% of out-of-network procedures, that will be 20% of the /maximum allowable amount/ set by your insurance company for each medical code/procedure. In my case, the out-of-network surgeons were charging much, much higher fees than the limit set by insurance company, such that 20% of what the insurance company's limit for the procedures (NOT 20% of the surgeon's stated fee), which is what the insurer would reimburse me for out-of-network procedures, was nowhere close to a meaningful amount. I like the peace of mind of knowing that by staying in-network, and having my procedure pre-authorized by my insurer, I would only be paying the out-of-pocket limit stated within my plan, for all procedures, pre- and post-op visits, prescriptions, hospital charges, etc. within the calendar year.

Additionally, I would not always rely solely on online reviews for major medical procedures. Online reviews in general tend to attract reviewers who've had problems, and exclude those who had perfectly fine experiences. I think this might be even more so the case for doctors as opposed to, say, restaurants. I would ask the surgeon's office to connect you to past patients who've had the surgery done and also look into your surgeon's background. Some states allow you to look up the medical license of your doctor and see if they have had any negative incidents. This should give you a better basis to evaluate your surgeon.

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