Understanding Health Insurance

Your Comprehensive Guide to Insurance & Sinus Surgery

Common Insurance Qs

Relax, and take a deep breathe.

If you are considering sinus surgery, deviated septum surgery, or any procedure, insurance can be an overwhelming and stressful hurdle. Navigating through pages upon pages of fine print and exclusions contained within your policy can indeed be frustrating, but it should not discourage your willingness to treat your sinus health issues.

During the last 15 years, Dr. Garrett H. Bennett has gained an extensive understanding of insurance policies and recognizes your concerns. To help guide you, he created this comprehensive manual as a tool for you to help make sense of your coverage, so you can move forward with your surgery with confidence.

Read below to learn about the ins-and-outs of your policy and how to achieve the lowest out-of-pocket costs for you or your family.

Types of Health Insurance Plans: HMO vs. PPO

The first step in understanding the basics of your health insurance policy is finding out whether you have a Health Maintenance Organization (HMO) plan or a Preferred Provider Organization (PPO) plan.

Note: Although HMO and PPO plans are the most popular, these are not the only two types of health insurance plans. Hybrid versions, such as EPO, POS and OA+ plans also exist.

HMOvsPPO

This chart explains the differences between HMO and PPO plans.

As a leading New York health provider, we are experienced in working with some of the largest local and national insurance companies. Through our years of experience, we often see patients struggle with swift policy changes and exclusions that have impeded the ability to make treatment affordable and attainable. Although many insurance carriers exist, our patient pool typically carries coverage with the following providers:

The Empire Plan

Group Health Incorporated (GHI)

Cigna

Aetna

Health Maintenance Organization (HMO) Plans

The classic HMO plan allows you to see a range of primary care physicians (PCPs) in a designated HMO group, in exchange for a monthly payment. The primary care physician is typically responsible for your overall health and well-being, and provides treatment concerning your general medical issues.

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HMO insurance plans rarely permit subscribers to receive treatment from specialists outside the HMO network, meaning you must cover the costs on your own.

Sometimes your condition extends beyond the realm of general health issues. In this case, you may require treatment by a specialist. HMO plans stipulate that your consultation and treatment are not covered until you first make an appointment with your PCP. After explaining why you wish to see a specialist and evaluating your condition, the PCP decides whether you qualify. For example, if you wish to speak to a sinus surgery specialist, you must first meet with your regular doctor, who will approve or deny your visit to the specialist. This added layer of bureaucracy is often cause for controversy for HMO holders.

Another issue that often frustrates those with HMO health plans is the number of specialists available to subscribers. If the specialist with whom you wish to meet is not among the list of contracted doctors and surgeons in the HMO group, he or she is considered “outside the HMO.” In this instance, you must contact your HMO directly to obtain an additional clearance to schedule the appointment. It is unlikely that you will receive permission as HMO insurance companies decide how much to pay the in-network doctors, and would need to pay more for an out-of-network specialist. This means that subscribers are essentially limited to one group of pre-approved specialists within the HMO group. On the plus side, visiting an HMO-approved specialist costs very little, since the HMO contracts for the payment for doctors and surgeons, as well as the procedure itself and any medications.

Preferred Provider Organization (PPO) Plans

The popular alternative to an HMO plan is the Preferred Provider Plan (PPO). Similar to an HMO, this type of plan also requires a mandatory monthly fee in exchange for access to a network of doctors who subscribe to the plan. PPO plans differ from HMO plans in that a PPO subscriber need not obtain permission from the primary care physician before making an appointment with a specialist.

PPO plan holders find their policies to be more convenient than HMO coverage, since PPO plans offer more flexibility in treatment

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PPO plans allow subscribers to meet with both in-network and out-of-network specialists.

options. So long as the doctor accepts your type of PPO insurance, your visit will be covered, either in full or in part. Some patients need only pay a small amount (usually $10 or $15 fee called a co-pay) after meeting with a specialist – depending upon whether the doctor is “in-network” or “out-of-network.”

If the doctor and your PPO have a pre-existing arrangement together (i.e.. the doctor agrees to treat patients at a certain rate) then the doctor is considered “in-network.” If no such agreement is in place, he or she is “out-of-network.”

Note: Just because your doctor is “out-of-network” does not mean that you cannot be treated, it simply means that you may be responsible for a larger part of the final bill than had if you had selected an in-network doctor.

How do you know if your doctor is “in-network” or “out-of-network”? Typically, your PPO plan offers a list of “in-network” doctors within your area. Check your PPO’s website for a directory, wherein you can search for doctors based on specialty, gender, location and other features.

If you wish to see an “out of network” doctor, always ask your PPO provider what percentage of the treatment it will cover. Sometimes, being treated by an “in network” doctor can mean significant savings, while other times, the difference between going out of network, and staying within the PPO network is marginal.

Dr. Bennett’s Office

Understanding the details of your insurance benefits, and how they apply to your medical issues is critical, however vexing it may prove to be. Insurance is a very hot topic in the news today, with big changes being rolled out constantly and dramatic increases in co-payments and deductibles. Insurance companies are also known to create separate deductibles for medication, as well as the different stages of treatment – whether it be a normal office visit, hospitalization or admittance to a surgery center.

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Dr. Bennett’s insurance specialists take pride in helping patients make sense of their policies, so that your treatment is affordable.

 

Having questions about your policy is normal, and Dr. Bennett expects his patients to come needing assistance. His insurance specialists are always on deck to contact your insurance representative and flesh out the details of your coverage eligibility. Typically, our specialists gather this information before or during your private consultation with Dr. Bennett, so that after, you can go home with all of necessary facts to make the most informed decision of whether to go forward with treatment.

Note: HMO insurance providers do not cover consultations with Dr. Bennett, however, as an out-of-network provider, we do treat patients from PPO plans.

Procedures like deviated septum surgery, sinus surgery and functional rhinoplasty can be expensive. Dr. Bennett and his staff, are committed to making your treatment as cost-effective as possible, so that you can continue to afford the other expenses in your life and care for your loved ones.

Insurance policies are constantly changing. It is not uncommon for your policy to change many times during the year and for that policy to be replaced with a completely different policy at the beginning of a new year. Keeping up with these changes and revisions is difficult. It is not uncommon to get a different answer from your insurance company each time you contact them. We can help.

Simply put, Dr. Bennett’s office makes treatment options understandable and affordable. Our staff specializes in obtaining the details of your coverage, submitting claims on your behalf and handling all additional paperwork. We will discuss your treatment options and can answer any and all questions along the way.

insurance_stethDeductibles, Co-Pays & Other Out-of-Pocket Expenses

Out-of-pocket expenses are perhaps one of the most asked-about portions of a patient’s insurance policy. There are two main types of out-of-pocket expenses: deductibles and co-pays.

Your policy is broken into different sections that outline each type of out-of-pocket expense and the corresponding details. Read below for a review of the standard policy regarding these expenses. Tip: When reading your personal policy, look for the “deductibles” and “co-pays” headings to find out the particulars of your out-of-pocket expenses.

Deductibles

A deductible is a threshold amount of money you are responsible for paying until your health insurance coverage “kicks in” and covers the remainder of the costs. For example, if you undergo a sinuplasty procedure costing a total of $10,000, and your deductible is $500, your insurance will be billed $9,500, and you must pay the remaining $500.

deductible

Find out how your insurance company structures deductibles, i.e. whether you are required to pay a single, or multiple deductibles per calendar year.

Once you meet your deductible, your insurance will cover the remaining costs until the next calendar year, meaning that come January 1st, you must pay the deductible again before coverage kicks in.  In recent years, insurance carriers modified benefits, creating multiple deductibles as a way to increase the amount paid by the policy-holder.

For example, if you undergo a septoplasty procedure for a total of $10,000, which includes charges for the procedure ($6,000), the hospital stay ($3,000) and the anesthesia ($1,000). Your insurance coverage may include three separate deductibles, such as a $2,000 surgery deductible, $1,000 hospital stay deductible and $500 anesthesia deductible. In this scenario, you must pay $3,500 of the total cost of the procedure, and your insurance will be billed for the remaining $6,500. As you can see, this is not only more expensive, but more complicated for the policy-holder.

The amount of your deductible depends on your policy and is subject to change every year. Some deductibles range from $0 to $20,000, depending on the provider.

health_ins_jar_coinsCo-Insurance

Co-insurance refers to the payment a policy-holder makes to his or her insurance provider. The co-insurance payment is normally calculated on a percentage basis. For example, most policies set an 80/20 co-insurance rate, meaning that your insurance covers 80% of the total treatment costs, and you are responsible for the remaining 20%.

Co-Pays

A co-pay is a small payment (ranging from $5-$100) to your treating physician or surgeon required by your insurance plan. Co-pays are usually required when you see your regular doctor for a check-up or when making an appointment to visit with a specialist. Co-pays are also involved if you go to the emergency room or visit the pharmacy to fill or re-fill a prescription.

co-pay

Your insurance card generally displays information about the co-pays required under your plan.

Note: Co-pays are normally not included in yearly deductible or co-insurance calculations. For example, if your deducible is $500, and you pay $15 to pick-up a prescription nasal spray at the pharmacy, the deducible will NOT be reduced by $15.

Fine-Print

Hopefully by now you have gained an understanding of the building blocks that make up a standard insurance policy. Dr. Bennett recognizes that you might still have questions regarding your coverage, especially in light of the recent policy changes. Our staff handles your information with care and privacy, and will alert you of any snags that may crop up. It is important that you know that insurance companies are for-profit. Money paid for medical care is money that does not go to shareholders or the corporate executives. Our office will advocate for you and let you know what your rightful benefits are.

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Constant policy changes in the insurance world make it important for you to stay up-to-date with your plan.

Our Office

Dr. Bennett treats your consultation as a privilege. He and his staff prepare themselves for each and every question you may have regarding your insurance or the procedure itself. Each member of his staff has their own role in making sure you feel at ease.

When you first walk into our newly-renovated office suite, you will be greeted by Kelly. She will make sure you are comfortable in our quiet reception area, and bring you a coffee or water. She will also ask you to fill out a standard health and medical history questionnaire, and probably before you have the last sip of coffee, Dr. Bennett will be ready to meet with you.

Dr. Bennett will lead you to the private consultation room, where, for 20-40 minutes, you will discuss your current health concerns, treatment options and be given an examination. During your meeting, Meaghan, the Office Manager and her team will be working to review your insurance coverage to help you decide the best and most affordable treatment options.

FAQ: Will my health insurance cover my nose surgery?

In general, most health insurance plans cover surgery that treats any condition harmful to the normal-functioning of the nose and have failed maximal medical management. Insurance never covers the cost of purely cosmetic surgery.

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Leave the paperwork to us! Dr. Bennett’s office. We will gladly assist you in finding out whether your insurance plan covers your sinus surgery.

Most insurance companies cover the common forms of nasal surgery – deviated septum surgery, turbinoplasty, septoplasty, sinus surgery for recurrent acute or chronic sinusitis, nasal valve stenosis or nasal fracture surgery.

There is normally a two-step process for sinus surgery approval by your insurance provider after maximal medical management has failed. First, you will have a consultation with an ENT surgeon (called an otolaryngolist or an Ear, Nose and Throat doctor). Dr. Bennett, a double board-certified ENT and Facial Plastic Surgeon, will examine your nose, recommend treatment options, and discuss what you can expect from your procedure.

Secondly, Dr. Bennett submits his surgery recommendation and detailed treatment plan to your insurance provider. Often times, your insurance requires that you undergo a sinus CAT scan. If you do not have a recent scan to bring to the office, Meaghan can pre-approve a scan through your provider and schedule the test. Park Avenue Radiology, a medical imaging office, is located across the street from Dr. Bennett’s office, so most patients simply take a short walk after the consultation to pick-up their CAT scan.

When the CAT scans are ready for review, Dr. Bennett will describe to you the conditions, if any, that are present in the nose that require surgical correction.

To prepare for surgery, our office will handle every approval and piece of paperwork required by your insurance company. We will also work with you to schedule your surgery at a time and date most convenient for you. You will leave the office with a handy post-op care package that is full of all of the important aftercare products you need, saving you a few dollars and a trip to the drugstore.

If you have doubts that your insurance will cover your nasal or sinus surgery, Dr. Bennett recommends that you allow our office to craft a custom-tailored treatment plan. We realize that you pay a costly premium every month to your provider, and that you are entitled to the coverage you deserve. The office’s practice philosophy highlights that all patients have a right to obtain coverage and affordable treatment for debilitating or painful sinus problems.

Septoplasty

A septoplasty is typically performed on patients who are diagnosed with a deviated septum that blocks breathing or causes sinus infections. The surgery focuses on straightening the dividing tissue between your nasal cavities to improve breathing.

Note: A septoplasty is what is known as a “functional” surgery, meaning that the working area of the nose is treated only. Purely cosmetic changes to the nose are not covered by insurance. Sometimes functional surgery will change and even improve the external appearance of the nose.

Turbinate Reduction Surgery

An  turbinate reduction surgery, commonly known as a turbinoplasty, involves decreasing the size of the turbinates, or the small pieces of bone and tissue in the nose that help you breathe. There are four kinds of turbinates from bottom to top of the nose– inferior, middle, superior and supreme.

When the turbinates grow or become inflamed, most patients experience intense breathing difficulty and congestion, since the enlarged turbinates block the nasal airways. Reduction is usually performed on the inferior and middle turbinates, the two that happen to become inflamed  and enlarged most frequently.

You may be a candidate for a turbinoplasty if you have first tried to decrease inflammation via steroid nasal sprays, antihistamines or decongestants with no dramatic signs of improvement. Some patients choose to combine a turbinoplasty with another nasal surgery such as a septoplasty in order to further improve nasal function.

Correcting a Broken Nose

Surgery to repair a broken nose, also referred to as a nasal fracture, is a commonly-covered procedure by health insurance providers, due to the seriousness of the condition and the urgency of treatment.

Dr. Bennett is double board-certified and can determine whether you have suffered a fracture. He will walk you through an effective and simple plan to restore your nose back to normal. If you suspect your nose is broken, he recommends either a closed reduction of the nasal fracture in his office or scheduling surgery within two weeks following the injury. Otherwise, the potential rises for the fractured bones to fuse together. Dr. Bennett also treats patients who have suffered a nasal fracture years ago, correcting the bones that have healed and caused deformity and dysfunction.

Nasal Surgery: The Day of the Procedure

Dr. Bennett dedicates his practice to making sure each and every patient is treated with a high level of quality and personalized care.

On the day of surgery, you will be asked to arrive at a state-of-the-art surgery center located on the Upper East Side of Manhattan. Dr. Bennett asks that you arrive roughly one hour before, so that you can review any additional paperwork and store your belongings.

After you are settled in, the nurses will greet you and make sure you have everything you need. They will start an I.V. to prep you for surgery. You will also meet with your anesthesiologist, who will answer any questions you might have about the anesthesia method. Lastly, Dr. Bennett will greet you and answer questions before taking you to the operating room. He will speak with you again in the recovery room after surgery, and find out if you or your escort have any questions about the aftercare instructions.

While you are in the recovery room, there will be nurses on staff to help treat any grogginess or discomfort. After you have rested, usually for an hour or two, you will be discharged and permitted to leave with your chaperone. Dr. Bennett’s patients typically leave without any nasal packing in the nose, merely instructions to become a couch potato for the following week.

After your Procedure

During your first week of recovery, Dr. Bennett will check in with you daily to find out how you are feeling. After a week has passed, you will return to his office for your first post-op visit, where Dr. Bennett will remove sutures (if any) and the nasal splint, as well as clean out any crusting in your nostrils.

You will probably still feel slightly congested and swollen during the first few weeks, but remember that while swelling takes months to subside, you should notice improvements in your nasal function. Remember to continue to rest and take it easy – this means no physically-demanding sports or activities.

Specific Insurance Policies

Each insurance provider has a separate cache of coverage, including information about premiums, deductibles, co-pays, etc. To help serve you better, we have created a guide outlining key facts and general policies of the top insurance carriers in the country. Scroll through the list and click on the insurance company under which you are covered.

The Empire Plan

Group Health Incorporated (GHI)

Cigna

Aetna