Financial information about having surgery


Unfortunately we realize that health insurance and medical care in US has been getting increasingly complicated.   It is a challenging situation for doctors and patients, and we hope that information below can help answer some of the questions you might have about cost of surgery and medical care.   Bottom line: most of the time your health insurance will cover your surgery if it is indicated.  Below are some of the details.


Question:  What does your office do to make sure cost of surgery it is covered by my insurance?


Answer:  A few weeks prior to your surgery, hospital will check with your insurance company if prior authorization (or pre-certification) is required for surgery. If it is required, we obtain the necessary authorizations. However, authorization does not guarantee full coverage (see below).


Question: I am scheduled to have surgery. How can I find out if my surgery will be covered by insurance?  Will I be responsible for any payments before of after surgery?


Answer: Despite this very simple question it is not an easy one to answer.  The main issue is that insurance companies and your employers are making patients pay for part of cost of surgery  or care (they call is “cost-sharing”).   “Out of pocket costs” is what you are responsible for playing.  Costs are divided into several compartments:


1.      Surgeon’s fee

Surgeons working for the hospital have different financial arrangement with the hospital, but in this practice, a code is submitted for each specific procedure by the surgeon, and the billing department submits this charge to the insurance company.  Surgeon does not benefit financially from any charges and she gets paid a pre-determined salary. This is called “surgeon’s fee.”


2.      Hospital charges

In addition to surgeon’s fees, hospital will charge for hospital fees.  This is also sent directly to the insurance company by the hospital.


The most accurate way to find out about the  coverage of the cost for your surgery is directly from your insurance company.  The reason for it is that different insurance companies have different coverage rules for “cost-sharing”.  In addition to that, your individual plan might have a deductible which varies from plan to plan (see below).  When calling your insurance company, you should have procedure code and diagnosis ready (which can be provided by your surgeon) and state that you are having surgery at Montefiore and ask for an estimate of “out of pocket costs.”


The real difficulty is that despite all these efforts to figure out the cost of care ahead of time, it is only an estimate, and final cost might not be the same as what was estimated beforehand.


3.      Anesthesiologist fees:

In most cases, there is no separate fee.


Question:  I would like to know how much Montefiore would charge me for my surgery


Answer: Hospital has a customer service line in finance department[VL1] , which can provide you with what is called “charge master” or “standard charges” for each procedure.  This information, however, will not help in figure out what your insurance company will or will not cover.


Question:  I got a bill from my doctor for an office procedure or a visit.  I have questions about it.  Who can help?


Answer:  For questions about individual bills from physicians you should  call professional billing. Your physician cannot resolve those questions for you as they do not control any billing procedures.  However, you can ask for them to advocate on your behalf if their input would make a difference.


Question:  I had surgery, and how I have questions about my claims about surgery or hospital charges.  Who do I call?


AnswerCall customer service at .[VL2] 


Question:  When I bought my health insurance, I thought everything was covered because I am paying monthly premium.  Now I am responsible for paying for some part of my medical care on top of that.  How can I find out more about this?


Answer: Unfortunately, in the last decade, cost of health care has been shifting from insurance companies and employers to employees and to patients.  That means that your co-pay (how much you pay for each visit) as well as deductibles (how much you have to pay out of pocket before any insurance coverage kicks in every year) have been going up.  This is completely separate from your premiums, which is what you pay on a monthly basis as actual “insurance.”   For example, you might be paying $300 per month for your insurance as premium.  In addition to paying $300 on a monthly basis, you have to pay a certain amount for each visit or procedure, which is what co-pay is.  While in the past, patients had $5-10 co-pays per visit, now they might be as high as $15-50.  Deductibles can be as high as $1000-5000 per year; this means that you would have to pay $5000 out of pocket before your insurance company pays anything for your care.  We try out best to inform you of any upcoming fees for visits or procedures based on the coverage you have.

 [VL1]Do you know what number to call?

 [VL2]Do you know what number to call?