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I need surgery and don't have insurance. What are my options?
October 7, 2010 7:59 PM   Subscribe

I need surgery and don't have insurance. What are my options?

I need arthroscopic knee surgery to repair a damaged meniscus. I do not have health insurance. I believe the surgery costs around $10,000.

Through the Philadelphia health centers, I have been able to get an MRI and have been diagnosed by a sports osteopath at the Hospital of the University of Pennsylvania. Unfortunately, the city programs will not pay for surgery. I am not eligible for Medicaid. My work offers a shitty health care plan with a $500 limit on outpatient services. I have a few thousand dollars in savings.

Is there anything I can do? Can I sign up for an individual insurance plan? Would I have to disclose the existing condition? (I have no moral qualms with not disclosing it if they cannot find out.) Is there any way it could be classified as inpatient services (my insurance covers up to $10,000)? Is there any way to comparison shop and find a hospital that does it cheaply? Can something like this be done abroad for cheaper? etc.
posted by christonabike to Health & Fitness (21 answers total) 4 users marked this as a favorite
 
Is getting a different job with normal health benefits an option (benefits usually take 3-4 weeks to kick in, so not feasible if you need the surgery urgently)? Even if you have to take a pay cut, it's unlikely that it'll be $10,000 and will deplete you of all your savings.

Also, keep in mind that the $10,000 price tag you're quoting is what insurance companies are billed. The actual amount you would owe could be significantly–as in, less than half–lower than that.
posted by halogen at 8:06 PM on October 7, 2010


Also, I don't know if that goes against MeFi rules, but the Facebook info that your profile links to informs that you graduated high school in 2003 and should be under 26 years of age. If so, you should be eligible to be on your parents insurance, in which case pre-existing conditions don't matter.
posted by halogen at 8:11 PM on October 7, 2010 [4 favorites]


My mother fell and shattered her kneecap a few years back. She was uninsured, and with very little money. The hospital had a program for low income patients to help them pay for their health care needs. It was an honestly run, low interest way of paying the hospital back. As far as I know, some fees were reduced or even waived outright. You might check with area hospitals to see if any of them offer similar programs for people in your situation.
posted by Ghidorah at 9:29 PM on October 7, 2010


Have you seen a surgeon to talk about these kinds of things? Why do you "believe" the surgery costs around $10,000? My arthroscopic knee surgery not quite two years ago now cost much less than that. Have you met with a surgeon to discuss the cost? To go over your insurance coverage and think about how it can be billed? To discuss a payment plan with the hospital or surgical facility? The billing staff at a surgeon's office will probably be happy to talk with you about specific costs and how they can be handled, once you're a patient.

If you have insurance at all, you will probably not have to pay up-front but will be billed; last fall, I had surgery and much of the cost applied to my deductible, which I couldn't pay all at once. When I called to set up a payment plan (most hospitals and doctors are very good about this; I have done it many times), they offered to knock 1/3 off the balance if I could pay it in one lump (I couldn't at that time, alas). With your savings, you might be able to negotiate something like that.
posted by not that girl at 9:30 PM on October 7, 2010


My husband had surgery on his meniscus a couple of years back, before he qualified for the public healthcare otherwise available in Australia (because we had only recently moved here). He ended up going to New Zealand (where he has permanent residence) to have the surgery, because he could get it done privately there for around $3000 NZD (about $1800 USD?) while it would have cost him about twice that in Australia (which sounds like it would still be cheaper than the USA, although the waiting list here is quite long).

That is to say, yes, you can probably get it done more cheaply abroad. But you should go to a country where you know people, speak the language, and have somewhere to stay while you recover!
posted by lollusc at 9:47 PM on October 7, 2010


Almost all hospitals have a free care option for low income and/or uninsured patients. They have to offer it, I believe. You should ask about this, and then apply.
posted by FlyByDay at 9:54 PM on October 7, 2010


First, check this: Also, I don't know if that goes against MeFi rules, but the Facebook info that your profile links to informs that you graduated high school in 2003 and should be under 26 years of age. If so, you should be eligible to be on your parents insurance, in which case pre-existing conditions don't matter.

Then, check this: Almost all hospitals have a free care option for low income and/or uninsured patients. They have to offer it, I believe. You should ask about this, and then apply.

If HUP can't help you, see if Jefferson can. FWIW, Jefferson's orthopedics (Rothman Institute) are ranked slightly higher than Penn anyway, and I can say that I've had far better experiences with Rothman too.
posted by The Michael The at 5:13 AM on October 8, 2010


Responses:
  • No issues with checking my age (I have no issues with my information being public), but unfortunately, I am 26.
  • Taking a different job for insurance purposes would be a last resort.
  • I will contact the hospital to see if the rate is negotiable, as well as other hospitals in the area - that is a good idea.
  • From conversations with people at HUP, I don't believe I am eligible for any of their programs for uninsured patients, but I will continue to research this.
One question I had that I didn't see addressed: what happens if I sign up for an individual health care plan knowing that I have this issue?
posted by christonabike at 6:29 AM on October 8, 2010


The actual amount you would owe could be significantly–as in, less than half–lower than that.

As perverse as it seems, most insurances companies pay less than individuals who have to pay their own way. Because they represent large groups of people, they are able to negotiate a discount on the normal fee for service.

And for about the nth time, definitely look into payment plans. This may even be something brought up by pre-registration when they establish how you are going to pay for the surgery. Most of your larger facilities/integrated delivery systems should be offering this.
posted by Apoch at 6:34 AM on October 8, 2010


What happens is they will find out, and you'll be liable for the surgery AND for dealing with the insurance company.
posted by fiercecupcake at 6:34 AM on October 8, 2010


One question I had that I didn't see addressed: what happens if I sign up for an individual health care plan knowing that I have this issue?

Well, that's insurance fraud. You bet your ass that if you get insurance and then immediately have orthopedic surgery that the insurance co. will be researching you.
posted by The Michael The at 7:17 AM on October 8, 2010


Talk with the doctor about making it an in-patient surgery, which will be covered by your insurance.
posted by mareli at 7:23 AM on October 8, 2010 [1 favorite]


Talk with the doctor about making it an inpatient surgery, which will be covered by your insurance.

If there is no medical necessity for inpatient care (and knee surgery without any complications or comorbidity does not meet medical necessity for inpatient care) then the inpatient stay will not be approved by the insurance company OR the facility itself. They have a Utilization Review department that verifies if inpatient stays are required, approved by insurance, and continue to verify that the patient's clinical state meets medical necessity for acute care.

Asking your physician to lie about medical necessity so you can have inpatient surgery is not a good idea. It puts him in the awkward position of either committing fraud or pissing off you the patient.
posted by Apoch at 7:41 AM on October 8, 2010


The Michael The: "Well, that's insurance fraud. You bet your ass that if you get insurance and then immediately have orthopedic surgery that the insurance co. will be researching you"

How is this insurance fraud? I can see perhaps the claim being rejected as a pre-existing condition, but fraud?

Tell us, then, if a patient has bad knees and applies for insurance, what is an appropriately non-fraudlent amount of time to wait to have surgery? A month? A year? Ten years? Are we only to join an insurance plan when we're perfectly healthy, and then accept treatment when it's convenient for the insurance company?
posted by xedrik at 8:18 AM on October 8, 2010


Have you read your insurance documents to be sure that same-day surgery counts as an outpatient procedure? Even though you wouldn't stay overnight, it does take place in a hospital, not a clinic. I believe some hospitals even "admit" you to the OR, for a few hours. I am no expert in these matters, but it might be worth double-checking to see if perhaps this would be covered. In the past I've been able to call my insurance to check whether something would be covered, so if your company is decent you might try the same. If the person on the phone says it would be covered, do your darndest to get them to send you a letter saying so. The prerecorded "you're on hold" message with these companies usually says that the representative cannot make a final decision to accept or deny a claim, so the more proof you can have in your possession, the better.
posted by vytae at 8:21 AM on October 8, 2010


How is this insurance fraud?

It's fraud because the asker would have to lie about his knee problem to get approved for individual coverage. No insurance company these days is going to take on somebody who needs surgery ASAP through an individual, voluntary plan.
posted by vytae at 8:23 AM on October 8, 2010


How is this insurance fraud? I can see perhaps the claim being rejected as a pre-existing condition, but fraud?
Soft fraud, which is sometimes called opportunity fraud, occurs when a policyholder or claimant exaggerates a legitimate claim. A car owner involved in a “fender bender” who pads the claim to cover the policy deductible is committing soft fraud. Another example is exaggerating the number and value of items stolen from a home or business. Soft fraud may also occur when people purposely provide false information to influence the underwriting process in their favor when applying for insurance. To lower insurance premiums or increase the likelihood that the application for insurance will be accepted, people may underreport the number of miles driven, misrepresent where a car is garaged, fail to provide an accurate medical history when applying for health insurance, or falsify the number of employees and the nature of their work for workers compensation coverage. [source]
Tell us, then, if a patient has bad knees and applies for insurance, what is an appropriately non-fraudlent amount of time to wait to have surgery? A month? A year? Ten years? Are we only to join an insurance plan when we're perfectly healthy, and then accept treatment when it's convenient for the insurance company?

"Bad knees" != diagnosed condition for which medical treatment is imminently necessary. I see your point, and agree, and generally hate the concept of "preexisting conditions" and strongly support insurance reform and regulation, but what the OP describes is, legally, insurance fraud for now. There's no way around that. In 2014, the provision prohibiting preexisting conditions goes into effect, but I don't think that one can live with a torn meniscus for >3 years. However, that PolitiFact link also points out "high-risk pools" to provide insurance for those with preexisting conditions until the 2014 date, so maybe the OP could look into those.
posted by The Michael The at 8:50 AM on October 8, 2010


Also, OP: are you absolutely certain that the $500 for outpatient procedures is the max cost and not your copay?
posted by The Michael The at 8:52 AM on October 8, 2010


Personal anecdote. I mentioned a small pre-existing condition to an eye doctor I saw about another matter about a decade ago. It was a slight heartbeat irregularity that had been diagnosed when I was a kid and hadn't popped it's head up again in 15 years-- I didn't take any medication for it, it never bothered me, and it had basically no symptoms. In other words-- it affected my health in no way, shape, or form.

Yet it still managed to keep me from getting Health Insurance in California, from ANYONE (unless I wanted to pay obscene, obscene rates.) I couldn't figure out why every health insurance company was rejecting my application-- I was in perfect health! Young, exercised regularly, no REAL issues. Which is all to say-- those suckers can find out anything-- they'll definitely find out about your knee. Don't bother trying to pull one over on them.
posted by np312 at 9:03 AM on October 8, 2010


The problem the OP has here is that the knee issue was officially diagnosed by the Philly doctor, which makes it a bona-fide pre-existing condition. It makes this a different story than if the Op's knee hurt, they got health insurance, and THEN went to go get a diagnosis/surgery. Surely things happen to people within a week of their applying for health insurance, but in this case it demonstrably did NOT happen within the time that passed between the application for insurance and the using of it. Unfortunately, if the OP lies about it, that is one of the more traceable cases of insurance fraud.
posted by deep thought sunstar at 12:32 AM on October 9, 2010


Thanks for the debate regarding disclosing conditions. I am going to try some of the various suggestions mentioned in this thread; I'll post an update eventually.

The Michael The: Yes, I'm absolutely certain it's not the copay. It's a very terrible plan.
posted by christonabike at 6:06 AM on October 9, 2010


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