Question:
Out of Network Dr & Hospital, Want to Know Estimated Cost

My Dr and Hospital is out of network and I know I have 60/40 with out of pocket of $3,000. Have heard insurance only pays resonable and customary and hospital bills you for the difference. I can't get any estimate what that might be. I would appreciate anyone telling me what they had to pay with 60/40....Thanks    — Barbara S. (posted on March 18, 2003)

March 18, 2003
I have the same problem, but I haven't pushed it yet. From what I understand, the billing dept. at the facility where you are having surgery should be able to give you the billing codes that they will use to bill your surgery. The insurance company should be able to use those codes to give you an idea of what "reasonable and customary" would be. However, your actual charges could vary widely depending on whether or not you have any complications or an extended hospital stay. Unfortunately (in my case) that "out of pocket maximum" only applies to the 40% of the reasonable and customary expenses. Patient is responsible for all charges between R&C and what is billed by the facility/surgeon. Check your policy and ask lots of questions if you don't understand everything. However, I don't think you will ever get a definite cost because so many things can cause a fluctuation in the amount billed. You might be able to pin down the surgeon and anesthesialogist costs since they are probably a flat rate. Good Luck
   — Carolyn M.