Facility fee for otherwise “fully covered” outpatient surgery?

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Hello,

Thanks everyone for any help in advance. I have an outpatient surgery scheduled for later this month and was hoping to get some help understanding/possibly contesting a facility fee.

Some background: I’m located in PA and have Keystone HealthPlan East’s POS Flex Plan. The Plan has a $0 deductible, 0% coinsurance, and a $50 co-payment for outpatient surgery at in-network, referred facilities performed by in-network, referred physicians. I have an active referral for both the in-network, referred ENT who will be performing the surgery and the in-network, referred facility (which is owned by a local hospital).

However, I have now been informed by the facility that, even though the procedure is “fully covered” by my insurance (and thus I owe only the $50 co-pay for the procedure), I will additionally owe them a $2,000+ facility fee because I’m having this procedure done at this particular in-network, referred facility (the only place, of course, my ENT performs surgery). In fact, I can’t have the surgery unless I pay the facility fee upfront.

I’ve been reading up about facility fees (the fun way we spend our time as Americans…), but I’m still a little confused and was hoping for some help. My understanding was that the insurance company has a contracted rate with the provider (the physician and facility) which sets how much the insurer will pay–both in terms of discount and actual money–for each procedure, and then I pay my co-pay or co-insurance if applicable (here, $50). So the facility fee feels like an end run around the insurance contract? I.e., it feels like the provider is double dipping by submitting the claim to insurance and then separately charging me for the procedure? Even if it’s legal–i.e. not a technical violation of the insurer-provider contract–it seems super unethical!

If I am forced to pay the facility fee, any tips on negotiating? I’d be able to pay it, but I’m obviously not keen to–especially given how much we already spend on insurance every year.

Thanks again!

submitted by /u/firsttimeaudio
[link] [comments]
Hello, Thanks everyone for any help in advance. I have an outpatient surgery scheduled for later this month and was hoping to get some help understanding/possibly contesting a facility fee. Some background: I’m located in PA and have Keystone HealthPlan East’s POS Flex Plan. The Plan has a $0 deductible, 0% coinsurance, and a $50 co-payment for outpatient surgery at in-network, referred facilities performed by in-network, referred physicians. I have an active referral for both the in-network, referred ENT who will be performing the surgery and the in-network, referred facility (which is owned by a local hospital). However, I have now been informed by the facility that, even though the procedure is “fully covered” by my insurance (and thus I owe only the $50 co-pay for the procedure), I will additionally owe them a $2,000+ facility fee because I’m having this procedure done at this particular in-network, referred facility (the only place, of course, my ENT performs surgery). In fact, I can’t have the surgery unless I pay the facility fee upfront. I’ve been reading up about facility fees (the fun way we spend our time as Americans…), but I’m still a little confused and was hoping for some help. My understanding was that the insurance company has a contracted rate with the provider (the physician and facility) which sets how much the insurer will pay–both in terms of discount and actual money–for each procedure, and then I pay my co-pay or co-insurance if applicable (here, $50). So the facility fee feels like an end run around the insurance contract? I.e., it feels like the provider is double dipping by submitting the claim to insurance and then separately charging me for the procedure? Even if it’s legal–i.e. not a technical violation of the insurer-provider contract–it seems super unethical! If I am forced to pay the facility fee, any tips on negotiating? I’d be able to pay it, but I’m obviously not keen to–especially given how much we already spend on insurance every year. Thanks again!
submitted by /u/firsttimeaudio [link] [comments]Read Morer/HealthInsurance

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