Do You Have to Pay for a Follow Up Appointment After Surgery?
Clarify if your post-surgery follow-up visits are covered. Understand medical billing nuances and insurance to manage healthcare costs effectively.
Patients often wonder if follow-up appointments after surgery incur additional charges. Billing for post-surgical care is complex and depends on several factors. Understanding how surgical services are bundled is important for managing potential costs and anticipating financial responsibilities.
How Surgical Follow-Up Billing Works
The “global surgical package” determines if a follow-up appointment is separately billed. This package is a single fee covering preoperative care, the surgery, and routine postoperative care. The global period, typically 0, 10, or 90 days depending on procedure complexity, includes routine follow-up visits directly related to the surgery in the initial fee. These visits should not be billed separately during this period.
Routine services within the global package often include wound checks, suture or staple removal, drain removal, and medication adjustments directly linked to the surgical recovery. If a patient returns to the surgeon’s office for these standard post-operative services within the global period, a separate charge for the visit should not be levied. The global period for minor procedures might be 0 or 10 days, while major procedures typically have a 90-day global period. For a 90-day global period, this includes the day before the surgery, the day of the surgery, and the 90 days following.
However, certain situations fall outside the global surgical package and may result in separate charges. Visits for complications requiring additional procedures or extensive treatment beyond routine follow-up are generally billable. For example, if a patient needs to return to the operating room for a complication, this would typically be billed separately. Similarly, visits for unrelated medical issues that arise during the global period, such as a new illness or injury not connected to the surgery, are not covered by the global package and can be billed.
Follow-up visits after the global period ends are billed separately. Services provided by a different provider or facility not part of the original surgical team or billing group may also be billed independently, unless there is a formal agreement for transfer of care. Diagnostic tests, radiological procedures, and treatment for an underlying condition not part of normal surgical recovery are also typically excluded from the global package.
Understanding Your Insurance Coverage
Understanding your specific insurance coverage for post-surgical follow-ups is important. Insurance plans vary, so review your policy documents, such as the Summary of Benefits and Coverage, for specifics on surgical benefits and follow-up care. This helps identify potential out-of-pocket expenses, limitations, or exclusions.
Contact your insurance provider directly to clarify coverage details before undergoing surgery or attending follow-up appointments. When speaking with a representative, prepare specific questions. Inquire whether post-operative care is included in your surgical benefits and what the global period is for your specific procedure. Also ask about any specific exclusions for follow-up visits, such as those related to complications or unrelated conditions.
Some follow-up care, even if related to the surgery, might require pre-authorization or referrals, despite the initial surgery being covered. Ask if any specific services, like physical therapy or specialized diagnostic tests, have such requirements. Understanding the distinction between in-network and out-of-network providers is important, as using out-of-network services can result in higher costs or reduced coverage. Your insurance company can confirm if your surgeon and any anticipated follow-up care providers are in-network for your plan.
Navigating Unexpected Bills
If you receive an unexpected bill for a follow-up appointment after surgery, review the Explanation of Benefits (EOB) document from your insurance company. An EOB is a statement detailing how your insurance processed a medical claim, outlining the services billed, the amount covered, and any remaining patient responsibility. Check the EOB for reasons for denial, such as “lack of medical necessity” or “service performed out of network,” or for discrepancies between the services listed and what you received.
Next, contact the provider’s billing department to clarify the charges. Request an itemized bill, which provides a detailed breakdown of all services, their corresponding codes, and costs. This can help identify potential billing errors, such as duplicate charges or incorrect procedure codes. If the billing department cannot resolve the issue, or if you believe the charge should have been covered by the global surgical package, contact your insurance company.
If your claim was denied, you have the right to appeal the decision. File an internal appeal with your insurer, outlining your case and including all relevant documentation like medical records and the denial letter. Follow your insurance provider’s specific appeal procedures and deadlines, as these can vary. If the internal appeal is unsuccessful, you may pursue an external review with an independent third party.
If the charges are legitimate but pose a financial burden, explore options for negotiating costs or setting up payment plans. Many healthcare providers are willing to work with patients to establish interest-free monthly payment plans. Some providers may also offer a discount for a lump-sum payment if you can pay the entire balance upfront. Additionally, inquire about financial assistance programs or charity care, as many hospitals offer such programs to eligible patients.