In October, my wife was advised by her orthopedic doctor to get a femoral nerve block for pain management, due to the lower back pain she was experiencing. We took the advisement and were referred to a surgeon who would perform the outpatient surgery. The day of the procedure we checked into the hospital clinic, filled out the necessary paperwork, and paid the hospital our $250.00 co-pay, for what we thought was the entirety of our financial responsibility for the surgery. We met the surgeon and he assured us the procedure would take all of 5 minutes, and recovery would take one hour. The prognosis was good, and in fact, her surgeon stated that some people have experienced relief from chronic pain with a similar procedure for 10 years. He never told us, as the hospital did, we owed him anything but our thanks. This treatment took a few weeks to kick in, but my wife was able to go on a scheduled trip to Washington DC during the Christmas holidays virtually pain-free.

One month post-surgery, we received a bill from the surgeon who performed the surgery for around $350.00. This was after the health insurance negotiated the cost down from a few thousand dollars. We paid the amount wondering why the doctor or our insurance company never warned us about the upcoming bill. Additionally, on the back of the doctor’s bill, it stated we might receive other bills from clinicians who took part in the surgery. Then the anesthesiologist sent us a bill for another $350.00. Our commercial insurance sent us an EOB (explanation of benefits) that we would be responsible for since we have not met our $600.00 deductible. Overall we ended up paying $1000.00 out-of-pocket — a small price to pay for long term relief of pain compared to the opioids she was taking.

The Healthcare system is unique in there is not much transparency in what medical procedures actually cost. We would not tolerate this from other sectors in our economy. We stayed in an Airbnb when we visited DC – what if we never knew what the costs were actually going to be? Imagine staying for a week and one month later being charged for the costs of the rental, and then get another separate bill for cleaning the apartment! We would never do that, but that is often the experience navigating the healthcare system.

After this experience, I wondered how we could have prevented the pain of sticker shock after the fact, and how others might benefit from this lesson of navigating the health care system?

Amber Conwell, one of our Health Advisors, who used to work for a commercial insurance company, was my go-to for advice here. Yes, even Health Advisors need advice!

What else could I have done, Amber, to be better prepared prior to the surgery?

“I have a few tips: To start, get to know your plan. Your insurance plan customer service representatives are there to help you understand and navigate your plan. Always call in prior to a procedure to get a breakdown of benefits information. This is important because you want to make sure the procedure is an actual covered benefit and to see about the potential associated costs. Next, make sure that all providers associated with your procedure are within your plan’s network. Ex: The doctor performing the surgery may be an in-network physician, but the provider performing anesthesia services may be out-of-network, resulting in you being charged out-of net costs which will be more money out of your pocket. (Also be mindful that some plans may not have benefits for out-of net providers at all, which then means you will be paying the entire cost.) Ask your doctor if the suggested procedure is a routine service or medical (major medical). If it is routine, most likely you will only pay the copay amount listed for that specific service. Routine services are generally those that you have during your wellness visit. Always check with your plan if you have any doubts about this. Medical services will be those services performed to treat an injury or prolonged illness.”

While I have you here, one more question. I have paid $3500.00 in co-pays and other medical costs in 2018 that were not credited towards my deductible. The insurance company told me that only major medical costs count towards my deductible. What are major medical costs?

“Major medical services and costs are anything outside the scope of a routine service and will always be subject to the deductible amount listed on your plan. You will be required to pay for services up until that amount listed before your plan’s benefit will kick in. So if your rep tells you that your procedure will be covered at 80 percent, subject to the deductible, this means that you must have fulfilled your deductible amount before the plan will actually pay the 80 percent. The following are some examples of major medical services/costs: A hospital admission/stay, chiropractor/physical therapy visits, anesthesia, allergy testing & treatment, both inpatient & outpatient surgeries, durable medical equipment services, lab work that is not performed for routine purposes, etc. Co-pays do not count toward your deductible. Co-pays are only credited toward the out-of-pocket total on your plan. Out-of-pocket is the sum of both your co-pays and the deductible amount.”

Lesson well learned! Thanks to Amber for providing guidance, and next time I will be sure to contact my insurance company prior to the procedure being performed to be better prepared and a wiser healthcare consumer.

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