Health Insurance Question

[Jim]

OK, important question coming up....

I am interested in getting user feedback from people that went through any type of Heart surgery at a hospital that was away from their regional locale and *Not* "in network". I live in Richmond, VA and am interested in looking at the option of going out of state/region to get an upcoming AVR surgery (to be more specific, to a hospital that specializes in minimal invasive surgery). While Richmond has very good hospitals, I have not come across any that have specialized in minimal invasive AVR.

I ran a check of 3 hospitals from Healthgrade.com and found average prices for AVR by hospital. I was surprised to see that my local hospital charges 195K on average for the surgery while the 2 out of network/region hospitals I checked charge ~90K. My out of network/region will pay 80% while I am stuck w/ a 20% coinsurance on top of a minimum copay for the surgery. A 90K surgery would cost me 18K out of pocket if I elected to go out of network/region.

My question is simple...when working w/ a claims case worker (either w/ the insurance company or at the hospital) do they take into consideration the costs associated w/ *where* you get the surgery in relation to getting it locally at a more expensive rate and adjust the coinsurance deductible accordingly? In my example, I think I could simply tell the case worker I would be willing to get the surgery out of network/region at the same benefit of my in network choice. A win/win situation all around! I would save $ and the insurance company would save $.

I am interested in hearing more feedback on this topic. In addition, I would like to hear other people's experience in dealing w/ insurance companies. I recently talked to a friend who had a heart *replacement* surgery and I found out his bill was over 4 million $ of which he had a 20% coinsurance deductible. You do the math!

Jim

 

[Mary]

Jim,
Do you have a maximum "out of pocket" limit? Usually it's the deductible plus charges not considered "usual". That amount would be much lower than what you're looking at in your post.

 

[Jim]

Jim,
Do you have a maximum "out of pocket" limit? Usually it's the deductible plus charges not considered "usual". That amount would be much lower than what you're looking at in your post.

The maximum out of pocket expense I have only applies to "in network". Basically, the coinsurance of 30% (I thought was 20% previously) applies to out of network with no maximum out of pocket expenses.

Jim

 

[BillCobit]

???

???

No experience w/ out-of-network heart surgery, but this is what I've wondered about when I read my EOBs from BC/BS. EOBs show "list price" as well as BC/BS negotiated price. Negotiated price was 1/2 list. SO if your insurance pays 70% of "reasonable" out-of-network, do they really pay 70% x 50% = 35%, leaving you w/ financial liability of 75% of a cost that is 2x what you'd expect to pay?

E.g.

List = 200K
Negotiated = 100K (what insurance co deems "reasonable")

so you'd maybe only get 35K coverage and be responsible for the remaining 165K??? Yeeouch, that would be tough to manage!!

Don't know if that's exactly how it works...hope not, but I wonder.

Editorial comment - this is how our 3rd party payor & provider system really scr*ws people who have to pay cash...who are most often those w/ limited financial resources. Providers try to fatten up on people who can least afford (don't interpret my comment as a vote for Hillary-style socialzed medicine...just making an observation.)

 

[catwoman]

I am interested in getting user feedback from people that went through any type of Heart surgery at a hospital that was away from their regional locale and *Not* "in network". I live in Richmond, VA and am interested in looking at the option of going out of state/region to get an upcoming AVR surgery (to be more specific, to a hospital that specializes in minimal invasive surgery). While Richmond has very good hospitals, I have not come across any that have specialized in minimal invasive AVR.

Jim: you're looking for a hospital that specializes in MIS. Have you investigated if any SURGEONS at the in-network hospitals do MIS? I think that would be the key right there -- finding a surgeon, not hospital, who specializes in MIS.

Also, what if the surgeon got in and decided that MIS wasn't feasible and had to do a traditional approach?
I know of a woman in NC whose surgeon did a "keyhold" incision for MVR, then reconsidered and had to open her chest up for the replacement.

 

[Georgia]

insurance

insurance

Insurance - pah! Although I've personally had really good luck with it, the whole thing's a nightmare.

Minimally invasive: I honestly think you might want to reconsider this if the result will be financial disaster/hardship/elimination of your 401k. MIS has its own set of problems. I certainly understand the lure of it; the thing is, the speed and ease (or difficulty) of recovery after ohs for valves is USUALLY not dictated by the incision, but rather by the heart itself.

Further, you haven't addressed the cost involved if you have complications. If you're out of network and you have to be in cicu for weeks or months like some of our friends here, the cost would be astronomical.

I just offer this as something to think about. I'm not sure that I'd want to deplete my financial reserves to such an extent only for MIS.

 

[Jim]

Further, you haven't addressed the cost involved if you have complications. If you're out of network and you have to be in cicu for weeks or months like some of our friends here, the cost would be astronomical.

Good point! I automatically assumed I would be in and out and on my merry way. Thanks for bringing me back to reality.

Jim

 

[M&M]

Hi Jim, I read your post quickly - if I understand what your asking is that you want MIS and the local hospitals don't provide it ???

That may mean your insurance will approve an out of 'network' hospital - due to the fact that, that particular 'surgery' is not available in your area. You will need the assistance of your PCP to help you.

I could be wrong - but this may be an avenue for you to pursue. Make sure you get 'written authorization or they may 'say' they'll pay - but without it in writing - you could still be liable. My insurance let me go out-of-network - because I had no in-network supplier for a piece of medical equipment.

Good Luck
Marilyn (runner)

 

[Jim]

Rachel, thanks for your input. I guess I am at the point where I do need to start working w/ the hospital to get their advice. If they want the $$$ and I want their surgeon/hospital, then it is in their best interest to work w/ me and my insurance provider to make sure that they can set up something that is cost feasible to me. Otherwise, I have no choice other than to look for alternatives in my local area.

Maybe I am making this more complicated than what it needs to be. I know that none of us at VR.com have the financial capacity of Bill Gates. It would be nice to come up w/ a solution of "best practices" primer of how to get the most out of health insurance in dealing w/ this unexpected surgery (or any surgery for that matter). It could be a case of different experiences under different circumstances that make this a hard thing to formulize; however, the valuable feedback of others in dealing w/ this will benefit others who have yet to go through this process.

Regards,
Jim