Out of Network Care/Insurance

Nicholas Fogelson, MD, LLC (DBA Northwest Endometriosis and Pelvic Surgery) is an out-of-network medical practice.

This means that while we are able to bill your insurance's out of network benefits to assist in the payment of some or all of your financial responsibility, we are not under contractual obligation with your insurance company to accept their negotiated and reduced payment rates.

Office rates are similar to average rates in our area, with new patient visits ranging from 350-450 dollars and return visits ranging from from 230 to 460 dollars. We often do an ultrasound at initial visits, which ranges from 100-240 dollars (usually 150). When patients have out of network benefits expected to pay some of these costs, we ask for a deposit of the expected amount of patient cost-share, after which we will invoice any residual amount of patient cost-share indicated by your insurance EOB. Cost-share amounts include your co-pay (if any), applicable deductible, and co-insurance, based on the amounts allowed by your insurer. If your insurance company allows less than our minimum cash rates, there may be some additional charges billed beyond your insurance company allowed charges. Patients without out of network coverage or who prefer to pay cash will be offered an approximately 30% discount from our insurance billed charges.

Surgical fees for endometriosis and other complex gynecologic surgeries vary depending on expected complexity of case. We set minimum fees for each surgery depending on expected time and complexity, which generally range from $4500 to $6500. Depending on your insurance coverage, we may ask for a deposit of a portion of the expected fees prior to surgery. After surgery we will bill your insurance for the costs of care based on our typical billed charges. In most cases, we will appeal claims several times to optimize your insurance's payment for your care. At the end of all appeals, we will invoice you for any remaining insurance cost share amounts. In cases where insurance allowed amounts do not meet our minimum fees, we will bill additionally to meet these minimums. As required by law, we are required to send a statement for all billed charges, which is in excess of our minimum required fees. We recognize that not all patients will be able to afford their full balance, and offer financial hardship and other discounts as needed. We do not retain a collections agency for post-deposit balances for surgical fees in most cases.

While most speciality practices will bill out of network for you, as an added value to you NWEPS retains a law firm to represent you in your medical claim with your insurance company. We have found that the support of this firm dramatically improves our ability to collect appropriate fees from your insurance company, thus reducing your financial exposure for the care you may require. In some cases, we are also able to apply to have your care treated as "in-network", called a GAP exception, particularly when there are no equivalent care providers within your care network. In cases of complex endometriosis, this is the case in many communities.

For patients who have high out of network deductibles where we do not expect to collect insurance payment for a service, our fees are set at the minimum fee for a given surgery (between $4500 and $6500 in most cases), with an option for patients to file their own insurance to apply towards their deductible.

So why are we out of network?

Commonly Asked Questions

1. My insurance is 100% paid up for out of network care. Why do I need to pay a deposit?

Your out of network benefits are based not only on your deductibles and co-pays/coinsurance, but also on what your insurance company will allow on a given service (the "allowed amount"). If your insurance company allows an amount that is above our minimum accepted amount for a surgery, you will only be responsible for insurance mandated co-pays/deductibles/coinsurance, as described by your plan. If your insurance company allows less than our minimum accepted amount for a surgery, you will be ultimately be responsible for the difference between this allowed amount and the minimum accepted amount for a surgery

2. What is the best insurance to get to pay for out of network surgery?

The best plans are large plans offered by large employers, or plans offered by state or federal government plans. The best payers for out of network claims in Oregon are Cigna, Aetna, some United Healthcare Plans (UCR based payments), State Governmental Plans (ie EBMS), and Federal BC/BS. Medium good plans are offered by Providence and MODA. The worst payers for out of network claims are Pacificsource, most commercial BC/BS plans, and some United Healthcare plans (Medicare based payments). If you are shopping on the individual market, there are basically no plans that offer good out of network coverage. Even if they have some coverage, they generally price claims very low and ultimately offer very low out of network assistance.

3. Why does my EOB for surgery show such a high patient responsibility?

We set our insurance billed charges similar to colleagues in the expert endometriosis world. Because endometriosis surgery is complex, our procedures often have many associated CPT codes, each with a different charge associated with it. In-network doctors do the same, but because they are contracted with the insurer to accept insurance rates, the excess between billed charges and what insurance allows is immediately written off and is never a patient responsibility. Furthermore, multiple procedure codes often have their fees immediately reduced by contractual reductions with insurance companies, and these immediate reductions do not occur when not in contract with insurance companies. While we are legally responsible to ultimately send a statement for all unpaid billed charges, we will routinely apply available write-downs to these amount, to the amount allowed by law.

4. I paid a deposit and my insurance paid the full allowed amount? Do I get a refund?

Sometimes. If there is a credit on your account after all insurance patient responsibility is paid (including unpaid billed charges), you are legally due a refund. We are not able to refund deposits when insurance allowed co-pays/deductibles/coinsurance is in excess of this deposit, even if insurance paid amounts are in excess of our minimum accepted fees for surgery. Refunds most commonly occur when another provider has absorbed some or all of your deductible / coinsurance, and the allowed amount for surgery exceeds our minimum accepted fees for surgery.

5. This is all super confusing and I don't get it.

It is super confusing and most people don't get it, because out of network billing is fundamentally complex. Each case is different depending on what is required and what coverage you have, and we will work with you to develop a mutually acceptable payment arrangement.

6. There is no one in my network that can provide expert level endometriosis care but I don't have good out of network benefits, or can't afford out of network cost share. Can I still see you?

Oftentimes the answer is yes. If we can document that there is no similarly trained expert endometriosis surgeon in your network (and geographical location), we may be able to get a GAP exception. If a GAP is approved, your carrier will process your claim using your in-network benefits. In some cases there are still additional fees that are not covered, depending on the carrier. If you would like to apply for a GAP, please contact us.