Question:
Question on 80/20 pre-pay - my surgeon's office has been in contact

with my insurer. They've been told my WLS would be covered under the Major Medical portion of my BC/BS insurance. This means that I will have to pay the hospital up front (about $36,000), then wait for the insurer to reimburse me following surgery. I'm trying now to get clarification on this from my insurer. If I had the $36,000, I'd be going ahead with this now. Any ideas on how to come up with that amount short-term? I believe my maximum out-of-pocket on this policy is $1600, which is fine, but I have no idea how to come up with the money up front. Has anyone else faced this situation and what did you do to resolve it?    — Carlita (posted on November 27, 2002)

November 27, 2002
I work for a very large hospital. Having to pay $36,000.00 up front sounds VERY fishy to me. Of course every state is different but in my state you must treat everyone the same. That means if we required bariatric patients to pay up front then we'd have to require EVERYONE to pay up front, maternity, heart bypasses, appendix, etc. I've never heard of anyone doing this. Additionally, the cash price at the hospital may be $36,000.00 but insurance companies do not pay the same as cash pay patients - they pay less. At my hospital we would require you to pay your deductible up front along with any co-pays or max-pays. I think you should speak with your insurance company and then speak with someone with more authority in the hospital business office. 2+2 doesn't seem to be equaling 4 here. It doesn't sound right. Best wishes to you.
   — ronascott

November 27, 2002
I have never heard of paying the major medical portion of the hospital bill upfront. When you have a CAT Scan, do you have to pay 4 grand for the CAT scan up front and then get reimbursed from BC/BS? No, I would say that most BC/BS pay the provider directly and then you are responsible for the rest. If it is in-state, then you should only be responsible for the contracted amount. If the provider is outside your state (in this case, PA), then you may be responsible for more. <p> Let me give you an example. At the time I was diagnosed with Non-Hodgkins' lymphoma back in 1995, I had BC/BS (I now have Aetna HMO). Some slides from a tumor in my neck were sent to a lab in Tennessee for further typing (I had no prior knowledge of this). This lab charged $1200 for the tests - PA Blue Shield paid $300 - what they considered the usual, customary and reasonable charge for the service. I received a bill from the lab for $900. I called them up and they informed me that they were not obligated to accept the PA Blue Shield payment as payment in full since it was an out-of-state insurance company. Luckily, I was able to set up a payment plan with them for the balance. <p> However, all of my in-state charges - for the tumor biopsy, an open bone marrow biopsy, 6 months of chemo, the doctor's visits, a hospitalization in December 1995 - was all covered in full once my out-of-pocket limit was reached (which was fairly early in the year). <p> I'd check again with the insurance company - either you are not explaining it correctly to them or they are misunderstanding what you are asking.
   — John Rushton

November 27, 2002
I had 80/20 with a maximum out of pocket of $1800. I have never heard of a hospital asking for the full amount up front!!! I received a bill about a month after my surgery for the $1800, called the billing office and I am paying it at $100 per month. I would call the hospital and ask to speak to a patient representitive.
   — Linda A.

November 27, 2002
Yeah, I agree with previous posters - this does not sound correct at all! DEFINATELY call your insurance company and ask them about this! They will be able to tell you if your physician is in or out of network. Ask them if the hospital is an in-network hospital. I understand how complicated this whole thing can be - I am an insurance biller by trade so I am at least familliar with the lingo. I thought I covered all of my bases prior to surgery - but I got a nasty surprise when I got a bill from the anesthesioligists office for 900.00! As it turns out, my surgeon was in-network, the hospital was in-network, but the anesthesioligist was not in network! I thought the anesthesioligist worked for the hospital but I was wrong. If I were you, I'd talk to the hospital billing dept about this prior to surgery- make sure that everyone that is going to be dealing with you is in-network or you could end up paying a lot more than you should!! Unfortunately, most healthcare providers DO NOT inform you if they are in or out of network - you must take it upon yourself to find out for yourself. Best of luck to you!!
   — Traci A.

November 28, 2002
If the hospital is contracted with BX, they can not ask for the insurance payment from you up front. They can however ask for your 20%.
   — RebeccaP

November 28, 2002
I agree. It sounds like the hospital and doc are out of network and if they are you need to find an in network doc and hospital. The first doc I dealt with was out of network he wanted $18,500.00 up front for surgical fees and said that BCBS MIGHT pay me 3 or 4 thousand back. Did a little investigating and found an in network doc they ask for nothing up front . Call BCBS yourself they can't ask for maony upfront if they are under contract with BCBS. Good luck:)
   — Kimmie C.