There are a wide variety of types of insurance plans. I will outline some of the more common in very general terms.
A. HMO - Typically the lowest cost plans. They pay doctors and hospitals the least and try to restrict your access as a patient only to doctors and hospitals who agree to very steep fee discounts. I do not contract with any of these. Often the only way to go outside of their narrow list of doctors and hospitals is to prove you need something that your list of doctors cannot provide. (e.g. hip surface replacement, a service that I provide). Frequently this requires an appeal to their review board. In my experience, this has been successful in approximately 50% of cases. If the insurance company agrees to pay, my standard fee schedule applies, if you would like to take this approach. If you company denies approval, your options include changing companies (e.g. at yearly open enrollment opportunities at some employers) or take advantage of our discounted global prepayment program.
B. PPO – Higher cost plans that give you a lower cost when seeing doctors in their network, but for a higher cost (higher co-pay and percentage) they allow you to see doctors outside their network. I have contracts with some of these companies. Our insurance counselor can tell you what our contracted price is, if I have a contract with the company. If I do not have a contract with your PPO, I would be considered “out of network”. You would apply your deductible and out of network percent patient responsibility from your plan to my standard fee schedule. Also, most plans have an out of pocket maximum for each year. If your calculated portion of all total fees (hospital, anesthesiologist, radiologist, pathologist and surgeon) is higher than the out of pocket maximum, you should only be responsible for the “out of pocket” max. Typically, for major surgery, you will hit your yearly out of pocket maximum. Therefore, this is most likely going to be your cost for the procedure regardless of what is charged. You may be able to use this as your bottom-line of the procedure. I am sorry this is so complicated. I did not create this system, I just struggle to work within it.
C. Indemnity plans - Cadillac care, the most expensive. They let you go to any doctor. They usually require you to pay a co-pay and a fixed percentage of all fees up to an out of pocket maximum.
D. Healthcare savings accounts – Coupled with a high deductible insurance plan. You pay everything up to a certain deductible, and then the insurance pays everything thereafter.
E. Government plans (Medicare, Tricare, Worker’s Comp, Medicaid) – The government dictates a very reduced fee schedule to the doctor and hospital, which is now significantly below the cost of overhead. The government then ties them up with endless bureaucratic rules and regulations. I have opted out of all these. If you are under one of these plans and still wish to purchase my services, we can enter into a private contract and you can prepay for my services personally under my discounted prepayment fee schedule. If you wish to take this option, the hospital, anesthesiology, radiology and pathology fee will still be handled in the usual fashion through the Medicare system. At this point in time, it is virtually impossible to purchase private insurance and stay out of the Medicare system, when you have turned 65. (One exception is, if you are working for a company that offers a group health plan). Many companies do offer supplemental policies to Medicare or Medicare HMO replacement policies. These still use the same physician payment schedule as standard Medicare and are therefore not acceptable to me.