Surgery Scheduling and Insurance: 48 Questions Patients Ask

Dr. Dold accepts most major insurance plans, including Medicare and Tricare. Please call 469-850-0680 to confirm your coverage. Our insurance page lists plans we are in network with, including Aetna, Blue Cross Blue Shield of Texas, Cigna, UnitedHealthcare, Humana and Baylor Scott & White Health Plan, as well as MultiPlan/PHCS network plans and self-pay patients.

A Health Maintenance Organization usually limits coverage to doctors in its network (except in emergencies) and often requires a referral from your primary care doctor before you see a specialist such as an orthopedic surgeon.^1,2 If you have an HMO, ask your primary care doctor for a referral before your visit.

A Preferred Provider Organization lets you see in-network doctors without a referral and usually pays less for out-of-network care. You pay the least when you stay in network.²

An Exclusive Provider Organization covers care only from in-network doctors (except emergencies), but usually does not require referrals.²

A Point of Service plan is a mix of an HMO and a PPO: you usually need a referral from your primary care doctor to see a specialist, and you pay less when you use in-network doctors.²

A plan with a higher deductible and usually a lower premium. Many HDHPs can be paired with a Health Savings Account (HSA), which lets you set aside pre-tax money for medical costs.^3,4

Original Medicare (Parts A and B) is run by the federal government; Part B covers doctor visits and outpatient surgery. Medicare Advantage plans are offered by private insurers, often have their own networks and frequently require pre-authorization for surgery and imaging. Coverage rules differ by plan.⁵

Yes. Medicare Part B covers medically necessary outpatient surgery, including at ambulatory surgery centers. With Original Medicare you generally pay 20% of the Medicare-approved amount after meeting the Part B deductible, unless you have supplemental coverage such as a Medigap plan.^5,6

Yes. With TRICARE Prime, you generally need a referral from your primary care manager for specialty care. TRICARE Select does not usually require referrals, but some services need prior approval.^7,8 Bring your referral or authorization information to your visit.

Self-pay patients are welcome. Under federal law, if you are uninsured or not using insurance, you have the right to receive a Good Faith Estimate of the expected charges before a scheduled service.⁹ Ask our office for an estimate.

The amount you pay for your insurance plan each month (or year), whether or not you use medical care. Premiums do not count toward your deductible or out-of-pocket maximum.¹⁰

The amount you pay for covered health care before your insurance plan starts to pay. For example, with a $2,000 deductible, you pay the first $2,000 of covered services yourself. Some services, such as office visits with a copay, may be covered before you meet the deductible, depending on your plan.¹¹

A fixed amount you pay for a covered service, such as $40 for a specialist visit. The amount varies by plan and type of service.¹²

Your share of the cost of a covered service, as a percentage of the allowed amount, usually after you have met your deductible. For example, with 20% coinsurance, if the allowed amount is $1,000 and you have met your deductible, you pay $200 and your plan pays $800.¹³

The most you will pay for covered, in-network services in a plan year. Once you reach it, your plan pays 100% of covered services for the rest of the year. Deductibles, copays and coinsurance count toward it; premiums and out-of-network or non-covered costs usually do not.¹⁴

The maximum amount your plan will pay for a covered service, sometimes called the negotiated rate. Your deductible and coinsurance are calculated from the allowed amount, not the billed charge.¹⁵

In-network doctors and facilities have a contract with your insurer and agreed rates, so you usually pay less. Out-of-network care usually costs more, may not be covered at all on HMO and EPO plans, and the provider may bill you for the difference between their charge and what your plan pays (balance billing) in some situations.^2,16

A statement from your insurer, sent after a claim is processed, showing what was billed, the allowed amount, what the plan paid and what you may owe. It is not a bill. Compare it with the bill you receive from the provider.

Many family plans have an individual deductible for each person and a total family deductible. Once one person meets their individual deductible, the plan starts sharing costs for that person; once the family total is met, it applies to everyone. Check your plan documents, because plans differ.

Most plans reset the deductible and out-of-pocket maximum at the start of each plan year, often January 1. Some employer plans use a different plan year. Your insurance card or member portal can tell you which.

It can. If you have already met your deductible or out-of-pocket maximum this year, having surgery before your plan year resets may cost you less. If you are early in the plan year, you may pay more of the cost yourself. Medical need should come first, but it is reasonable to ask our office for an estimate for different dates.

It depends on your plan. HMO, POS and TRICARE Prime plans usually require a referral from your primary care doctor for specialist visits; PPO and EPO plans usually do not.^1,2,7 If your plan requires a referral, please bring it to your visit.

A decision by your insurer that a service, such as surgery, an MRI or some injections, is medically necessary before it is done. It is also called prior authorization or pre-certification. Pre-authorization is not a promise that the plan will pay; payment still depends on your benefits and eligibility.¹⁷

Our surgery coordinator submits the pre-authorization request to your insurer with the information from your visit and imaging, and calls you with your surgery date once it is approved. You can reach Bonita Yusaf, our surgery coordinator, at 469-850-0680 or byusaf@starorthopedics.com.

It varies by insurer and by procedure, from a few days to a few weeks. Some plans need additional records or a review by one of their physicians. Bonita will keep you updated.

Many plans, especially Medicare Advantage and many commercial plans, require pre-authorization for MRI. Our office will submit the request when one is required.

Our office may provide more information or request a discussion with the insurer’s physician reviewer. You also have the right to appeal a denial: first through an internal appeal with your insurer and, if that is unsuccessful, through an external review by an independent organization.¹⁸

Approvals are usually valid for a set period and for specific procedures and dates. If your surgery is postponed or the plan changes, a new authorization may be needed, so let our office know as soon as possible.

After you and Dr. Dold decide on surgery, our surgery coordinator handles the pre-authorization and contacts you to schedule a date once it is approved. Questions about scheduling or insurance can go to Bonita Yusaf, our surgery coordinator, at 469-850-0680 or byusaf@starorthopedics.com.

Dr. Dold performs surgery at ambulatory (outpatient) surgery centers and hospitals. Where your surgery is done depends on the procedure, your health and your insurance. Your coordinator will tell you the location when your surgery is scheduled.

Usually more than one. You can expect separate bills from the surgeon, from the surgery center or hospital (facility fee) and from the anesthesia provider. You may also receive bills for imaging, lab work, pathology, physical therapy or equipment such as a brace or sling.

Yes. Our office can provide an estimate of your expected share of the cost based on your insurance benefits. Estimates depend on the information your insurer provides and on what is done during surgery, so the final amount can differ. The facility and anesthesia providers may provide their own estimates.

You may be asked to pay your estimated share of the surgeon’s fee before surgery. If the final amount after your insurer processes the claim is different, the difference is billed or refunded.

Depending on your age, health and the procedure, you may need blood tests, an ECG or clearance from your primary care doctor or a specialist. Our office will let you know what is needed and when.

Please contact Bonita as soon as possible. Changing the date may require updating your pre-authorization and rescheduling with the facility.

Tell our office right away. A new insurer usually requires a new pre-authorization, and network status, deductibles and out-of-pocket costs may change.

Yes. Payment plans are available. Ask our office about options that fit your situation.

Yes. We accept Health Savings Account (HSA) and Flexible Spending Account (FSA) cards. Eligible medical expenses generally include doctor visits, surgery and many related costs; check with your plan administrator if you are unsure.^4,19

Under the federal No Surprises Act, if you are uninsured or choose not to use your insurance, providers must give you a Good Faith Estimate of expected charges for scheduled care. If your final bill is substantially higher than the estimate, you may be able to dispute it.⁹

The No Surprises Act protects people with most private health plans from surprise bills for emergency care and for certain out-of-network care at in-network hospitals and surgery centers, such as some anesthesia services.¹⁶

Call our office at 469-850-0680. Have your bill and, if possible, your insurer’s Explanation of Benefits in front of you.

Your insurance card, a photo ID, a list of your medications, any previous imaging or MRI reports, your referral if your plan requires one, and your completed new patient forms. See our insurance page for more.