Insurance & Nose Surgery: A Guide

Before you schedule an appointment with a nose specialist, the first question on your mind is usually: “Will my health insurance cover my surgery?”

Navigating the endless details contained within the pages of your health insurance plan can be overwhelming and frustrating. Understanding even the most basic concepts of an insurance policy can be clouded by fine print and exceptions.

New York City Sinus Specialist, Dr. Garrett Bennett, has created this online guide to help current and potential patients learn the ins and outs of your health insurance policy, to ensure that you get the best care for the lowest out-of-pocket expense.

The first question you must answer when evaluating your health insurance plan is figuring out what type of health insurance you have. There are two major types: an HMO plan and a PPO plan. There are many hybrid versions of these including EPO, POS and OA+.

HMO stands for health maintenance organization. Here, a monthly payment allows you to see any doctor within the HMO group. However, seeing a doctor is not as seamless as making an appointment. Before your HMO will pay for your consultation, you generally must first meet with your PCP, or primary care provider.  Your primary care physician is your normal doctor that you see when you need a check-up, or when you need advice or treatment concerning general medical issues.

You will speak with your PCP about the type of HMO specialist you wish to see, and your PCP will decide whether you in fact qualify for the appointment. For example, if you suffer from sinusitis, before you can see a sinus surgery specialist you must first meet with your regular doctor, who may approve you for the consultation with the specialist.

Another potential problem concerning HMOs occurs in the event that you wish to see a specialist that is not among the group of doctors who subscribe to the HMO group. In this instance, the doctor is referred to as “outside” the HMO. You must contact your HMO directly in order to obtain clearance to meet with the outside doctor, but it is not common practice to receive an approval. Therefore, if you have an HMO insurance plan, you are essentially limited to the doctors that exist within the HMO group. On the bright side, you will pay lower rates because the HMO is able to pay discounted rates to in-network doctors.

Preferred Provider Organization (PPO) Plans

The second type of insurance you can buy is called a Preferred Provider Plan (PPO). Similar to an HMO plan, you pay a monthly fee in order to have access to a certain network of doctors that subscribe to the plan.

The difference between an HMO and a PPO is that you do not need to seek clearance from your primary care physician in order to see a specialist. Without the requirement of a referral, it makes seeing a specialist easier and faster. You also have more flexibility in finding a doctor – as any doctor who takes your PPO insurance means your visit is covered. Some visits are covered more than others. If a doctor has a specific agreement with your PPO to treat you – then this doctor is “in-network.” If your doctor does not have any type of contract with your PPO, then he is referred to as “out-of-network.” Out-of-network doctors, like our office, can still accept your PPO plan, but you may pay more than if you had selected an in-network surgeon or specialist.

It is important to therefore do your research about the doctor you wish to visit, because it could mean significant savings for you if you eventually decide to select surgery or another expensive procedure. You also want to extensively research your doctor’s on-line reviews and credentials before obtaining your appointment. You can generally get an idea of the kind of care you will recieve from other patient’s who have had similar conditions and treatments.

It can be difficult for any patient to understand what their benefits include. Insurance policies change almost every year with deductibles and co-pays increasing. Procedures that are covered are subject to change as well as the criteria used to determine how those procedures are covered.  In addition, there are frequently separate deductibles and co-insurances for in-network, out-of-network, hospitalization, office visits, imaging studies, medication, both in- and out-of network surgery centers, in- and out-of network anesthesia, etc. These expenses may be additive. To make your benefits clear to you, Dr. Bennett’s insurance specialists will contact your representative to get the necessary details and let you know what your coverage includes.

If you have an HMO, your insurance will not cover your visit to our office. As an out-of-network provider, we do treat patients from certain PPO plans. Dr. Bennett understands that nasal surgery can be expensive, and not every family can afford such a life-changing procedure. However, he also realizes that this procedure is absolutely necessary for many of his patients. His staff will work with you to make your care as affordable as possible, while obtaining the maximum amount of benefits owed to you from your insurance policy.

We check your benefits, submit all claims and handle all of the paperwork we are able with insurance companies. If you receive additional forms from them, we can help answer their questions as well.

Your insurance policy will likely have sections that outline the policies for deductibles, co-pays and other forms of out-of-pocket expenses. Our office will check these for you and let you know what your insurance covers. We have a no surprise surgical billing policy.

Deductibles

A deductible is the amount of money you must pay before your health insurance benefits are triggered and begins to cover the costs. For example, if your deductible for a surgery to correct a deviated septum is $1,000 then you must pay the first $1,000 of the total cost. After this payment is made, your insurance may cover expenses related to the surgery.

When you pay your deductible in full, it does not “reset” until the next calendar year. This means that once you meet your annual deductible, your deductible will be “met” by your policy until the new year. If you change insurances then your deductible also starts over. It has become common practice for your policies to stipulate that different deductibles exist for different procedures. For example, you may have a $1,000 deductible for sinus surgery, but a $500 deductible for the surgery center ($1500 total). Deductibles for different medical costs may range from nothing to $20,000 or more.  Co-insurance is usually an additional expense above and beyond your deductible.

Co-Insurance

Co-insurance is a form of payment in your policy whereby you must contribute a certain percentage of each medical bill submitted and received by your health insurance provider. For example, a common percentage set forth by insurance companies is 80/20; meaning that you are responsible for 20% of the total bill and your insurance is responsible for the remaining 80%. This continues until your reach the pre-determined amount of co-insurance paid which could be anywhere from $1000 to over $10,000.

Co-Pays

Co-pay is simply a set amount of money your insurance requires you to pay each time you visit a doctor, go to the emergency room, or pick up a prescription at the pharmacy.

Co-pays are generally small amounts, ranging from $5 to $100. Co-pays exist independent of deductibles and co-insurance. If your policy stipulates a $25 co-pay to meet with your nasal surgeon, it may or may not count towards your overall yearly deductible.

Fine-Print

It may not be possible for you to read, never-mind understand your entire insurance policy. With frequent policy changes it is also understandable how you could call your insurance on different occasions and be given different information.  Our staff will check or even double-check that your information is correct. With our extensive experience with insurances, we are also aware of which policies are most likely to have a problem.

Dr. Bennett and his staff are prepared for your insurance questions on the day of your consultation.  Our friendly will greet you in our private mid-town east location when you walk in and offer you coffee, tea or water.

You will sit in our quiet and comfortable reception area and fill out a basic health questionnaire and sign the required medical paperwork. Probably before your coffee is finished, Dr. Bennett will greet you and take you into a similarly styled room. You will spend between 20 to 40 minutes discussing your medical history and care and will also receive a thorough examination.

While you are meeting with Dr. Bennett, his team will review your insurance and determine the best way to obtain the maximum coverage for your procedure.

Generally speaking, health insurance plans will cover you if you suffer from a condition that impairs the way your nose functions, and cannot be remedied simply by medication.

For example, common conditions that the majority of insurance carriers fully cover include: a deviated septum, recurrent acute sinusitis, enlarged turbinates, nasal valve stenosis, or a nasal fracture.

There are several steps in order to have these procedures covered by your insurance. First, you must meet with a surgical specialist. Ear, nose and throat doctors (ENT), commonly called otolaryngologists, or a facial plastic surgeon (an ENT with additional training in facial aesthetics), must examine you to make the determination that you indeed suffer from a medical condition. The specialist must also come to the conclusion that this type of condition must be treated with surgery, and that over the counter or prescription medications will not effectively improve your condition.

Dr. Bennett will outline a surgical treatment plan that is tailored to you, and recommend this plan to your insurance company. If you need a sinus CAT scan, you will see Meaghan, our office manager, who will pre-approve and schedule your test. Some insurance carriers require that we speak to a representative to approve your sinus CAT scan, but we can normally approve your test in 10 to 15 minutes.

You will then be able to go across the street to an in-network state-of-the-art facility, Park Avenue Radiology, and have your CAT scan performed within about 30 minutes.

When you return to our office for your follow-up appointment, Dr. Bennett will show you the sinus CAT scan films and describe, in a way that you can understand, what is going on inside your nose.

If surgery is needed, we will take care of all approvals, paperwork, insurance paperwork and scheduling. We have also found it helpful to give you a post-op care package, which includes everything you will need after your return home following your surgery, so you won’t have to buy it.

Dr. Bennett’s office is committed to understanding your needs as a patient, and your desire to get the most out of your insurance plan. He understands that you contribute money each month towards your premiums, and you deserve the best assistance possible from your insurance carrier.

If you come in to the office for a deviated septum surgery, also known as a septoplasty or septal reconstruction, this means that surgery is needed to straighten the septum so that you can breathe easier. A septoplasty is performed to increase the functional capacity of your nose only – and it will generally not change the nasal cosmetic appearance. If the septum is deviated near the  tip then this can cause the shape of the nose to change with the tip being off to one side. Septoplasty in this case will change the appearance of the nose in addition to improving breathing

Turbinates are small structures inside your nose that help with the airflow inside your nose as you breathe. There are four types of turbinates – called the inferior turbinates, middle turbinates, superior turbinates and supreme turbinates. When the turbinates become inflamed or swollen, this can cause difficulty breathing. Typically it is the inferior turbinate or middle turbinate that become enlarged and need to be reduced.

Before surgery can be considered, doctors usually recommend that you try a nasal steroid spray, decongestants and antihistamines to help shrink the turbinates. However, some patients suffer from abnormally enlarged turbinates that affect breathing so dramatically whereby surgery is the only option.

Turbinate surgery effectively reduces nasal congestion and helps a patient breathe freely, without blockages or feelings of “stuffiness.”

A patient may require several simultaneous procedures in addition to turbinate surgery alone. For example, many of Dr. Bennett’s patients suffer from a combination of a deviated septum and enlarged turbinates. It is recommended that a patient receive all of the necessary procedures at once – in one surgery, to restore breathing capacity to the patient as quickly as possible and avoid multiple recovery periods.

A nasal fracture is one of the common conditions that require immediate surgery in order to treat a patient. Broken noses are almost always covered by your health insurance plan although many college insurances do not cover any nasal surgery.

Dr. Bennett frequently sees patients with collapsed noses that need surgery in order to transform the nose to an optimal functioning shape. He recommends that patients schedule surgery to correct a broken nose within the first two weeks of the injury, so as to correct the fracture before the bones fuse. However, some patients suffered a broken nose in their past, and do not even realize it. Dr. Bennett is skilled at identifying patients who have suffered a nasal fracture and designing a plan to restore the nose to its intended appearance and function. We will contact your insurance company to pre-approve your nasal fracture repair before your procedure so you will not have any surprise billing.

You will go to a state-of-the-art in-network facility on the East Side of Manhattan. You will arrive one hour before the procedure, fill out more paperwork, and change out of street clothes.

You will be introduced to the nurses, who will start an IV. You will meet your anesthesiologist next, who will give you details about the anesthesia used for the procedure. Finally, you will see Dr. Bennett, who will speak with you before the surgery about your after care before you are taken into the procedure room.

When you wake up after the operation, you will be stuffy and may experience some discomfort. Your nurse will treat these symptoms in the recovery room. Dr. Bennett will talk to your escort and to you as well after the procedure. When you feel ready, usually after an hour or so, you’ll be able to go home with the person your escort. You will likely go home without nasal packing, and will become a couch potato for a week.

Dr. Bennett will call you by phone during the week to make sure everything is well. You return to the office after 6 to 10 days for suture and dressing removal and cleaning of any crusting. Don’t forget that congestion and discomfort improve over time and you will soon be back on your feet and able to progressively exercise.

Specific Insurance Policies

We have put together additional information on the major health insurance carriers below:

Aetna

Cigna

The Empire Plan

GHI

United Healthcare Group

United Healthcare Oxford