With Thanksgiving and end-of-year holidays right around the corner, elective health care you’ve been putting off might be far from your mind. If you’ve met your insurance deductible or out-of-pocket maximum though, this is a perfect time to take care of conditions like inguinal hernias, hiatal hernias, skin lipomas, diverticulitis as well as procedures including gallbladder surgery, thyroid surgery, or parathyroid surgery.
How to pay for appointments and procedures is one of the important decisions you’ll have to make when scheduling your surgery. If you don’t have insurance, you will be responsible for self-pay rates. Paying with insurance is a bit more complex, however.
You will pay the estimated patient responsibility for your surgery, which is based on Austin Surgeons’ contracted rates with each insurance carrier. Depending upon your insurance policy, patients are typically responsible for a copayment, deductible and coinsurance until reaching the out-of-pocket maximum.
A deductible is the amount a patient pays for covered healthcare services before the insurance plan starts paying for services.
After that, the patient will be responsible for a copayment or coinsurance.. Usually called a “copay,” the copayment is a fixed amount patients pay for a service after reaching the deductible. Coinsurance is a percentage of healthcare service costs a patient is responsible for paying after reaching a deductible, up to the out-of-pocket maximum.
Paying a Copay
Here’s an example of a patient with a copay who needs a minor procedure done in the office:
- Insurance plan’s allowable cost for a procedure: $500
- Deductible: $2,000
- Copay: $35
- Out-of-pocket maximum: $5,000
If the person has not reached their deductible this year, they will be responsible for paying the allowable cost of the procedure, or $500, up to their out-of-pocket maximum
If they have reached their deductible, they are responsible only for the copay, which is $35 in this example.
If the patient has already reached their out-of-pocket maximum $5,000 for covered health care services this year, they will not be responsible for any of the cost of this procedure.
Coinsurance Share
Here’s an example of a patient with coinsurance who needs a procedure done in surgical facility:
- Contracted rate for your surgery is $20,000
- Deductible: $2,000
- Coinsurance: 25%
- Out-of-pocket maximum: $5,000
If this patient gets the surgery done before reaching their deductible, they will be responsible for the first $2,000. Then they pay 25% of the remaining $18,000 ($3,600) until they reach the $5,000 out-of-pocket maximum.
The patient in this example is scheduling their surgery in January, before paying anything toward their deductible. So the patient’s share of this surgery would be the $2,000 deductible plus $3,600 coinsurance, for a total of $5,600.
Since the total is more than the $5,000 out-of-pocket maximum, the patient is responsible for paying only $5,000. After a patient reaches their maximum, the insurance company will pay for the rest of their covered services for the remainder of the plan year.
However, if the person gets this surgery in November, after reaching their deductible for the year, they would only be responsible for 25% of the cost of the procedure ($5,000) up to their out-of-pocket maximum. Since the patient in this example already spent at least $2,000 (the deductible), the most they would possibly need to cover for this surgery before reaching their out-of-pocket maximum would be $3,000.
If this patient already reached their out-of-pocket maximum, the insurance should cover the entire cost of the surgery. This major difference in patient financial responsibility is why the end of the year is such a great time for those who’ve met their deductible and out-of-pocket maximum to schedule procedures.
Additional Financial Considerations
When budgeting for any procedure, it’s important to remember your payment to Austin Surgeons covers only your surgeon’s fee. A patient may receive bills following surgery from others involved in the procedure including the facility (the hospital or surgery center where the surgery is performed), anesthesiologist, lab, radiology and surgical assistant.
Payment for office visits and procedures is due to Austin Surgeons at the time of service. Payment for surgery is due when it is scheduled. A payment plan may be available in some circumstances.
If you pay Austin Surgeons more than is owed, we will mail you a refund once the claim has been processed by your insurance company.
For more information or to schedule an appointment, visit austinsurgeons.net or call (512) 467-7151.
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