Question:
In network vs. out of network

I'm having an insurance dilemma. If I stay in network my out of pocket cost is $100 but the Dr. has done less than 50 surgeries. If I go out of network - my insurance won't pay anything but I'll get to choose who I want. I need some input! Thoughts?    — J. B. (posted on March 19, 2002)

March 19, 2002
There are pros and cons to both sides of this...Go with an out of network doc. if you feel more comfortable with his experience. Your health/life are far too precious to risk on a doc. you're not comfortable with. Having said that, I am going with an out of network doctor team and hospital (at a cost of about 4k) with less than 50 surgeries because I found the network doc (to be found!) to be condescending and overworked...I am comfortable with the less busy doc I have chosen because I don't think I will become just another "pouch to create/gut to bypass" to them! Whatever you decide, good luck...
   — rebeccamayhew

March 19, 2002
Hi! Have you gone to the Surgeons page on this site and checked out all the surgeons in your area? If you are planning on having an RNY, finding an in-network surgeon within a reasonable traveling distance shouldn't be too difficult. I made the mistake of choosing a surgeon because he was close to home but luck was with me and I ended up changing to one a few hours away. The second one was in-network and a wonderful, caring surgeon. If your insurance company won't (or can't) tell you which surgeons are in-network, start calling each one and ask if they accept your insurance. Good luck on your journey!
   — grammie5

March 19, 2002
Keep in mind that if you are in an HMO and go out of network, which is what it sounds like, not only will you have to pay for the surgeon, the hospital, the anesthesiologist, etc., but if you have any complications, you will probably have to pay for that too. I would try very hard to find another surgeon who is in network and whom you feel comfortable with.
   — garw

March 19, 2002
J.B. I can understand your situation fully. I myself had to decide whether to go out of network or in network. Although I have an out of pocket maximum if I choose to go out of network. It is quite a bit more than if I chose to stay in network, but I want to go to a specialist and not a general surgeon. An option that you have is to appeal the decision to the ins. co. I am doing that and hoping to have it covered in network. Good Luck. Whatever decision you make is a good one.
   — David R.

March 19, 2002
Be aware that just because a surgeon and hospital are in-network, does not mean the entire operating team will be. I had two instances where part of the surgical team were out-of-network and the insurance company only covered 70% of their bill. Not a pleasant surprise.
   — grammie5

March 20, 2002
In response to the last post, check carefully. If the hospital is a member of the insurance company and the operating team is working at that hospital, your insurance company has to pay them. I have an HMO and have had surgeries and e.r. trips. When I use the participating hospital, the e.r. doc isn't on my plan, but my insurance HAS to pay them because of their contractual requirements with the hospital. Same with my gall bladder surgery: the anesthesiologist and pathologist were not on my plan but my insurance HAD to pay them their full fee. The insurance WILL try to send them less money and you have to call them and tell them to pay the rest. Sometimes more than once. But they have to pay. Good luck and make sure you are comfortable with whoever you choose.
   — cjabates

March 20, 2002
I work for an insurance company and the only time on an HMO when we cover non contracted doctors is if they are anesthesiologist, pathology, Emergency Room doctors,and radiology. Hmo's cover these servises from non contracted doctors due to the members really don't have a choice. This group of providers are usually on staff and the member should not be held accountable if the go to a Par Hospital and one of these speciality providers are not contracting, so HMO's pay at the higher benefit level. In your case you are chosing to go to a non-par surgeon so the HMO can nont cover this provider. Sorry, does your insurance only has one contracted surgeon for this procedure? You might check to see if there is anyone else.
   — Shelley R.