Sunshine Too
Member
Sorry for a long post, but I figure more details are better. I'm hoping @DianaCox, @Larra and others can help.
THE GOOD NEWS:
Had my consult with Dr. Ayoola this past Friday. Fantastic doctor, very down to earth, spent over an hour with me explaining and answering my questions. He has agreed to do DS on me and noted that I had good reasons why I wanted it and that I was well educated. I would be very comfortable with him as a surgeon.
THE BAD NEWS:
My struggles with figuring out my insurance coverage continue, and its only worse after visiting with Ayoola’s insurance staff. As Ricky used to tell Lucy, “you got some splainin to do!”
WHAT I KNOW SO FAR ABOUT MY INSURANCE:
I have United Healthcare. It is a self insured plan. They cover DS. I meet requirement for under 40 BMI with comorbids. There is a 6 month physician supervised diet, which I am fine with since it works well with when I wanted to have surgery anyway. Also there is a psych eval which isn’t a problem either. So it looks like I can satisfy all the insurance requirements.
General terms of my insurance are a $2,600 in-network individual deductible (which I will meet anyway even absent DS surgery) with 90/10 coverage for most everything else involved in DS (surgeon, hospital, anesthesiologist, labs). However, the employer (my wife’s employer, on self insured plan) has placed a $15,000 hard cap on benefits for weight loss surgery. So regardless of any other benefit terms/provisions, once insurance pays $15k then they are done paying. Ayoola’s office initially told me about the $15k cap. I have subsequently verified the existence of the $15k cap with United and with my wife’s employer.
Interesting, two different United reps told me about the $15k cap, but told me it was contained in some super secret confidential document that they were not allowed to send me. This raised big red flag for me. I have been trying (unsuccessfully so far) to obtain a copy of the full Evidence of Coverage/Benefits Manual/Policy. Various people at United keep telling me they have never heard of such a document. Another person from United to me to get it from HR. HR told me to get it from United. I have moved it up the chain at HR and still working on it. So for the moment, I’m accepting the $15k cap at face value, but still working on trying to confirm or get more info on that.
HERE’S WHAT’S CONFUSING FOR ME:
Ayoola’s insurance person is telling me that I would be better off doing their self pay option for $25k than going through insurance. Here’s how I break that down given the info he gave me. FYI – this discussion was based on him doing DS, gall bladder removal and liver biopsy.
Their self pay option covers Ayoola, hospital, anesthesiologist (he said most of the labs and testing he could get covered by insurance even if I wasn’t do the DS on insurance). He told me that Ayoola makes about $13k if it goes through insurance, and slightly less than that if its self pay. So for self pay, I’m guessing Ayoola makes about $12k and the hospital/anesthesiologist make about $13k.
On the insured side, he quoted me something like $3,600 for my out of pocket for Ayoola only. Backing into the numbers, the first $2,600 would be deductible and the last $1,000 would be my 10% coninsurance, meaning insurance was paying $9,000, and Ayoola would get a total of $2,600 + $1,000 + $9,000 = $12,600, which is about equal to the $13k he told me Ayoola gets with insurance.
Then he went on to say that he couldn’t tell me what the hospital and anesthesiologist would charge if I went the insurance route, and that I would have to call them myself to figure that out. This raised a red flag for me. You’re telling me you do this surgery all day long every day and you can’t tell me what the other parties charge (not to mention that you have a side deal cut with them as to what they charge on self pay). But then he goes on to speculate that hospital and anesthesiologist might be $35k or so, and that since I would only have $6k left in insurance coverage (the $15k cap less the $9k insurance paid Ayoola), then I would be stuck with this huge bill of $35k minus $6k = $29k, plus the $3,600 I already would have paid Ayoola = $32,600 total out of pocket.
I am confused by this calculation given some other comments I have read, as well as my own common sense. I have looked up on United’s website and found that Ayoola and the hospital are in-network on my plan. I have read that some physicians/facilities may be in network for some services but out of network for others, so that is something I guess I need to check into with United. Notwithstanding that, we all know that insurance companies heavily write down what the providers bill. So I have a hard time believing that the amounts he is quoting me are the in-network discounted prices that have been negotiated with United.
LAST INTERESTING ITEM:
Ayoola’s office gave me CPT codes in case I wanted to call the hospital and anesthesiologist to inquire about costs. They gave me 43659 for the DS, but that code is actually “unlisted laparoscopy procedure, stomach”. I’m wondering why they would code it that way. They also gave me 47100 for liver biopsy and 47563 for cholecystectomy (gall bladder removal), both of which appear to be correct.
QUESTIONS:
1. Does any of this sound fishy to any of you?
2. Anybody else heard similar song and dance about how self pay would save you money, only to find out that wasn’t true?
3. Would anyone be willing to share with me an EOB (personal info blacked out) of your DS surgery? I’m interested in the amount the providers billed vs what insurance actually allowed for in-network?
4. One idea I have is to offer to self pay for the hospital/anesthesiologist only (estimated $13k) and then have the surgeon file with my insurance (which by his numbers would cost me about $3,600) for a total of $16,600. Thoughts?
5. Any other ideas/thoughts?
THE GOOD NEWS:
Had my consult with Dr. Ayoola this past Friday. Fantastic doctor, very down to earth, spent over an hour with me explaining and answering my questions. He has agreed to do DS on me and noted that I had good reasons why I wanted it and that I was well educated. I would be very comfortable with him as a surgeon.
THE BAD NEWS:
My struggles with figuring out my insurance coverage continue, and its only worse after visiting with Ayoola’s insurance staff. As Ricky used to tell Lucy, “you got some splainin to do!”
WHAT I KNOW SO FAR ABOUT MY INSURANCE:
I have United Healthcare. It is a self insured plan. They cover DS. I meet requirement for under 40 BMI with comorbids. There is a 6 month physician supervised diet, which I am fine with since it works well with when I wanted to have surgery anyway. Also there is a psych eval which isn’t a problem either. So it looks like I can satisfy all the insurance requirements.
General terms of my insurance are a $2,600 in-network individual deductible (which I will meet anyway even absent DS surgery) with 90/10 coverage for most everything else involved in DS (surgeon, hospital, anesthesiologist, labs). However, the employer (my wife’s employer, on self insured plan) has placed a $15,000 hard cap on benefits for weight loss surgery. So regardless of any other benefit terms/provisions, once insurance pays $15k then they are done paying. Ayoola’s office initially told me about the $15k cap. I have subsequently verified the existence of the $15k cap with United and with my wife’s employer.
Interesting, two different United reps told me about the $15k cap, but told me it was contained in some super secret confidential document that they were not allowed to send me. This raised big red flag for me. I have been trying (unsuccessfully so far) to obtain a copy of the full Evidence of Coverage/Benefits Manual/Policy. Various people at United keep telling me they have never heard of such a document. Another person from United to me to get it from HR. HR told me to get it from United. I have moved it up the chain at HR and still working on it. So for the moment, I’m accepting the $15k cap at face value, but still working on trying to confirm or get more info on that.
HERE’S WHAT’S CONFUSING FOR ME:
Ayoola’s insurance person is telling me that I would be better off doing their self pay option for $25k than going through insurance. Here’s how I break that down given the info he gave me. FYI – this discussion was based on him doing DS, gall bladder removal and liver biopsy.
Their self pay option covers Ayoola, hospital, anesthesiologist (he said most of the labs and testing he could get covered by insurance even if I wasn’t do the DS on insurance). He told me that Ayoola makes about $13k if it goes through insurance, and slightly less than that if its self pay. So for self pay, I’m guessing Ayoola makes about $12k and the hospital/anesthesiologist make about $13k.
On the insured side, he quoted me something like $3,600 for my out of pocket for Ayoola only. Backing into the numbers, the first $2,600 would be deductible and the last $1,000 would be my 10% coninsurance, meaning insurance was paying $9,000, and Ayoola would get a total of $2,600 + $1,000 + $9,000 = $12,600, which is about equal to the $13k he told me Ayoola gets with insurance.
Then he went on to say that he couldn’t tell me what the hospital and anesthesiologist would charge if I went the insurance route, and that I would have to call them myself to figure that out. This raised a red flag for me. You’re telling me you do this surgery all day long every day and you can’t tell me what the other parties charge (not to mention that you have a side deal cut with them as to what they charge on self pay). But then he goes on to speculate that hospital and anesthesiologist might be $35k or so, and that since I would only have $6k left in insurance coverage (the $15k cap less the $9k insurance paid Ayoola), then I would be stuck with this huge bill of $35k minus $6k = $29k, plus the $3,600 I already would have paid Ayoola = $32,600 total out of pocket.
I am confused by this calculation given some other comments I have read, as well as my own common sense. I have looked up on United’s website and found that Ayoola and the hospital are in-network on my plan. I have read that some physicians/facilities may be in network for some services but out of network for others, so that is something I guess I need to check into with United. Notwithstanding that, we all know that insurance companies heavily write down what the providers bill. So I have a hard time believing that the amounts he is quoting me are the in-network discounted prices that have been negotiated with United.
LAST INTERESTING ITEM:
Ayoola’s office gave me CPT codes in case I wanted to call the hospital and anesthesiologist to inquire about costs. They gave me 43659 for the DS, but that code is actually “unlisted laparoscopy procedure, stomach”. I’m wondering why they would code it that way. They also gave me 47100 for liver biopsy and 47563 for cholecystectomy (gall bladder removal), both of which appear to be correct.
QUESTIONS:
1. Does any of this sound fishy to any of you?
2. Anybody else heard similar song and dance about how self pay would save you money, only to find out that wasn’t true?
3. Would anyone be willing to share with me an EOB (personal info blacked out) of your DS surgery? I’m interested in the amount the providers billed vs what insurance actually allowed for in-network?
4. One idea I have is to offer to self pay for the hospital/anesthesiologist only (estimated $13k) and then have the surgeon file with my insurance (which by his numbers would cost me about $3,600) for a total of $16,600. Thoughts?
5. Any other ideas/thoughts?
