Self-Pay Options and Health Insurance Information
We are here to help...
If you don’t have insurance, we can help!
If you have a health insurance plan with such a high deductible and/or high co-insurance costs that you can’t afford the cost of surgery even with insurance, we can help!
If you are an employee of a self-funded employer, we can help your employer too!
Hospital and surgery center fees can be as high as $15,000 - $20,000 for a simple hernia repair, and that cost does not include the anesthesiologist fee or surgeon fee. So if a patient is uninsured or is insured but has a high deductible of $5000 or $10,000 plus their co-insurance, the price of surgery is simply not affordable for many. Therefore, even a simple repair for their hernia is just not possible. But we are here for you!
This method of payment for surgical procedures is also known as self-, direct- or private-pay. And surprising to many patients, with our low discount rates, it is often less costly for patients to pay out of pocket rather than to use their health insurance. We can help you understand your insurance benefits so that you can compare for yourself.
Many patients come to us because we have made hernia surgery affordable for most. For the absolute most common hernias (inguinal and umbilical hernias) that make up the majority of what we do, we have done the work for you and have negotiated a special low self-pay discount rate with our preferred anesthesia providers and preferred surgical facilities. We have negotiated the best all-inclusive price we are aware of.
It is one of our missions to make hernia surgery affordable to as many people as possible. Toward that goal, we offer the absolute best self-pay FLAT FEE of $4000 for standard open umbilical and inguinal hernia repairs, plus the cost of the individual mesh implant if used. The price of the mesh varies by the type and size of the mesh used, but ranges from $58.00 - $800.00. This is the actual cost of the mesh from the manufacturer, and it is not marked up at all by our practice or the surgical facility. You pay the actual discounted rate offered directly to the surgical facility by the manufacturer or supplier.
So, as stated, other than the actual cost of the mesh (if used), the self-pay fee is ALL INCLUSIVE, and there are no additional fees, hidden charges, or surprise costs. The remaining facility fees, anesthesiologist services, and surgeon services, are all included for the ONE LOW COST. There is simply no way to further decrease the cost for operating room time, medications for surgery, preoperative nursing care, supply costs, cleaning and sterilization costs, physician care, and postoperative nursing care. All follow up visits and post operative care are also included in the self-pay price.
For more complex hernias that require advanced techniques such as laparoscopy or robotic surgery (or if you personally choose one of these surgical approaches), we will personally go to the facility administration (Chief Executive Officer and/or Chief Financial Officer) to negotiate on behalf of the patient for each individual case to obtain the best possible self-pay price for that patient. We have been very successful in getting facilities to substantially reduce their fees.
For those more complex hernia repairs that require the use of a hospital facility, our AHS cash pay pricing structure is a payment option for those who are uninsured or have a high-deductible insurance plan, are employees of self-funded employers, or are "medical tourists." Our cash pay model is affordable and discounted based on a formula that considers what Medicare, in-network insurers, and out-of-network insurers pay for the same procedures.
Cash pay pricing does not include:
Preoperative Lab tests (or any other preoperative testing that may be indicated).
Prescribed post-discharge medications
Expenses incurred from potential complications after discharge from our facility
Individual patient cash pay prices are non-negotiable and are available only to those who pay the entire amount in advance of their procedure.
Insurance Plan General Information:
Every health insurance plan is different, and your financial obligations will vary based on your specific plan. You are responsible for your premium, along with any cost-sharing your plan requires. Co-pays, deductibles, and co-insurance payments are all agreed-upon, shared costs between you and your insurance company. When you sign up for a health insurance plan, you should understand what your co-pay, co-insurance and deductible will be from the beginning. Additionally, some medical services may not be covered by your plan. If you obtain services that are not covered by your plan, you will be financially responsible for those services. In general, you should make sure to familiarize yourself with the benefits provisions, exclusions, and limitations of your plan before you seek any healthcare services whatsoever, so you don’t incur unnecessary or unexpected expenses.
"Cost-sharing" is a percentage of charges (for healthcare services provided) that you are responsible to pay, regardless of whether you go to an in-network or out-of-network provider. For example, it is very common for health insurance plans to have “80/20 Coverage,” which means that they will cover 80% of the charges, and you (the patient) will have to pay 20% of the charges (your co-insurance). A patient who has a plan with a 20% co-insurance will pay 20% of the costs of care out-of-pocket after they have paid their deductible, if there is one. To verify the cost-sharing you will have for specific services, check your "Schedule of Benefits" for details, or you may contact your health insurance company for assistance (phone number can be found on your insurance card). In many cases, we can help you obtain this information.
At AHS, our providers are "out-of-network" with ALL insurance plans. What does this mean?
If you would like to have surgery using your health insurance, the anesthesiologist and the surgical facility fees will be paid directly by your plan. However, you will need to pay AHS directly for surgery. If you have "out of network benefits," you may submit your AHS fee to your insurance company for reimbursement.
Health insurance companies are cutting their costs by paying providers less and raising deductibles on patients, increasing the burden on consumers, thus increasing insurance company profits. In a PPO, the consumer basically has an arrangement that allows the insurance company to pay their own determination of the “Maximum Allowable Charge” or a percentage thereof. The insurance companies are selling “in-network” hospitals, while often NOT negotiating with physicians who staff those hospitals. Allowing insurers to unilaterally determine “allowable” reimbursement lacks transparency, encourages manipulation, and is not based on the costs of providing care by the physicians.
For the insurance companies to make the most profit, they leverage their size and influence to force physicians and other providers to agree to accept a significantly discounted rate paid by the insurance company for covered provider services under their health plan for the “privilege” of being a member of their insurance network. These healthcare providers that perform services for a vastly discounted rate are considered “in-network.” The “in-network” providers hope to make up the difference for the discounted rate by capturing the potential large volume of patients that the insurance company purportedly provides by “participating” in their “network.”
For the healthcare providers that are very specialized, as we are at AHS, the portion of the total population we treat is small, and therefore the volume of patients is comparatively small, as opposed to a primary care practice with thousands of patients, for example. It is consequently of no benefit for us to “participate” in an insurance company “network” and accept the greatly reduced reimbursements they offer.
We would not be able to offer the same exemplary and higher quality care for the negligible contracted payment we would receive from the insurance company.
Also, please note that for many insurance plans, certain services require prior approval, regardless of the benefit plan you have. We will verify that information for you and if your insurance plan requires an authorization, we will obtain that approval/authorization on your behalf at an additional charge of $100.
Again, our cash pay pricing structure for individual patients is a payment option for those who are uninsured or have a high-deductible insurance plan, or are employees of self-funded employers, or "medical tourists" from out of town. Our Self-pay model is affordable and based on a formula that considers our actual costs and what Medicare, in-network insurers, and out-of-network insurers pay for the same procedures.