To Wait Or Not To Wait?

Saturday, April 29th, 2017

Northern Indiana Hand and Wrist

(Reader warning:  Sleep inducing words like “insurance”, “deductible”, and “out-of-pocket” are flagrantly used below.  Grab some coffee.)

It’s that time of year again.  I’m not speaking of the time where you see Christmas displays pop up before Halloween (although it’s certainly that time of year, too).  I’m speaking of the time where, as the year draws to a close, patients are faced with the decision whether to have surgery before the year ends or in January when most deductibles re-set.

Typically, our office experiences a deluge of patients needing or requesting surgery before year end.  There are three identifiable groups:

Patient Group A—Why Wait?

For various reasons this group has met both their yearly deductible and out-of-pocket amount.  For this “lucky” group, their approved and allowed medical treatment, including surgery, will be covered at 100%.  These patients typically want to get additional medical treatment taken care of before January 1st, and who can blame them?

If you have a high deductible health plan and have met your $5,000 or $7,500 deductible, you know what I’m talking about.  Having been in that boat myself during one particularly surgery-laden year, it makes sense to use your benefits to their fullest extent.

Patient Group B—What Do You Mean I Need Surgery Now?

These folks haven’t had much in the way of medical expense.  They’ve paid their co-pays at their doctor visits throughout the year, but none of their deductible or out-of-pocket amounts have been met.  In the case of surgery, they will be responsible for their entire deductible amount plus a percentage of medical costs that accrue toward their out-of-pocket.  In most cases, this is a significant cash outlay and could range from several hundred to several thousand dollars.

Many patients in this group will require surgery now because waiting could result in significant damage to their hand and/or overall functional ability.  Unfortunately, these patients have no choice but to proceed with treatment and, consequently, meet their deductible and in some cases, their out-of-pocket amounts knowing that both re-set January 1st.  It’s basically a financial double-whammy.

I, too, have been a passenger on this ship and needed anti-nausea medicine.  My advice:  don’t let your husband chip ice off his truck with a hunting knife in late November.  It’s a no-win situation.

Patient Group C–I Like It Up Here On The Fence

Sorry to put you in a tough spot, but that’s where you are.  You need surgery, you want surgery, your deductible is met but your out-of-pocket amount isn’t.  Your benefits re-set on January 1st.  If you have surgery now, you’ll only pay—for example—20% of the charges your carrier allows up to your out-of-pocket amount.  If you wait until January, you’ll pay your deductible (maybe hundreds, maybe thousands) all over again PLUS another percentage that goes toward your out-of-pocket.

What’s a patient to do? With a nod to the current election year and the art of not actually answering questions, the answer is:   It depends.

If your symptoms are tolerable and if delaying surgery doesn’t put you in harm’s way, you can wait.  Often it makes sense to pay the majority of your out-of-pocket expenses, including your deductible, in January so that you have an entire 12 months in which to pay a lesser or, perhaps even zero, amount on your medical care.  You’re movin’ on up—all the way to Group A.

If your symptoms are tolerable, but your insurance plan is changing on January 1 to a high deductible health plan, and you have a $5,000 behemoth (I mean deductible) hanging over your head, you may want to have it now.

I’m captain of this vessel right now.  My family deductible is met, but I still have to pay 20% of the next $5,000 on my out-of-pocket.  My husband needs an MRI, but it’s not emergent.  Do we pay approximately $400 co-insurance now, in November; or do we pay a $2,000 deductible in January knowing that we then have all year in which to pay only 20% of his allowed medical charges?

I hope his back holds out.  I’ll be on this fence awhile.

Jill Cozart

Practice Manager, NIHW

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