Hernia Repair Cost w/ Insurance?

[tUrRrRa]

I am trying to get an understanding of what I should expect (in general terms) price-wise for my groin hernia repair that I'll be getting this November. I do have insurance. My deductible will be $400, plus I am responsible for 20% of the cost after the deductible is met.

I have read all kinds of ranges for hernia repair costs, up to $25,000! These were for NO insurance though, and I know that insurance will often negociate the price down quite a bit. I also have a maximum out of pocket cost of $2,500 per year not including deductible. I figure the worst case scenario would be the $2,500 plus $400 deductible, but would hernia surgery TYPICALLY cost $12,500 and up WITH insurance? Or is this higher cost typically for those without insurance? I will be getting the traditional method used for surgery to repair 2 hernias... not the larascopic method, and no mesh used. I figure this will help somewhat since those two factors can raise the price.

I just want to be ready for whatever cost it will be! I am getting married this December and wedding costs are already $20,000+. Yikes! I'd appreciate any information on this

[Cowpin8]

My Hernia Surgeon told me that if I choose to have the surgery in an actual Hospital as opposed to his private surgical center, the price would be in the range of $20,000. This would be charged to my insurance company but obviously I would have to lay out some of it. I figure it would have cost me at least $3,000 if I had the surgery at the Hospital. I paid almost $5,000 out of pocket at the Surgical Center and I got back $2,500 from my insurance company. So it came out about even. If I would have chosen to have the surgery in the Hospital, I would have to wait at least 1 month depending on the hospitals schedule. If I had it at his private Surgical Center he would do it literally the following day! I was in too much pain to wait. So I chose to have it at the Surgical Center the very next day. To be honest with you, for me, money was NOT a part of my decision. I just wanted to get this thing fixed ASAP and get on with life. However...as you may know, I am having problems again. I think I will choose the next surgery (if I definitely have it) at the Hospital this time.
Good Luck!!!

[tUrRrRa]

I am quite confused now. I received a call from my surgeon saying that I pay my deductible up front, then I am billed for the 20% that my insurance will have me pay. I just received a phone call from the hospital and was told a 20% amount of the TOTAL bill before deductible for the procedure, but nothing about the deductible. I thought I was asking pretty straight-forward questions, but I didn't get a straight-forward answer. I asked if this was in ADDITION to what my surgeon would charge and they seemed unsure. I asked if the 20% was before or after taking out the deductible, and they didn't give a direct answer, but I was able to get the total amount of the procedure and say that this is BEFORE the deductible. I thought you pay 20%after paying out the deductible. I know I'm rambling on, but I hate to not understand.

Either way, whatever amount I end up paying will range from $400-1200, so definitely not anywhere near $20,000! I appreciate this as these places take all money up front the day of the surgery. I'm a young professional a year out of college and while I am doing fine financially, I'm still building up my savings and working on my lifestyle (and am getting married in December, but luckily family is helping out with that since the wedding will end up around 20K).

Cowpin8, do you happen to understand how insurance works for these kinds of things? Sorry I am so mixed up about it! I appreciate ALL of your help

[SpineAZ]

If you have not used your health insurance this year then you have to meet your deductible before any bills are paid by the insurance company.

For example, let's say you had a broken arm in May and you met $300 of your annual deductible by June, you'd still have $100 left for the plan year. Most plans run 1/1-1/31. I that time period you owe $400 deductible and $2500 out of pocket. Then next year you go back to again having a deductible of $400 with out of pocket of $2500. Also keep in mind many plans have one out of pocket max for in network benefits and one for out of network. And regular office co-pays do not go toward out of pocket maximums.

With the hernia surgery each entity will bill the insurance company and then after they do so will let you know what you owe. You should get Explanation of Benefits from the insurance company after each transaction.

Each entity (physician, anesthesiologist, surgical center/hospital, etc) will bill the insurance company. Let's say they bill $1000 for the recovery room and they are the first to submit a claim after the surgery. The insurance company would agree to pay the hospital/surgical facility the previously agreed upon contractual rate for that service instead of what is billed. So if they actual negotiated rate is $900 you would owe $180. With the arm example the first $100 of that bill goes to your deductible (since you'd have $100 left) and the $80 goes to your out of pocket maximum. You'll pay in piece meal until you get to $2500.

You are correct that basically you owe $400 plus $2500 for a max of $2900. So if your treatment cost $50,000 the most you'll pay is $2500.

You end up paying your $2500 out of pocket in increments - $75 here, $35 there, etc. And you will still be responsible for any co-pays even after you reach $2500 (so if you later have met the deductible and out of pocket max and see your allergist for your annual visit and a $40 copay is required you will pay it). This of course all depends on how your plan is structured.

If you have had medical treatment this year, and don't have it handy, call your insurance carrier and ask for a summary of this years activity and your balances on your deductible and out of pocket max OR ask if you can register on line for this and how to do it. I do this via the internet with my insurance company and can always see where I stand in my deductible and out of pocket max. Becuase the plan year is a 1/1-12/31 I want to get my spinal surgery in as I'll meet my deductible easily.