Fees and Insurance
(Updated 5/22/2008)
II. Quick Reference for Insurance Coverage
I. Expanation:
If I do not have a contract with your insurance plan, I am considered “out of network”. If your insurance company does not appear on the following list, I am NOT in your network and this section applies to you.
“In Network” plans:
1. Aetna PPO
2. Beechstreet
3. Blue Choice
4. Blue Cross Blue Shield Federal Employee Plan
5. Blue Cross Blue Shield SC *
6. Blue Cross Blue Shield State Health Plan (SC)
7. CCN
8. Corvel
9. Ethix / Southcare
10. Evolutions
11. First Health
12. Guardian Resources
13. Plan Administrators (PAI)
14. Premier
15. Select Health
16. United Healthcare
17. Wellpath / Coventry
*Most standard Blue Cross/ Blue Shield plans from other states have a reciprocal agreement with Blue Cross of SC and are therefore also “ in network”. We can tell you if this applies to your Blues plan.
If your insurance plan does not appear in the above list, I am “out of network” with your insurance company, and the following does apply to you. You have two payment options:
a. Plan A: Full prepayment
You pay the discounted surgeon plus assistant fee in advance, we bill your insurance company the full fee and refund to you any amount they pay, up to the amount you paid in advance. Any remainder we keep.
Your advantage: you probably will pay less
Your disadvantage: you have to pay more up front and wait until your insurance company pays for reimbursement of some of this.
My advantage: I don’t have to wait on your insurance company.
My disadvantage: I probably will get paid less.
b. Plan B: Partial prepayment
You pay $2000 in advance. We bill your insurance company the full surgeon plus assistant fee after surgery. After your insurance company pays what they see fit, we apply $2000 to this and bill any remainder of the full fee to you.
Your advantage: you pay less in advance, and don’t need to wait on your insurance company payment.
Your disadvantage: You probably will pay more.
My advantage: I probably will be paid more.
My disadvantage: I have to wait on your insurance company, and then on you, to pay the remainder.
To make a decision about which plan is best for you, you will need to determine how much of my fee your insurance company will pay. We bill an insurance company for a surgical service with a CPT code. The amount they will pay on this code is what they call an “allowable”. Often the insurance company will not provide this number to us or to you. This can be extremely frustrating. Fortunately, we sometimes have a record of what they have paid on this CPT code for other patients. If we have this number, we will tell you this, but we have no way of holding an insurance company to this number. The best thing to do is to call your company and ask them how much of my fee they will pay for a certain CPT code. Other details you must know about your insurance contract are:
• Your copay for a procedure.
• Your percent responsibility for an “out of network” service.
• Your yearly out of pocket maximum.
• The month when this “year” starts and ends.
• How much of my fee is applied to this out of pocket maximum (usually the portion of the “allowable” that you, rather than your insurance company has paid).
Other than the “allowable”, all of these other numbers are relatively easy for you to obtain from your insurance company.
II. Illustration:
To illustrate the above options, I will provide a simplified sample worksheet for both options for primary hip or knee replacement procedures:
Plan A
• You pay the discounted
Fee in advance: $6000
• The standard fee is billed
to your insurance carrier: $8000
• Any payment up to $6000
from your insurance carrier will
be returned to you ICP*
• Your total payment: $6000 – ICP*
• My total receipt: $6000 --- $8000
Plan B:
• Your down payment : $2000
• Standard fee schedule bill
to your insurance carrier: $8000
• Insurance company pays
their required amount: ICP*
• Any amount less than the
Remaining $ 6000 that
is not paid by the insurance
company will be billed to you $6000 – ICP*
• Any payment over $6000
from your Insurance company
will be returned to you ICP* - $6000
• Your total payment: $8000 – ICP*
• My total receipt : $8000
* Insurance company Payment
III. Sample calculations:
Finally, I will provide you with a set of sample calculations for CPT code 27130 (applies to primary total hip replacement or hip surface replacement) for an “out of network” insurance plan:
a. your copay amount for a procedure.
b. your percentage responsibility for “out of network” providers.
c. your insurance company’s “allowable” amount for CPT code 27130 (hip replacement)
d. your yearly out-of-pocket maximum per your insurance contract.
For the above categories (a-d) we will use typical numbers for a set of example calculations. You will need to find out the applicable values for your insurance contract to do your own calculation.
For example, if:
a. = $100
b. = 30%
c. = $5500
d. = $5000
Then the following calculation could be done:
Plan A:
Advance discounted payment to me: 6000
My bill to your insurance co.: 8000
Your ins. co. payment to me: 5500-100-(5500x 0.30) =5400-1650
=3750
Refund from me to you: 3750
Net paid by you: 6000-3750
=2250
Amount that applies to your yearly 1650+100
out-of-pocket maximum: =1750
Amount that does not apply: 2250-1750
=500
Your true out-of-pocket maximum for 5000+500
the year: =5500
Plan B:
Advance partial payment to me: 2000
My bill to your insurance co.: 8000
Your ins. co. payment to me: 5500-100-(5500x0.30)
=5400-1650
=3750
My bill to you: 8000-2000-3750 =2250
Net paid by you: 2000+2250
=4250
Amount that applies to your yearly 1650+100
out-of pocket maximum: =1750
Amount that does not apply: 4250-1750
=2500
Your true out-of-pocket maximum for
the year: 7500
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