Out of network surgery provider – can I get reimbursed directly
25 F NY – Tried my best to get this information from my insurance and will write out what I got from them regarding this. My insurance is Meritain Health (still covered under my parents plan). I have a 10k deductible and the out-of-pocket limit is 18k for my plan. I have currently spend 1300 of my deductible. For an out of network provider, the insurance will cover 50% of the bill including the facility fee, anesthesia fee, and surgery cost. I am confused about the out of pocket limit versus the out of network coverage and hoping to get clarity.
Background: The surgery cost for my septorhinoplasty revision will be $32,800. I understand this is extremely expensive, but because my previous in network provider botched the surgery and did not repair my septum's its worth it to spend the money for the best surgeon. I previously had a septorhinoplasty with an in-network provider in 2021, they completely botched me and I know have to go to a revision surgeon in nyc who specializes in these cases. The doctor does not accept insurance, but has worked with me to get insurance to approved the pre-authorization for the surgery with him listed as an out of network provider. He also said he will work with me to get insurance coverage, but their office does not directly submit claims. Meritain Health has already auto approved the pre-authorization for this surgery with this surgeon which is at least a good starting point.
Question 1, with the doctor saying he does not accept insurance, does that mean he will not accept the reimbursement payment from the insurance claim which would require him to then refund me? I will note that multiple Meritain health workers said that even though he doesn't accept insurance he will be treated as an out of network provider. I am asking because if he does not accept the insurance reimbursement then that will require me to get the reimbursement directly. I will be paying for the surgery upfront ahead of time, so in theory, insurance will need to be reimbursing me and not the provider. Meritain health alluded to the fact that I could potentially get reimbursed directly, but is this a possibility? Question 2, with the out of pocket limit, does that mean the max I will pay is 18k for this surgery? What are other limiting factors that I should prepare for in case insurance refuses this claim? Given I got pre-authorization, does that mean they will approve the claim?
This is the first big surgery where I've managed the insurance bills and want to cover all bases ahead of time. These are probably stupid questions, but the system is confusing. any advice on dealing with meritain health and with an out of network provider will be helpful.
submitted by /u/No_Music9597
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