PPO insurance

[B]

I am looking toward Los Angeles and the House Ear Clinic for translab AN surgery.
 
Can anyone offer advice in dealing with PPO insurance?
 
I'd like to go out there knowing how much I'll have to pay. I know I'll have to cover the travel costs and the annual "out of pocket maximum". But I'm concerned that the so called UCR - usual, customary and reasonable - insurance payment and the actual charges will be far apart, shrouded in secrecy and put on me in the end.
 
Dr. Luxford's nurse is checking into it for me but she was not optimistic regarding getting the specifics in writing in advance.
 
Thanks for any advice.
 
Byron
 
 

[Battyp]

Byron, speaking from my own experience..I have blue cross blue shield ppo

They told me in before surgery that I'd have to pay a maximum of 1000 out of pocket and I had already paid 379.00 towards that.  When it was all said and done I paid more than 1000 out of pocket between the hospital a and testing.  I think it was about 1,200 in copays and coinsurance.  When I questioned bcbs I never realy got an answer on how things came up to that.  She had one but jumped to something else before explaining it. 

The doctors in network can not charge you the difference between what the insurance company pays and they bill.  I had a doctor try that many years ago and got his hand slapped by the insurance company.  I know for my AN stuff they charges far exceeded the insurance payment but I only was billed what the EOB said I owed and the hospital/doctors/lab etc... wrote off the difference.

Keep in mind that for tax purposes you can itemize your travel, meals, and out of pocket expenses for your surgery So save receipts.

Hope that helps! 
Michelle

[Captain Deb]

B
See my thread in the General Discussion called "insurance woes," --also House itself has consultants for the finance part.  They do require a $3000 up front charge, but I was refunded that by them.  Just make sure you get itemised everything before you shell out a penny to anyone.
Capt Deb

[vcschaub]

I had my surgery at House in November of 2005. I was not required to pay $3,000 upfront. If the providers are participants in your PPO, you only pay the percentage that your insurance states (in my case 20%) of the allowed amount for the particular care or procedure, not 20% of what you are actually charged. That is, the charge, minus adjustments to agree with the allowed amount. For example, one of my surgeons charged $18,000 for his services. My insurance deemed that the appropriate charge was $6,000. The insurance paid 80% or $4,800. My 20% responsibility would be $1,200 but I had already accumulated $650 of my out of pocket expenses (which in my case is $1,000). So I only had to pay $350 and my insurance then additionally paid the balance of of $850 of the $1,200. After that point, my insurance paid 100% of the adjusted charges and I owed nothing. By being participant providers the doctors agree to accept the allowed amount only.

Your experience might be different, depending on the agreed percentage of allowed amounts that your insurance will pay and your maximum out of pocket.

[B]

Thank you all for the help. The insurance turns out to be "in network".  Yeah!!  It's looking good and I'm scheduled at HEI - St.Vincent in May.

B