Prior to Surgery

Managing Your Insurance Before Surgery

Taking control of your insurance coverage before your procedure is the most effective way to avoid unexpected financial surprises later.

By proactively gathering the right details from your provider first, you empower yourself to have a more informed conversation with your insurance company and get an accurate picture of your out-of-pocket costs.

STEP I - Questions for your Provider

Before contacting your insurance company, speak with your provider and collect the details that guide the conversation.

Ask:

What is the exact name of the procedure?
What billing code (CPT/HCPCS) will be submitted?
Will this be inpatient or outpatient?
Who will be involved in my care (surgeon, anesthesiologist, assistant surgeon)?
What is the anticipated date of surgery?

These details help you ask informed questions and receive accurate answers.

Step 2- Preparing to call insurance company

Once you have the answers to these questions, you are ready to contact your insurance company. Be sure to have all the necessary information readily available for a successful conversation.

Checklist for a Conversation with Your Insurance Company

✓ Ensure your insurance card is easily accessible.

✓ Know the name of your surgery, the accompanying code (if available), and the proposed date of surgery.

✓ Know the name and contact information of your doctor.

✓ Have a notepad and pen to write down key information learned.

✓ Note the name of the person with whom you are speaking, as well as the date and time.

You may be on the phone for some time. Be patient. The information you are gathering is crucial for a smooth experience with your insurance company. Once you are speaking to a live agent, kindly explain that you have some specific questions about your upcoming surgery. The agent should be happy to assist you with your questions, but if not, feel free to ask to speak with a manager.

Step 3- Questions for your Isnurance Company

Questions to Ask Your Insurance Company Prior to Surgery

The following questions will help you to sort through your coverage:

Approximately how long will it take to get all of the approvals (pre-certification) I need prior to scheduling my surgery? (If your surgeon or hospital is out of network, you will likely have a longer approval process.)
If I use an out-of-network provider, do I need a referral from my primary care clinic?
How much will this procedure cost me after my insurance pays its portion?
What is the maximum coverage on my policy, and will this procedure meet or surpass that amount?
What type of coverage do I have if I need rehabilitation or home healthcare after surgery?
Will any special equipment I need after surgery, such as a durable medical equipment or assistive devices, be covered?

Click here to download a printable version of our Surgery Insurance Prep Guide so you have all the information you need right at your fingertips.

Determining the Costs of the Procedure

Before you have surgery, discuss the costs with someone from the finance department at your doctor's office. These costs may include, but are not limited to, the following:

The surgeon's fee for surgery
Ambulatory Surgical Center fees for outpatient services.
Separate billing for other services. You will also be billed separately for the professional services of others who might be involved in your care, such as the assisting surgeon, anesthesiologist, and other medical consultants.
Check with your health plan prior to surgery to be certain of what portion of the costs you will be responsible for. If your anticipated costs present a problem, discuss other financial solutions with your doctor prior to the surgery.

Terms You Should Know

CO-PAYMENT: A flat dollar amount which a patient must pay when visiting a healthcare provider.

DEDUCTIBLE: A dollar amount that a patient must pay for healthcare services each year before the insurer will begin paying claims under a policy.

DISABILITY INSURANCE: A form of insurance that includes paid sick leave, short-term disability benefits, and long-term disability benefits in the event that you cannot work (and therefore cannot earn) your salary.

IN NETWORK: Healthcare providers explicitly covered by an insurance plan and included in all plan fees.

OUT OF NETWORK: Healthcare providers that are not included in the insurance plan will incur additional fees.

PRE-CERTIFICATION: Some health insurers require precertification (or approval) for certain types of healthcare services, such as surgery or hospital visits. This means that you or your doctor must contact your insurer to obtain their approval prior to receiving care, or else the insurer may not cover it.

Why Asking Questions Prior to Surgery Is Important

It can be tempting to believe that your insurance will cover your claim with no questions asked. Unfortunately, this is sometimes not the case. By contacting your insurance provider prior to a scheduled procedure or surgery, you can proactively manage your care and coverage.

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