Prior to undergoing a planned procedure such as a knee replacement or gall bladder removal there are questions you can ask to help with calculating your out-of-pocket costs.
1. What is the exact name of the procedure? Ask your doctor to clearly print the name of the procedure. Correct spelling is important and many surgery names sound similar.
2. What ICD-10 codes will be used? Your health plan pays healthcare providers based on these diagnosis codes, which the doctor’s office or hospital will provide to them. The coding system was recently updated from ICD-9 to ICD-10, which is much more detailed than ICD-9.
3. What is the CPT® code for this procedure? One or more five-digit CPT codes are the billing codes that are used by providers—usually for physician services—throughout the United States.
4. What tests will I need before the surgery? Blood tests, diagnostic imaging tests, such as a CT scan or ultrasound? Ask for specifics about which blood tests will be ordered. Ask the doctor if you have a choice of facilities for getting these tests done. Check with your health plan before you have the test to find out where your out-of-pocket cost will be lowest.
5. Will other doctors be involved in my care and bill me for their services? A pathologist, a radiologist, and an anesthesiologist may be involved in your care. Even if your surgeon and the hospital are in your health plan’s network, other doctors involved in your hospital care may not be.
6. What kind of anesthesia will I receive? Many surgeries will involve care by an anesthesiologist and other doctors who may or may not be part of your health plan’s network.
7. After my surgery, will I go right home from the hospital? What medications and follow-up care will I need? After you are discharged from the hospital, you should be able to go directly home. After some operations, you may need care in a rehabilitation unit or skilled nursing facility for a while. Or you may need home health care. Your health plan can provide information about coverage and prices.
8. What else should I know about—such as potential complications—that might affect the cost of the procedure? For example a minimally invasive (laparoscopic) gall bladder surgery has to be changed to an “open” cholecystectomy, which may or may not be more expensive. You and your doctor should already have discussed this when you talked about the risks and benefits of the surgery. If not, be sure to ask questions about the open procedure before the day of surgery. Having a different procedure (or an additional procedure) is likely to change the cost. And if you need to stay overnight in the hospital for any reason, that is generally more expensive than an outpatient procedure.
Ultimately you may to call your insurance company (groan) or set up an online account on their web site (further groan). This may or may not give you an answer. You could also wait for that Explanation of Benefits (EOB) statement in the mail – good luck with making sense of that document !
All of the above can entail a lot of time and effort on your part. The good news is that the whole process is a lot easier with new electronic tools that are now available. These tools do the math for you and calculate these costs. They also make your medical bills easier to read and decipher those confusing EOBs. Check to see if your employer offers these tools to their employees.
For more information on the tools offered by Obeo Health please watch the video on the home page.