The medical payment system is unnecessarily complex and bewildering. I believe that one of the primary problems in healthcare in this country is a lack of transparency in the system that pays for care. Therefore; in this document, I will attempt to shed some light on this system.
The typical sources for healthcare bills can be from professionals, hospitals, pharmacies, and home health agencies. Professional fees include charges for office visits, x-rays in the office, surgical fees and in-hospital consultation fees. These include your medical doctor, surgeon, radiologist, pathologist and possibly an in-hospital internal medicine consultant. Then there is the hospital bill, which will include numerous items such as the room fees, orthopaedic implants, medicines, physical therapy fees and supplies.
Many insurance companies have contractual discounts with professionals and hospitals. Also, these same insurance companies have complex contractual agreements with patients (co-pay, deductible, in-network and out of network rules, out of pocket maximum). Neither patients nor physicians have much control over these contracts; insurance companies are in the position to pressure us into accepting these arrangements. Therefore, to figure out in advance what your final cost will can be is extremely complicated.
To assist you with this, we can have your speak with our insurance counselor regarding the likely cost for my orthopaedic professional services. We can also connect you with an advisor at the hospital to help you with the hospital cost estimates (By far, the largest cost item).
The services I offer as an orthopaedic surgeon and joint replacement specialist are billed as professional fees in the following categories.
Office visits
X-rays in office
Injections in the office
Surgical fees
I have entered into contracts with several insurance companies to treat patients covered by these plans for a discounted fee. I bill the insurance company my normal fee, they then disallow a certain percentage as the contractual discount which I am obligated to write off. As demands for my services increase, I will gradually drop these contracts. Generally, specialists with the least demand for their services feel compelled to sign contracts with more insurers at higher discounts.
Later in this document, I will provide detailed figures so you will be well informed about costs before you choose me as a consultant and surgeon. First; however, I will provide a quick reference section to allow you to quickly estimate what your likely costs will be, depending on your insurance type. If you want to learn more about the whole system and how you fit into it please read the remaining sections.