Most people put real effort into choosing a surgeon. Far fewer ask what else they will be billed for, or where the procedure will actually happen. Both questions can change what you pay.
contributed by Yvonne Powers
One procedure, usually three bills
Most patients expect one charge from their surgeon. In reality, you will typically receive at least three separate bills:
The surgeon’s fee, for the surgery itself.
The facility fee, from the hospital or surgery center where the procedure happens. It covers the operating room, nursing staff, equipment, and supplies, and is often the largest of the three.
The anesthesia fee, usually from a separate anesthesia group billing under its own name.
Depending on the procedure, you may also see bills for lab work, pathology, or imaging. Each is processed by your insurance separately, and each can carry its own copay or coinsurance.
Where it happens changes the biggest bill
A knee arthroscopy, carpal tunnel release, or rotator cuff repair can often be performed in a hospital, a hospital outpatient department, or an ambulatory surgery center (ASC), a freestanding facility built for same-day surgery. The surgeon may be the same. The facility fee often isn’t. Medicare pays hospital outpatient departments more than surgery centers for the same procedure, and many commercial insurers follow a similar pattern.
Ask about facility fees
Facility fees aren’t limited to surgery. When a doctor’s office is owned by a hospital system, it may be billed as a hospital outpatient department, meaning a facility fee on top of the physician’s fee for a routine visit or X-ray.
Cheaper isn’t automatic. Check your plan.
Under traditional Medicare, your share of a hospital outpatient procedure is capped, so for some larger procedures your out-of-pocket cost at a surgery center can be similar or even higher. With a Medigap supplement, the difference may disappear. With Medicare Advantage or a commercial plan, it depends on your contract.
Questions to ask before you schedule
- Where will this be done: hospital, hospital outpatient department, or surgery center?
- Who will bill me? Your surgeon’s office can name the facility; the facility can name its anesthesia group. Ask each, or your insurer, for an estimate.
- Are the facility and the anesthesia group both in-network with my plan?
- Am I a good candidate for a surgery center? Ask your surgeon. Patients with certain heart, lung, or sleep apnea conditions may be safer in a hospital.
- On Medicare? Compare national average costs by setting with the free Procedure Price Lookup tool at medicare.gov/procedure-price-lookup.
The right setting is always the one that fits your health first. But when more than one option is appropriate, asking a few questions up front can save you money and surprises.
Yvonne Powers is the Practice Administrator at Austin Orthopedic Institute in Georgetown, Austin, and Marble Falls, with 30 years in healthcare administration.
Austin Orthopedic Institute • Board-certified orthopedic surgeon specializing in sports medicine, joint reconstruction, and orthopedic trauma, with over 15 years of surgical expertise.
AustinOI.com • 512-856-1000