Out-of-network surgery reimbursement and "allowed maximum amounts"

I'm in California. I require a surgery (orthognathic surgery) for which most of the surgeons are out-of-network. I've picked a good surgeon and the quote I got from him is $45k (for surgeon fees, hospital is covered by insurance 100%). I've got the CPT codes from him, called the insurance and they've told me that they think that these CPT codes cost $5k and that's what they will base their calculations for reimbursement on. They call this thing "allowed maximum amount" or "fair price". The assumed cost they've provided is ridiculous and no surgeon would ever do this surgery for $5k, the cheapest quote I've got from a fresh graduate surgeon is $11k. After all the calculations they've also told me they will just give me $1k for the surgery.

So the question is – is there a way around this bullshit?I heard that these "allowed amounts" only apply if they pay the out-of-network surgeon directly but if they reimburse you later on then you can force them to pay more. Is that true? If so – how is it done?

submitted by /u/Unique_Username2020
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