Question:
I am having surgery at a out-of-network hospital...

...I have been approved by BC/BS PPO but because BC/BS cuts the check to me the hospital wants the surgery paid for up front in full (which I don't have a problem with). The question that I can not get answered by the hospital or BC/BS is how much money will I get back from BC/BS? They only tell me that I have a 80%/20% copay but no dollar figure. I would appreciate any light anyone could shed on this matter.    — Earl Z. (posted on December 15, 2002)

December 15, 2002
Earl: I do not think BC/BS in PA would be different than BC/BS of WI in relation to payments, so in order to avoid the payment going to you and having to lay out the whole amount it is a matter of the hospital billing with the box that says "pay provider" checked. Then the payment goes to them.<p>That said I believe what is going on here is that the hospital is assuming they will not get their full 80% from your insurance and by you having paid everything up front they know they will get their money. It could mean you end up having to cover anywhere from 20-???% That's a pretty big unknown. What might be possible is to get the typical list of procedure codes that will be billed and how much each will be billed and have your insurance respond as to whether they will cover that amount in full. In other words that the total charge falls within UCR (usual, customary and reasonable). If it does then you would know that 20% of that cost is your's. If it's less than 80% you would still know what you are looking at. I assume you realize that the total hospital charge could be $15,000-40,000. It seems to vary drastically across the country. My doctor, if you are self-pay, offers a complete package for $26,000, which would put the hospital's portion at about $17,000, as the surgeon's fee they expect to get is $6,000.<p>Don't forget if there are any complications then you could be looking at a whole lot more. I'm not trying to scare you just make you aware what could be in store. I would call the hospital and ask to talk with a financial counselor as they should be able to give you some fairly reliable cost information for a "by-the-book" surgery. I hope everything goes perfect and your cost is as minimal as possible! Chris D.
   — zoedogcbr

December 15, 2002
I have Anthem BC/BS in Colorado and they will not pay an out-of-network provider. They send me the check and then it is up to me to pay the provider. You really want to find out ahead of time what the hospital will charge you and what your insurance will pay. Since the hospital is out-of-network, it has no agreement with your insurance company. That means that if the hospital charges $20,000 for your stay and BC/BS considers $15,000 as its normal charge, you will have to pay 20% of the $15,000 plus the other $5,000 that BC/BS doesn't consider part of its normal payment. <p> You might also want to make sure that you have an agreement with the hospital regarding any unusual circumstances. I had complications from my original surgery and had at least 2 more hospital stays at the same hospital where I had my surgery. I also had stays at 2 other hospitals and 3-4 weeks each in a step-down unit and a skilled nursing facility. At last count, my insurance company had paid out $200,000 plus on my behalf this last year. <p>One other important thing. My insurance originally sent me EOBs saying they were paying at out-of-network rates for providers where I had no control, the surgical assistant, for example. My brother called them on it and they agreed that they would pay in-network rates, where I didn't have a say in who the provider was. I'm sure that saved me quite a bit, since none of the ambulance companies (and I had 8-10 ambulance trips) is in-network for me. That alone was somewhere in the neighborhood of $4,000.
   — garw

December 15, 2002
Under the patients bill of rights you have the right to an estimate of charges from the hospital. It's only an estimate, however it should give you a ball park figure of what your hospital expenses would be for your surgery. It's just like an estimate for any work that you get done on your car before they start work.. You will get an estimate of how much your surgery will cost. Don't let the hospital take advantage of you.. you have the right to know how much it's going to cost you up front. Best wishes in your journey :)
   — Heather S.

December 16, 2002
I agree with Heather, the previous poster, the patient's bill of rights is VERY important-I'm currently dealing with the same type issue and have plans to pursue further action regarding my enormous hospital bill of $59,000 of which BCBS only paid $about $15,000...
   — yourdivaness

December 17, 2002
If the hospital gives me a $59,000 bill for a by-the-book surgery and stay they will be getting a letter from a lawyer as that is insane. The $15,000 BC/BS paid is probably also insane but not as bad as the charges. While I don't have a network there are certain doctors and hosptials they have contracts with which guarantee me that they will write off whatever BC/BS doesn't pay but unfotunately the hospital my surgery will be at does not have that, so I will be requesting info before surgery so I can try and identify if I have a huge problem. I've had other expensive tests at this hospital and there hasn't been a problem being fully covered in the past so I'm keeping my fingers crossed.
   — zoedogcbr