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Surgery and Insurance

SURGERY AND INSURANCE:  (Inoffice/Outpatient).  Knowing your financial responsibilities in regards to having foot and ankle surgery can be confusing to a patient.  We at The Foot and Ankle Associates try to make it as simple as possible when we explain to the patient the insurance obligations with inpatient and outpatient surgery.  The majority of the insurance plans now usually require a deductible anywhere from as low as $500 to as high as $5000 for outpatient surgery.  What that means is, usually before your insurance makes any payment on your claim, the deductible has to be satisfied.  For example, if you have surgery performed in an outpatient setting, i.e., at a hospital or surgery center and you have a deductible of $1000, wherein that deductible applies to outpatient surgery, you are required to pay the first $1000 before your insurance will provide coverage.  If you get a bill from the surgeon or the hospital, you will receive the deduction of the $1000 wherein you will be responsible to pay.

From our experience, the majority of the plans that we accept do not have a deductible for in office surgery, that means usually you just have to pay your copay and your insurance pays the rest of your coverage, which is usually 100%.  If you have insurance coverage that pays 80% the insurance responsibility and 20% your portion, and you have a copay, then again the only thing you pay is your copay and then you are responsible for the 20% of the remainder of the bill and again there is no deductible.  Most outpatient surgeries again usually have a minimum of $500 to a maximum of $5000 wherein you are responsible for that deductible, whatever that may be,  along with usually your 10% to 20% to 30% portion which you have to pay. 

In comparison, most outpatient procedures are done with sedation or MAC, which means medicine given to make you sleepy, and the majority of patient’s are unconscious while the procedure is performed.  However, in the large majority of the office surgeries just a local anesthesia (a needle injected into the area where the surgery is being performed) is usually used to numb the area where the surgery is being performed.  You are usually awake, however, you do not feel the procedure being performed.  Most people bring an iPod and listen to music or they read a book usually while they are comfortably lying back.  Inoffie surgery procedures are usually very, very short wherein you are usually not in the office no longer than an hour to an hour and a half.  When you have outpatient surgery, expect to be at the outpatient facility an hour and a half before the scheduled procedure and approximately an hour after the procedure.  That means if the procedure starts at 12 p.m. you have to be at the facility 10:30.  If the procedure is scheduled for an hour and you have to be in an hour afterwards, then you are at the facility usually for a minimal of 3-1/2 hours. 

Also with office surgical procedures the financial aspect is also more beneficial because usually the only person that gets reimbursed from the insurance and the patient is the physician performing the services.  Usually in an outpatient facility, the anesthesiologist gets reimbursed, the facility gets reimbursed, and the physician performing the surgery is reimbursed.  We like to think of this as a  3:1 ratio.  At least three different providers are reimbursed in the outpatient facility, with only one provider being reimbursed in an office setting.  Usually this is more beneficial to the patient financially; however, finances should not take a precedence where you are thinking about having foot or ankle surgery.  You should be very comfortable with the physician performing the surgery along with being comfortable where the surgery is being performed.  Surgery that is performed at an inpatient facility is more sterile than surgery performed in an office setting.  When surgery is performed in the office, sterile techniques are adhered by, and usually antibiotics are prescribed. You as the patient should discuss all options with your doctor pertaining to surgery and the financial aspects before any surgical procedure is performed.