Elective Surgery: How to Hold Down Costs

Some conditions require emergency surgery. Appendicitis, for example, may call for removal of the appendix right away. In other cases, the choice of whether and when to have surgery is up to you. That gives you time to think about how to hold down costs.

Elective Surgery and Health Insurance

When you have a choice about whether and when to have an operation, that’s called elective surgery. Examples are knee or hip replacements and most hernia repairs. Before elective surgery, you have time to ask some questions. Some of these are medical. They include: What are the benefits and risks of surgery? Are there alternative treatments to consider? How long before surgery should you stop eating and drinking? When can you return to regular activities after surgery?

Other questions are financial. If you have health insurance, the first question to ask may be: Will my health insurance cover the operation? Some kinds of elective surgery may not be covered. For example, with some exceptions, most health plans don’t cover cosmetic or plastic surgery. Common exceptions include breast reconstruction surgery after mastectomy, or a nose job for a patient with a problem breathing.

Some health plans may not cover bariatric (or weight loss) surgery. Similarly, some health plans may not cover LASIK, which is laser surgery to fix the cornea, a part of the eye. Before having elective surgery, call your health plan representative or check your plan documents to see if your health plan covers the procedure.

Even if your health plan covers the procedure, it may not pay the entire cost. Find out from your insurer and your doctor what your costs will be. You might have to pay some of the costs as a deductible, the amount you have to pay before your insurer will pay anything. Or, you might have to pay a copay (a fixed cost) or coinsurance (a percentage of the cost).

How to Use Your Insurance Wisely

Let’s say your health plan does cover the operation that your doctor recommends. Find out if your plan requires prior authorization for the procedure (also called pre-authorization). If so, that means the doctor has to inform the insurer that the operation is medically necessary before you have the operation. Make sure the insurer has given prior authorization before your surgery. Otherwise, you may end up paying for the whole thing.

Make sure that all the care you receive is within your network. A network is the group of doctors, hospitals, labs and other healthcare providers that have contracts with your health plan. Your insurer may not pay benefits if you go out of network. Or, they may pay something, but less than if you stayed in network.

Make sure the surgeon is in your network. Also check that the hospital or other facility where you’re getting the surgery is in your network. Make sure that the anesthesiologist, the person who keeps you from feeling pain during the operation, is in your network too. Make sure that any other providers involved in your surgery are also in your network.

Sometimes, even if you’ve taken these precautions, you may get a “surprise” bill from a provider who was not in your network. Some states have laws to protect you from such surprise bills. Check with your state insurance regulator to find out if yours is one of them.

If Your Elective Surgery Isn’t Covered

If you want to get an elective procedure but your insurance doesn’t cover it, or you have no insurance, you’ll have to pay the full price. Use the cost lookup tool at fairhealthconsumer.org to estimate what the surgery usually costs in your area ahead of time. That way, you can budget for the costs. Is the usual price lower than your provider’s price? Then, you can use that information to talk about cost with your provider. You may be able to negotiate a lower price.

If you have a flexible spending plan, you can use that to hold down the costs. Flexible spending plans help you save money by letting you spend pretax dollars. That’s money that you earn but that hasn’t been taxed.

Elective surgery gives you time to think about how to pay for the surgery. You can put that time to good use.