Having surgery can be confusing and frightening even in the best of circumstances, and there are a lot more variables when you’re trying to get one as a member of a HealthShare. We’ll walk you through what you need to think about before you get the procedure scheduled–please keep in mind that HealthShares differ dramatically from one another, so we can only offer generalized advice. Hopefully, however, seeing the different factors involved written down will help you stay organized and understand what questions to ask your HealthShare.
1. Does your HealthShare use a network?
Many HealthShares no longer use networks. Instead, they allow their members to use any provider or facility that is properly licensed. Before a surgery, you should double-check whether your HealthShare uses a network or not. If they do, you need to check that both your surgeon and the facility are in-network. This isn’t a HealthShare-only problem; people with health insurance can also run afoul of out-of-network prices.
It’s easy to assume that if a facility is in network, you should be fine, or if the head surgeon is in network, it won’t be an issue, but these are dangerous assumptions to make. It is common for surgeons to travel to different facilities, and there is no guarantee that whichever hospital or surgical center they operate in is in your HealthShare’s network. Not to mention, more providers are involved with a surgery than the head surgeon–you need to think about nurses, surgical aids, and anesthesiologists. In most cases, surgical staff bill under the supervising surgeon, but this is not always true. If you have doubts, you should call the surgical facility to check.
2. Is your surgery eligible for sharing?
Keep in mind that as a HealthShare member, your surgery may not even be eligible for sharing. Guidelines vary dramatically from HealthShare to HealthShare, but common reasons why you might not receive help for the bill include:
- The surgery will correct an injury received when doing something against your HealthShare’s Guidelines. This might include participating in war, professional sports, or an activity judged overly-hazardous, such as skydiving.
- The surgery relates to a pre-existing illness or injury. Most HealthShares have a waiting period before pre-existing conditions are considered shareable; this ranges from 1-3 years. HealthShares also usually cap how much they share for pre-existing conditions–a common price limit is $25,000 for year 2, with that limit increasing slightly until year 4. If your surgery does relate to a pre-existing condition, check price limits. If you can manage to wait a while for the surgery, it may be worthwhile to do so.
- The surgery is not medically necessary (such as cosmetic surgery).
- The surgery is experimental / not medically approved.
3. If your surgery is eligible, does your HealthShare want you to get a preauthorization for the procedure?
This is less common, but there are some HealthShares that want to review and authorize any major procedures before they happen (barring true, life-threatening emergencies where notice is not possible). Review your Member Guidelines to check, or better yet, call your HealthShare and ask. This could be worth your time even if your HealthShare does not require prior authorization; they may be able to help you work out pricing or payment options with your provider.
4. How does your HealthShare want you to pay for your surgery?
Many HealthShares reimburse their members, but others can pay providers directly or even pre-pay for some services. Surgery can be insanely expensive, so you should iron this out as early as possible. Not having to worry about money will remove some stress from your recovery, so it’s far better to get this sorted before you actually go in. Call your HealthShare and ask what the best way forward would be. Would they like you to pay your portion directly to the provider, and then they’ll step in? Would they like all bills sent to them directly? Would they like you to pay everything, then get reimbursed? Ask! Also, keep in mind that many HealthShares do help with medications related to acute recovery (such as after a surgery), so ask about their process for sharing those as well.
Although surgery can be stressful, arming yourself with some knowledge in advance should make the process much simpler. Work with your HealthShare to decide the best option for you, and, when possible, get their directions in writing (as an easy reference for both you and them should you run into any problems). With some preparation, surgical procedures can go smoothly and, hopefully, leave you with nothing to worry abut except recovery.
