Potential Meniscus Surgery – Use Insurance or Pay Out of Pocket

Looking for advice regarding paying for treatment of a knee injury. I have very little history/experience with medical issues.

I am in PA and buy insurance on our exchange. I have a health savings account eligible plan with a deductible equal to my out of pocket max of $7,250. Don’t have any ongoing medical expenses and haven’t had any medical charges go through my insurance yet this year.

I have a knee injury, a suspected meniscus tear. It has been a problem for about 8 months, hurts and locks up occassionally but doesn’t slow me down. I had an appointment with an orthopedic surgeon yesterday who took x-rays. He couldn’t definitively diagnose anything and referred me to scheduling for an MRI. Logical conclusion is that it is a meniscus tear and will likely require arthroscopic surgery. He said if MRI confirms that course of action, he can’t promise that surgery would be completed by the end of the year.

I talked to billing on my way out and haven’t yet schedule the MRI. They indicated that they would likely bill my insurance between $1,000-$2000 for the MRI. They wouldn’t estimate how much a potential arthroscopic surgery would be billed at. No idea what my insurance will negotiate those prices down to.

I asked about paying out of pocket and they gave me a packet of their out of pocket services/prices. They list an MRI @ $584 and Knee Arthroscopy at $4,085. Follow up visits with the doctor are $162.

It seems like if I proceed with my insurance, I am risking spreading this procedure out over more than 1 year and paying more than a single year out of pocket max. Even if it finishes within this year, it seems likely they will likely bill my insurance more than my out of pocket max and I’ll end up paying more than if I just pay out of pocket.

I plan to call this week and find out if they can actually estimate how much I would pay through insurance and also if there are any charges that wouldn’t be covered in those out of pocket prices. Am I likely to get this information? Any specific questions I should ask?

Paying these bills isn’t any particular financial hardship for me, I would just like to do it in the most cost effective way possible. I understand that if I pay out of pocket and have another health issue by the end of the year, I run the risk of having even higher expenses.

I could also wait until next year and sign up for a better health insurance plan with a lower deductible… but that seems to largely be a wash. Any savings from a lower deductible will be chewed up with higher premiums.