Question:
Do

According to my insurance (First Health Network - PPO)I will be responsible for 20% of the usual and customary fee for my surgeon. Can anyone give me a ballpark figure? I haven't read to much about costs on this site? Thanks, Gina    — ftworthgirl (posted on June 8, 2003)

June 8, 2003
since you have a PPO, odds are there is a maximum yearly out of pocket you have to pay. Your 20% can't exceed that amount. U&A varies by company.
   — [Deactivated Member]

June 8, 2003
As long as your surgeon is "In Network", you won't have to pay any more than you out of pocket maximum. However, if your surgeon is "out of network", you will be responsible for the 20% of Usual and Customary (U&C) up to your out of pocket maximum PLUS whatever the difference is between U&C and what is billed.
   — Carolyn M.

June 8, 2003
I had surgery at a Bariatric Treatment Center in Michigan. Last week while speaking with them, I asked about my bills from the surgery. I was told my surgeons bill was about $8700.00 and the hospitalization was $48000.00 (I was in the hospital 75 hours and the surgery was uneventful). I'm not sure about the surgeon, but I know the hospital cost is much higher than most if not all others(that's why BCBS PPO has pulled their contract with BTC).
   — colleenkenn

June 8, 2003
Just my two cents worth. I went out of network and my insurance said I would be responsible for 40% of reasonable and customary fees. I had to remit my out of pocket maximum to the hospital prior to surgery. I had Lap RNY on 4/22 and my hospital remitted all of my money but 30.00. They accepted the resonable and customary! Yea. You just can't tell what they are going to do and NO ONE will tell you in the insurance business what resonable and customary is. Good Luck!!
   — Barbara S.

June 9, 2003
You can ask your insurance company the usual and customary allowance for this procedure - the CPT codes are on this website somewhere I think - and they can give you an idea. I think my insurance allows around $2000.
   — bethybb

June 10, 2003
Gina, The Usual and Customary is industry set standards. It can vary from company to company, but mostly it varies from city to city. The insurance companies look at what the average is being charged by providers (doctors, hospitals) in certain areas(usually zip code based) and they come up with a figure from there. If you go to a doctor that is in the First Health network (he has a contract with that insurance and he will only be paid the allowable amount for that procedure) you will probably be charged the 20% of the contracted rate, which is considerably lower than the U&C. If you go out of network, which I'm assuming you are since you asked about U&C, then you will be charged according to the U&C rate. This rate is programed in the insurance companies claim paying system and the Customer Service Rep you speak with on the phone cannot tell you what it is. You can try to speak with a Manager or Supervisor in the claims department, but that may not be of help either. Your best bet is to find out what the doctor charges for the procedure and calculate from there. Keep in mind you will have additional charges...assistant surgeon, anethesiologist, hospital, etc. I know this may not be the specific dollar amount you want to hear, but insurance companies don't want you to know the figures for their own gain.
   — Robin J.