I am having a procedure done in a few weeks, and my insurance company said that I need to pay my $500 deductible, and then the service will be covered at 100 percent of the allowed charge if the doctor is in-network. Does this mean I shouldn't have to pay anything other than the $500 deductible? From what I
I am having a procedure done in a few weeks, and my insurance company said that I need to pay my $500 deductible, and then the service will be covered at 100 percent of the allowed charge if the doctor is in-network. Does this mean I shouldn't have to pay anything other than the $500 deductible? From what I understand, if an out-of-network surgeon does my operation, I could be subject to the actual charge instead of the "allowed" charge.
Didnt read all the answers. Wanted to point out that "approved amount" means how much they think it should cost. Anything over that you could be liable for. Unless you have an HMO in certain states. California is one of those states.
be real careful that your doc and the facility is in network, that is a real catch 22, because the facility also matters where you have this procedure done
A deductible is a deductible no matter where the service is and YES, you MUST pay this and then they will pay the rest.
As Stephen said, you have to make sure that ALL of the providers are in network. If the facility isn't, then that charge would be handled differently. Same goes with the anesthesiologist. So, don't just check to make sure the surgeon/doctor is.
As a general rule, if the provider is out of network, then insurance (only) pays the "in network rate" and any difference would be balance billed and owed by you.
So as an example, the procedure costs $1,500, is in network that is "negotiated" by your insurance to $750, so you pay $500 and insurance pays $250. But, the provider is out of network, so insurance pays $250 and you would pay $1,250, which is your $500 deductible and $750 balance billed, since the out of network does not agree to the $750 amount that insurance "believes" should be charged.
See the difference? When you go out of network, then they do not agree with what your insurance "believes" is reasonable, and can charge what they "feel" is the correct amount owed.
This means that if every provider, including the surgeon, the facilty, the anetheseologist (I may be spelling it wrong, but you should now what I mean) are ALL in network, then you just pay what they said — but if any are out of network, then you pay a lot more.
Depending on what the procedure is, there may be other separate charges to consider besides the surgeon. The hospital or outpatient surgery center will have a separate billing. An anesthesiologist will have a separate billing. Any radiologist work will have a separate billing, etc. You need to try to stay "in network" for all of these providers.
As long as your doctor is in-network (check with the insurance company) then yes, your out-of-pocket for the doctor will be $500, However, there may be other charges that will not be fully covered (i.e., the drugs).. There is no way of knowing up front if there will be additional charges.