Policy for Covered Surgery for Patients with Insurance

Dr. Moses is not in-network for any of the insurance plans. But most people have insurance with out-of-network benefits, meaning that their insurance will reimburse for out-of-network physicians like Dr. Moses, though at a slightly lower rate than they do for in-network physicians. For covered procedures in patients who want to use their insurance, first we will confirm that they have out-of-network benefits. As with all patients, there is a $500 deposit to reserve a date, and the balance of the pre-payment is due 2 weeks prior to surgery.

Two weeks prior to surgery, we will ask patients to pay the remainder of their annual deductible and the co-insurance (i.e., that portion of the covered charge that their insurance will not pay). Then patients will sign an “Assignment of Benefits” form, assigning the payments from their insurance company to us. After surgery, if the total of the payments from the insurance company, plus the pre-payment, is greater than the overall charge, we will refund that difference to the patient. If the total of the pre-payment plus the insurance payment is less than the billed charge, we will bill that balance to the patient.

Insurance Example

For example, a patient wants a procedure that will cost $5000. She has a $1000 deductible, and her out-of-network benefits reimburse at 75%. For the $5000 procedure, we would ask for the $1000 deductible and their 25% co-insurance, which would be $1000 of the remaining $4000. If her insurance pays more than $3000, we will refund that overpayment to the patient. However, in the same example, if the insurance only pays $2500, the patient will be billed the balance of $500.


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