Combined Insured and Uninsured Surgical Services – How to Bill

From time to time a patient will elect to undergo an uninsured surgical procedure at the same time that he/she is scheduled for an insuredsurgical procedure.  Combining insured and uninsured surgical procedures is permissible where it is agreed to, in advance, by the surgical facility or hospital. When this does occur, however, complicated questions of billing often arise.

Although Manitoba Health will pay for all insured services the patient is responsible to pay for all aspects pertaining to the uninsured procedure, including the surgeon’s fee, the anesthesiologist fee, the surgical assistant’s fee (if utilized) and any fees that may be charged by the surgical facility or hospital. In most cases these can be broken down as follows:

  • Surgeon: The surgeon should submit a claim to Manitoba Health for the appropriate tariff for the insured surgical procedure.  The patient must be billed directly for any surgical fees related to the uninsured procedure.  This is usually a relatively straightforward matter of determining the fee for the uninsured surgery and advising the patient. Doctors Manitoba does not recommend that fees be “discounted” because the surgery is being done in conjunction with an insured procedure.
  • Anesthesiologist: Claiming for anesthetic procedural services is complicated because anesthetists bill based on time.  When insured and uninsured surgical procedures are rendered during the same operation the anesthetist should reduce the amount of the anesthetic procedural services time billed to Manitoba Health by the additional surgical time required for the uninsured procedure.  E.g., patient undergoes a combined insured /uninsured surgical procedure requiring a total of 165 minutes of anesthetic procedural services time.  The uninsured procedure requires 30 minutes of operating time. Claims to Manitoba Health should be for tariff 8515 Pre-anesthetic evaluationplus 135 minutes of anesthetic procedural service time.  The patient should be billed directly for the uninsured 30-minute portion of the operation.  Note that charges for the anesthetic services for an uninsured surgery do not necessarily need to be based on a time system.  It is acceptable for the patient to be charged a flat fee or a minimum fee for the provision of anesthetic services for the uninsured service.
  • Surgical Assistants:  If a surgical assistant is required to assist the surgeon for the insured surgical procedure, then the surgical assistant should submit a claim to Manitoba Health based on the total value of the insured surgical procedures rendered in accordance with the surgical assistant benefit schedule (page B-27).  The patient must be billed directly for any surgical assistant fees related to the uninsured surgery.
  • Surgical facility or hospital.  A surgical facility or hospital will often charge a flat fee for the use of the operating room, regardless of the specific nature of the uninsured procedure to be provided.  If the surgery is performed in a hospital, the patient will be charged a per diem for any post-operative admission arising from the uninsured procedure.  In addition, the patient is responsible for the cost of any surgical implants used for the uninsured procedure.

Uninsured surgical procedures are the one circumstance where a physician may request payment in advance of rendering the service.  You should, however, clearly explain your refund policies in the event the uninsured procedure is cancelled or could not be performed.  Facilities will also typically request payment in advance of the uninsured surgery.  (If the fee is not paid the uninsured portion of the surgery will usually be cancelled).

For the uninsured procedure, the patient is to be billed directly. In order to avoid disputes it is important that all costs associated with the procedure be disclosed and discussed with the patient prior to the services being rendered.  Because in many cases the surgeon is the primary contact with the patient prior to the procedure, it is advisable that he/she also inform the patient of the costs related to the facility and the anesthetist.

Questions?

Ian Foster
ifoster@docsmb.org
(204) 985-5854

Updated: November 2016