Surgeons Roles and Fees in Health Insurance

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How does your health insurance handle surgical fees, and what is the surgeon’s role in your health plan coverage?

Surgeons Roles and Fees in Health Insurance

Needing surgery can be stressful. Will it be painful? How long will it take to recover? On top of this, you’ll likely have financial concerns. What percentage of the total cost of the procedure will be covered by your health insurance?

A comprehensive medical plan will likely cover a considerable portion of costs for operations that can be deemed a medical necessity. In other words: surgeries that can save your life or prevent serious illness that is likely to develop in the absence of the required surgery.

This can include relatively minor surgery that can sometimes be performed as an outpatient procedure. For example, the surgical removal of an abscess. It can also include complex, higher-risk surgical procedures such as quintuple bypass surgery. It may even include procedures usually associated with cosmetic surgery – something not usually covered by health insurance. However, this would only be in cases where the surgery serves a medical purpose (i.e. rhinoplasty – a nose job – to correct a breathing problem).

What can be considered medically necessary can vary depending on various factors. Exactly what is covered – and to what extent – can vary significantly based on your insurer.

Coverage Varies by Insurer

As you know, each health plan is different. With some medical insurance, you will have the option of choosing your hospital and surgeon. To increase your knowledge of the financial impact of your surgery:

  • Check what your insurer covers. Insurance companies typically list covered and excluded costs on their website or in a pamphlet.
  • Find out what your insurers require with regard to referrals from primary care providers. You will likely need an authorized medical referral for the procedure to be covered.
  • Ask your surgeon for a breakdown of the cost of the procedure, including costs associated with the preparation, care, and post-op prescribed medication. Note that doctors give rough estimates in these regards, as varying factors affect costs.
  • Expect that high premium, comprehensive healthcare plans cover most surgery fees in full.

What Adds to the Cost

Coverage for surgery involves more than cover for the cost of the surgery itself. Note that the surgeon's fee is typically separate from the fee for the actual surgery. Depending on the circumstances, there may also be an assistant surgeon or even multiple surgeons, who may also charge a separate fee.

Your health insurance coverage for surgery should cover a portion of these fees. Coverage should extend to associated costs of surgery, such as:

  • Preoperative and diagnostic tests such as x-rays and blood analysis that ensures you are prepared and fit for surgery
  • Use of the operating room
  • Use of a hospital bed/room and the costs of associated inpatient care
  • Pre-op and post-op prescribed medicine
  • Post-op medical equipment (crutches, a wheelchair, etc)
  • Anaesthesia and intravenous medication used in the operation. Anaesthetist fees may also be applicable
  • Other specialist fees and medical staff fees.

Depending on your insurance, each of these items may have different coverage levels. It is useful to familiarize yourself with what may be excluded, or covered with only minor coverage.

Use CompareInsurance to determine the best available insurance option for surgery. CompareInsurance makes it quick and simple to review and compare all types of medical insurance policies to ensure you have the best possible option.

In this article

Coverage Varies by Insurer

What Adds to the Cost

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