Out of Network Care

Out of Network Billing

How Does Out-of-Network Surgery Work? The process is very similar to that when you see an in-network provider. First you see the surgeon (Dr. Hubert) for a consultation. We charge $100 for that consultation, which will count against your out-of-network deductible. If surgery is recommended, then we go to work getting prior authorization for the surgery from your insurance company. Then you have the surgery. Afterward, the bill will be submitted to your insurance company, just like it would be for in-network procedures. The insurance company will then pay that claim at the customary in-network rate. The patient is still responsible for their IN-NETWORK cost sharing (i.e. co-pay and deductible). The customary in-network rate that the insurance company pays is usually less than what the doctor bills as an out-of-network provider. But once the initial claim is paid by the insurance company, the patient is not responsible for anything more than their in-network copay and deductible. If the in-network claim that they paid is significantly lower than the out-of-network charges of the doctor, then our billing company goes to work. This dispute, however, is between the doctor and the insurance company, and the patient is protected from all of this by the No Surprises Act.

What if I do not have Out-of-Network benefits with my insurance plan? If you have a plan that does not have out of network benefits, or if you have Medicaid, you may still have options with Dr. Hubert, especially for complex surgeries that few doctors are able to perform in your area, such as DIEP flap breast reconstruction. In those cases, we can sometimes get single case agreements with the insurance company for your surgery just because there are few or no other surgeons in your area able to provide those services. It might take a little extra time to get this accomplished. But for complex surgeries like DIEP flaps, it will be worth it for you in the long run.