Health Insurance Articles

How To Find Medical Insurance Coverage For Outpatient Surgeries

2010-10-12

Finding medical insurance coverage for outpatient surgeries isn't hard if you know where to look. There are different types of medical insurance plans that allow for outpatient medical coverage, unlike some managed care plans. PPOs, or preferred provider organizations, are a managed health insurance plan that typically will not allow for outpatient surgeries with a co-payment. HMOs are a bit more lenient, generally.

This is where coinsurance comes into play. When a managed health care insurance plan disallows for a co-payment to cover outpatient services, you will be charged a percentage of the bill. A typical coinsurance scenario is an 80/20, meaning the insurance pays 80 percent and the patient pays 20 percent of the total costs. Typically, the higher your annual deductible, the lower your coinsurance.

Many health insurers have encouraged their clients' use of the often less expensive outpatient medical services. Outpatient surgeries tend to be less extensive, more minor procedures, and thus, generally much less costly. The incentive is high for patients, employers and health insurance carriers alike for patients to opt for these cheaper procedures. Some carriers even offer financial incentives for patients who go this route.

Plan Ahead

Make sure to plan ahead for any outpatient cost/coverage contingencies. Call your health care provider's customer service number and speak to a representative who'll help make clear exactly what will get covered, when and for how much. You don't want to get stuck with the bill--either due to ignorance or for not playing by a health care organization's rules.

Outpatient Coverage Statistics

Most insurance-covered employees are enrolled in health care plans that require cost sharing for an in-network doctor's office visit, in addition to annual deductibles they may pay. Seventy-five percent of covered workers have a co-payment for their primary care physician office visits, while only 16 percent have coinsurance, which most plans require for adequate coverage for outpatient surgeries.

It's worth noting that employees enrolled in HMOs, PPOs and POS (point of service) plans are much more likely to have co-payments than workers in high-deductible health plans (HDHP), for both primary care and specialty care physician office visits. So, if you can afford the better coverage plan, and you anticipate having future outpatient surgeries, go for the high deductible plans.

Look for health care plans that give you an "all-in-one" scenario. Do they cover prescription medications? Do they cover COBRA or payments during times of unemployment? Deductibles, co-pays and coinsurance for all hospital and inpatient services, as well as physician and outpatient services? Know exactly what you're getting from a health care provider--your life may depend on it.