If insurance is covering part of your surgery costs, do you typically pay the surgeon for the full cost of surgery upfront?

Hi there, I'm looking into getting breast reduction through my insurance. I found a doctor I really like and since she's out of network, I would be responsible for 40% coinsurance and my insurance, Blue Shield of CA, would pay the remainder. If you're insurance is covering part of your surgery costs, do you typically have to pay the surgeon for the full cost of surgery ($10,000) upfront and then later be reimbursed for the amount the insurance company ends up paying the surgeon?

Doctor Answers 6

Full Cost of Surgery Up Front?

Yes, this is a very common scenario. Many surgeons, like yours, have stopped participating in insurance programs because they routinely shortchange the physician, delay payments for 6 months or longer, deny payments and misplace claims. It is has become a nightmare for physicians to collect the money that they are rightfully due for the work that they have performed. Patients historically have been shielded from the outrageous manipulations of the insurance companies but you are about to become painfully educated. Your doctor is essentially shifting the risk of non-payment from themselves to you. You are being asked to pay upfront so that if the insurance company fails to pay, or doesn't make payment for six months, you will be the one to bear the burden. 


If this seems unfair, you can thank the insurance companies for creating this nightmarish  process which only benefits the insurer. You may also be in for some additional unpleasant surprises. Insurers typically have what is called an "allowable" amount that they will pay for surgery. This is usually far less than what the physician charges for the procedure. So in your case if your surgeon is charging $10,000, the insurance companies may only "allow" a payment of $6,000. You are responsible for a 40% copay of this $6000 ($2400), and your insurance company (you hope) will pay the balance of the $6000 ($3600). But this means that YOUR total out of pocket expenses will be $6400 ($4000 that your insurance company didn't allow plus the $2400 that was your 40% copay of the allowable). 


So welcome the to the world of insurance of payments and best of luck to you. In our office we try to help patients negotiate with their insurers, but the systems are intentionally designed to not be user friendly. Hopefully your doctor will do the same for you, but be prepared to spend hours on the phone dealing with your insurance company and waiting many months before you see any payments. 

Breast Reduction and Insurance

Hello,

Basically what you are experiencing is now normal if you go to an out of network provider. This is what I tell my patients: You pay me for the surgery, and then you bill them for any reimbursement. I also say that the likelihood you get any money is low.  That's why I tell them they should just get a surgery loan and go to the best surgeon in town, you're going to pay for the surgery anyway. 

Best of luck!

Gerald Minniti, MD, FACS
Beverly Hills Plastic Surgeon
4.9 out of 5 stars 79 reviews

When you have insurance

your are much better financially to have your procedure done by a contracted provider.  Going out of network just because you like someone is going to cost you quite a bit.  And if your deductible is not paid up yet, its best to wait until the cycle starts all over again.  If you must go out of network, expect to pay up front and to pay a lot more than what you may have thought as you technically are responsible  for the difference between what your insurance pays (pitiful amount) and what your surgeon charged you.  Its best to find a participating surgeon since you're covered if you can.

Curtis Wong, MD
Redding Plastic Surgeon
4.8 out of 5 stars 32 reviews

Insurance Coverage

Hi and thank you for your question. Yes it is normal to pay money upfront if your insurance covers a percentage of the cost. You as the patient have a deductible that has to be met and that is usually the portion the doctor will have you cover. It's always a gamble when dealing with insurance payments because the surgeon doesn't always get the full payment that the surgery is billed for. In most cases the Surgeon won't even see the full percentage that your insurance covers. Good luck on your surgery!

Michael K. Obeng, MD, FACS
Beverly Hills Plastic Surgeon
5.0 out of 5 stars 46 reviews

If insurance is covering part of your surgery costs, do you typically pay the surgeon for the full cost of surgery upfront?

I doubt we can give you a good answer on that as insurances differ so much and so do individual office policies. However, if a surgeon accepts insurance from certain companies they are forbidden by contract from charging more than the insurance company allows. It sounds like your surgeon may be outside that circumstance in which case the doctor is considering the procedure cosmetic and you may be requested to prepay as with other cosmetic surgery and you would be refunded anthing the insurance company pays the surgeon. Hopefully that fee includes the surgical facility and a board certified anesthesiologist as it sounds quite high if simply for a surgeon's fee. But that may just be California. 

Ronald V. DeMars, MD
Portland Plastic Surgeon
5.0 out of 5 stars 24 reviews

Breast Reduction/Breast lift / Breast Augmentation/ Breast Implants/ Anatomic Gummy Bear Implants/ Silicone Implants

I appreciate your question.

I would recommend that you discuss above with your surgeon as every surgeon have their own respective financial/insurance protocols.  And yes, what you describe above is common if you are going to an out of network provider.

The best way to assess and give true advice would be an in-person exam.

Please see a board-certified plastic surgeon that specializes in aesthetic and restorative breast surgery.

Best of luck!

Dr. Schwartz

Board Certified Plastic Surgeon

#RealSelf100Surgeon

#RealSelfCORESurgeon

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.