Charged for Unexpected Procedure During Surgery: Uncovering the Facts About Your Insurance Coverage

Charged for Unexpected Procedure During Surgery: Uncovering the Facts About Your Insurance Coverage

What is Preventative Care under the ACA?

Under the Affordable Care Act (ACA), certain preventive care services are fully covered without any cost to you. This includes services like annual physicals, mammograms, and screenings for certain chronic conditions. The goal of these services is to detect health issues early on, when they’re easier and less expensive to treat. However, it’s important to understand that not all medical procedures or tests are considered preventative care.

Unexpected Charges and Insurance Coverage

In the case presented in the post, the individual had a bilateral salpingectomy, a sterilization surgery that is fully covered under the ACA. However, during the surgery, the doctor discovered a benign ovarian cyst and removed it, adding an additional CPT code to the claim. The individual was subsequently charged almost $2,000 for the cyst removal.

This situation raises the question of whether the individual is responsible for paying for this unexpected procedure. To determine this, it’s important to understand the insurance policy and the specific coverage for the surgery. In many cases, insurance companies will cover the cost of medically necessary procedures that are performed during a covered surgery. However, if the additional procedure is considered unrelated to the original surgery, it may not be covered.

Understanding Medical Necessity and Insurance Coverage

Medical necessity is a key factor in determining whether an insurance company will cover the cost of a procedure. In general, a procedure is considered medically necessary if it is performed to:

Diagnose or treat an illness or injury
Prevent a serious health condition from developing
Improve the function of a body part

In the case of the ovarian cyst removal, the insurance company may argue that it is not medically necessary because the cyst was not causing any symptoms and did not pose an immediate threat to the individual’s health.

What to Do If You’re Charged for Unexpected Procedures

If you receive a bill for an unexpected procedure that you believe should be covered by your insurance, there are steps you can take:

Contact your insurance company to ask why the procedure was not covered.
Request an explanation of benefits (EOB) from your insurance company, which will provide a detailed breakdown of the charges and coverage.
Appeal the denial of coverage with your insurance company. You can submit additional documentation or evidence to support your claim.

Additional Tips for Navigating Insurance Coverage

Read your policy carefully: Make sure you understand the terms and conditions of your insurance policy, including the coverage for preventative care and unexpected procedures.
Talk to your doctor: Discuss potential additional procedures or tests with your doctor before undergoing surgery, to ensure they are medically necessary and covered by your insurance.
Seek professional help: If you’re having difficulty resolving coverage issues with your insurance company, you can reach out to a licensed agent or healthcare advocate for assistance.