Question:
Dr. not in network.... have AETNA, PPO; Will I have to pay anything?

   — pamela1 (posted on August 15, 2002)

August 15, 2002
I went out of network with Aetna PPO, and I will have to pay my maximum yearly deductible... about $3000. I have yet to get a bill, but that is what the surgeon's office said was the max I would end up paying.
   — Greg P.

August 15, 2002
HI. I don't have Aetna, but I can tell you that if you have PPO with any insurance company and your surgeon/dcotor is out of network, then yes, you do have to pay. In my case, my insurance pays 70/30, but if my surgeon was not in network, it would have been 50/50. My deuctible OON is $2000 more too. Call your insurance company to make absolute sure about the coverage as well as your deductible! Good luck!
   — karmiausnic

August 15, 2002
I would review your policy very carefully. When you go to an out of network provider, not only are your deductibles higher then if you were using the In Network benefit, but your co-pay percentage and annual out of pocket maximums will be higher. For instance, if you go In Network, let's say your insurance pays 90% in Network - the 90% is paid based on a negotiated/contracted rate - meaning that the doctor has agreed w/the insurance company that he will accept that payment and write off the difference between what they paid and what you were actually billed. Your 10% responsibility is then based on the charges the insurance company approved, NOT what the doctor billed you. So, if they billed you $100, the insurance approved $95 they would pay $85.50, you would pay $9.50 and the doctor would write off $5.00. If you were to use a Non-network doctor, the percentages paid are based on reasonable and customary charges for your area. The doctor doesn't write off anything, they pretty much want their full payment. So if your company reimburses out of network at 70%, your expense is higher. For that same $100, the insurance company feels that only $95 is reasonable, at 70% that is 66.50 they would pay - you would pay the difference. Your 30% (28.50) is still based on the amount they approved, $95, but this time, your doctor wants all his money, so you have to pay that difference - $5. This is just an example, but look at it from the cost of surgery itself! I would also check you deductibles. For instance, my in network deductible is $250 -out of network it's $500. My in network annual max out of pocket is $1,500 - non-network it's $4000. Basically the out of pocket max is an amount that you have to pay out of YOUR pocket before your insurance company would pay benefits at 100%. As I stated, review your policy very carefully. If you have questions, feel free to email me - I'm a Benefit Administrator and worked at a brokers office for years - benefits are my life!
   — Rosario T.