Hi Martin,

Can you please help the few of us who are considering going to UPMC in the near future, What would be your recommendation’s on what to expect? Like:

How long was the first evaluation? One day?

How treatment is managed if you're from another area or from another state?

How much was your initial deductible or total cost? At least if you can, give us a ballpark, so we can have an idea of the cost. That would help us a lot.

Feel free to add any other suggestions.

Thank you.

I can tell you that your deductible will be based on the health plan you have . Many plans will not cover out of network evaluation and treatment like UPMC. Some plans have a stricter definition of 'medically necessary' than others.

Some plans have a very high deductible for out of network care compared to local, in-network care.

So, your first effort should be to read your Health Plan Benefits manual. Pay attention to medical care vs mental health counseling/therapy vs physical/occupational/vestibular therapy. A Neuro Psych is not usually considered medical care. The deductibles and co-pays can be higher and have a limited benefit amount.

It can get very disturbing to see bills after the fact when one did not plan ahead. Even planning ahead can leave one in a mine field.

Totally agree with you, Mark. It is complicated to calculate the cost of health care, especially for therapy, etc.

You can still manage to get an estimation of the cost from a former patient. What we all know is that UPMC must be expensive, but how much?

Hopefully we won’t get sticker shock with the answer…lol

I suggest you call UPMC and talk to them about the common services and treatments they provide to someone with your range of symptoms. They should be able to give you the CPT (procedure) codes. Then, you can call the billing department and ask what the fees are for those codes.

Many never see the direct costs, just the part they need to pay. Plus, the costs they may see are the 'list prices' that can be twice what the real amount they accept as payment are.

I've been dealing with three surgeries in the past 4 months and making sense of a bill takes an accounting degree. EOBs (Explanation of Benefits) will show the gross (list price) amount, what the insurance paid and the amount owed by the insured. So, you need to add up the amount the insurance paid and the amount the insured owes to get the amount the provide will likely accept.

If your insurance is not good, you can check out the prices Medicare pays for the various CPT codes and expect to have to add 60% to that amount to get to an amount they will likely accept. There are health plans that do not use networks, that use this Medicare plus 50, 60 or 70% price structure to pay providers. Here is a link to the CMS fee schedule. Click ACCEPT and the next page has a CPT based fee lookup. Choose all modifiers. You can look up your locale and enter it, too. This can give you a starting point.

Called today a few times with no luck and left a message. I know the drill with clinics, so I know it will take patience and a little luck to talk to the right person.

Nevertheless, I will follow your approach. Thanks.

Mark you had three surgeries? Or a family member? Wow! Either way, I hope everything is ok.

Two surgeries for me in October. A nasal rebuild (deviated septum and turbinoplasty) and a shoulder scope and repair. Both went fine except the shoulder is still a problem. Sorting out the nasal bill was easy but cost me $200 more than I was told it would. The shoulder surgery bill was a mess.

My wife had one surgery in January and is headed for a second surgery next week. Had to change health plans to get the specialists she needs. Prior health plan refused to refer her to an out of network specialist. Fortunately, she had an open enrollment period that ended Feb 29. We took advantage and got her better coverage.

So, I have become an expert at understanding how providers bill and how insurance companies pay. I also learned a lot about how insurance companies define medical necessity so they can avoid the specialists.

Wow, thank God you seem to be ok after all those health challenges. I will keep both, you and your wife in my prayers.

You’re definitely the go to guy.

The deviate septum was likely from my concussion bike accident in 1965. It was causing trouble with our Idaho dry humidity during the winter (nose bleeds, etc). Now, I can finally breath without restriction. The shoulder was an accumulation since the 1970's and an injury 2 years ago just pushed me to get it fixed. At this point, that was a mistake. I was better before the shoulder surgery. Maybe more time will help.

Thanks for your prayers. We need them.

wow..No problem!

Hi Javier,

Yes, I can help with this.

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How long was the first evaluation? One day?
* Yes. It takes about 5-6 hours to see everyone. Bring a lunch!

How treatment is managed if you're from another area or from another state?
* I was given an at-home physical and vestibular therapy program to follow. I am attaching the physical therapy instructions I got. I don't have a copy of the vestibular. But keep in mind, that every concussion is different and these exercises might be totally wrong for you. It should give you an idea though.

How much was your initial deductible or total cost? At least if you can, give us a ballpark, so we can have an idea of the cost. That would help us a lot.
* I paid about 3 copays, which for me were 35 each. I had already met my deductible for the year, so that was all I had to pay. When you call them they will ask for your insurance and make sure you are covered. Between them and calling your insurance company (my wife did it for me because I was in no shape to figure that out), you should be able to figure out your total out of pocket costs.

Hope this helps!
Martin

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