Outpatient Surgery

Other articles in this series cover inpatient hospital confinement benefits by examining typical sample provisions of an individual health insurance policy. This article will examine typical policy wording dealing with health insurance benefits for outpatient surgery.

Participating Provider Services Subject to Co-Pay

(The following introductory wording is a summary. See “Benefits and Claim Procedures: Health Insurance co-pays and deductibles: A Primer” for complete wording.

(Typical wording*) Subject to all Policy limitations, exclusions, applicable deductibles, co-pays and maximums, the Company agrees to pay for policy-defined covered expenses for the following described services, if they are medically necessary: 2. Outpatient Surgery at a Hospital or an Ambulatory Surgical Center: Subject to satisfaction of each applicable Surgery Co-Pay, the following services Provided by the following Participating Providers in connection with surgery performed on an Insured on an Outpatient basis: a. Hospital or Ambulatory Surgical Center (subject to Surgery Co-Pay) – expenses that constitute Covered Expenses will be considered for payment for the pre-operation, operation, and recovery rooms, as well as for medications, and other miscellaneous items, services and supplies; provided television, telephone and radio are not considered Covered Expenses; b. Primary Surgeon Fees – subject to Surgery Co-Pay; c. Assistant Surgeon – professional fees that constitute Covered Expenses will be considered for payment for one assistant surgeon in connection with surgery for which a Benefit payment has been made under this Section for the professional fees of a primary surgeon; d. Anesthesiologist or nurse Anesthetist – professional fees that constitute Covered Expenses will be considered for payment, for a Participating Provider who is either an anesthesiologist or a nurse anesthetist for services rendered during administration and monitoring of anesthesia, during surgery for which a Surgery Co-Pay has been applied hereunder for the professional fees of a primary surgeon; and e. Pathologist Fees – professional fees that constitute Covered Expenses will be considered for payment for a pathologist’s evaluation and/or interpretation of any tissue specimen removed during or in connection with such surgery.

 

An ambulatory surgical center is a licensed public or private establishment with permanent facilities that is equipped and operated mainly to perform surgery. It also has registered professional nursing services. It does not provide for overnight stays for patients. It is not a facility that primarily terminates pregnancies. It is also not a provider’s office maintained for the practice of medicine or for the practice of dentistry.

Note that the cost of TV, telephone and radio are not covered expenses even though these devices will undoubtedly be found in your room. If the hospital or ambulatory surgical center has a separate charge for them, 100% of those charges will be your personal responsibility unless you are able to have them removed from your room or from your half of the room if you are in a semi-private room. If the charge for these items is built into the room charge, the insurance company will ordinarily not try to arbitrarily segregate out (and thereby not cover) a portion of the room charge as being for these items. But with the steadily increasing cost of medical care for all parties these days, you never know – a given insurance company may try to segregate out a charge for these items. In that case, you can challenge the reasonableness of the assessed charge.

Laboratory and diagnostic tests and any kind of therapy that might be done while you are at the hospital or ambulatory surgical center are not covered expenses under this provision. They may be covered under other provisions of the policy. Check with your agent to be sure.

*Wording may vary from contract to contract and from state to state.