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How many of us have had this experience:  we are told that we need a medical procedure so we select a participating provider, pre-certify the procedure, have the surgery and then . . .  the bills start coming in?  We go through them on a cursory basis until one or more catch our eye: the insurance carrier is paying little if any of the cost because something was billed by a non-participating provider.

What happened and where did we go wrong? Who was the provider whose name we do not recognize, and how was that service not in-network?

Many of us think that once a procedure is pre-certified with our insurance carrier we are set to go.  Unfortunately, pre-certification with the insurance company before a service is simply the process by which we get approval to have a service performed.  It is a requirement for most surgeries and other expensive or questionable procedures.  But beware, it does not address whether providers are in or out of network.

Pre-certification does not guarantee that all charges will be provided by network providers.  All too often there are providers who do not contract with the insurance carrier, but are somehow part of our surgical experience.  Radiologists, pathologists, anesthesiologists, emergency room physicians and assistant surgeons come to mind immediately.  Any of these physicians can participate in a surgery and we do not seem to have an opportunity to ask whether or not they are in our network.

It is our responsibility to ask all the questions we can possibly think of before a procedure, but had we thought to ask about who might be in surgery with our doctor and how they are paid?  Well, we need to start asking exactly that question and addressing the issue before it is a problem.  We may not have a choice of who performs procedures on us, but we should at least ask if we might.  Additionally, it would be good to be prepared for extra expenses that we might not have included in our “surgical budget.”

So, what do we do after the surgery has been completed and the explanation of benefits statements start coming in from the insurance carrier reflecting that there are bills for which we are now responsible? The first course of action is to go back to the surgeon’s office to determine who these providers were and why they were not participating providers.  Ultimately, we will need to address excess charges directly with the providers and some will reduce their bills while others will not.

With all the stress that accompanies a medical procedure let us at least take this issue off the table to the extent that we can.  Making it very clear to our surgeon that cost is a consideration for us will put some responsibility on the surgical team to help us to access as many participating providers as possible. There are plenty of  bullets to dodge, so let’s avoid those that are the most obvious.

Have you had this happen to you? CDA Inc is here to help you navigate these complicated issues. Give us a call if you need help.