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Insurance Coverage for Houston ENT Procedures: Copays, Deductibles, and Network Coverage

June 13th, 2017 | 4 min. read

By Chuck Leider

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health insurance coverage for houston ent procedures


We all know health insurance is important to have, and chances are good that you have coverage. But do you really understand your coverage and what's on your policy? Just as important as it is to have health insurance, it's also important that you understand your coverage, especially with all the changes your insurer makes, such as higher deductibles, for instance.

A big concern to many patients when it comes to diagnostic and surgical procedures is whether or not their insurance will cover them. Here at Houston ENT & Allergy clinic, we offer

 a wide range of treatment options relating to conditions from sleep apnea and snoring to allergies and sinuses and there's a lot of testing and procedures that go along with your diagnosis. Procedures like this can be quite costly; therefore, if you're concerned about whether or not you're covered, it's a valid concern.


Does Insurance Cover Houston ENT Diagnostic and Surgical Procedures?


Typically, the answer is yes, and in some cases it depends. However, most insurance companies offer some form of reimbursement for diagnostic and surgical procedures. And, although it's almost impossible to know exactly what you can expect from your insurer and what they reimburse, Houston ENT is in a network with most commercial insurance carriers. This includes:

  • Medicare

  • Blue Cross Blue Shield (BCBS)

  • Aetna

  • Cigna

  • United Healthcare

To understand your policy, you need to know its terms and conditions, including deductibles, copays, specific testing protocols, out-of-pocket limits, coinsurance, and more. You may also be confused on some of the terms that are written in your policy and this could lead to you having to pay for a service that you thought was covered.

To help clarify,  below we have explained are a few of the common terms you’ll find on your health insurance policy.


In Network vs Out of Network Coverage


Your insurance provider will have its own network of approved doctors. When you select a doctor within this "network", you can receive discounted services and rates and save more money. In other words, if you choose a doctor inside our network, you'll save more on your hearing or ear & balance disorder procedures than you would if you went to a doctor outside this network.

This doesn't mean you're required to use any of the doctors in the network. You still have the option to find an out-of-network doctor. Just keep in mind, that if you do so, your reimbursements may be substantially lower.

If you've been referred to our clinic here at Houston ENT & Allergy or another specialist for a specific procedure, you should consult with your insurance provider first to see if that specialist is "in network" so your out-of-pocket costs will be minimal.


Insurance Deductibles

insurance deductibles houston

Your deductible is the amount of out-of-pocket money you pay for your medical costs before your health insurance coverage kicks in. For instance, if you have a $2,000 deductible and your procedure costs $3,000 and you have had no procedures done yet that year, you'll have to pay that $2,000 out-of-pocket first and your insurance will cover the other $1,000. This applies even if you choose an "in-network" doctor.







Your coinsurance, or insurance copays, is the percentage you’re responsible for your medical services after you've satisfied your deductible. The average coinsurance percentage is usually 80/20 where your insurer pays 80 percent of your medical bill and you pay the other 20 percent. Coinsurance percentages can differ with insurance companies, so be sure to check your policy ahead of time so you know how much money to bring with you.




out of pocket expensesin houston healthcareThis is the maximum amount you'll be responsible for out of pocket for your medical expenses for that year. Most insurance policies start off with a deductible that needs to be met, then a coinsurance up to a certain amount (20 percent of the bill). Once you've reached that amount and have paid your maximum out-of-pocket amount, your insurer will begin covering your medical expenses 100 percent thereafter.

So, if you have a facial & plastic surgery procedure done by Houston ENT & Allergy services at the beginning of the year, you can expect to pay a little more than if you've met your deductible and out-of-pocket expenses limit. If you have paid out the maximum limits, your insurance company should pay your medical bill in full, depending on your policy.




Cash Pay


After reviewing your insurance coverages, you may decide that it's cheaper for you to pay in cash than putting the expenses on your health insurance. We even offer you a discounted rate for cash payments so you can take advantage of our services for a cheaper cost. This is also good for people who don't have health insurance. 

Also, clients of Houston ENT can also use Care Credit to pay for their higher deductibles. Care Credit makes it easy and convenient for you to access medical care.



Things to Consider about your Health Care Coverage


There might be times where your insurance company rejects paying for a test or procedure. This is usually if they deem it unnecessary medically. Even if your physician says it's important medical necessity insurance coverage houston entthat you have a test done, your insurance company might not agree. Your insurance company might agree to one specific test over another. Only once your doctor reviews this test and then insists the initial test is necessary, will your insurance company agree to pay for the test. 

There are specific guidelines your health insurance company puts in place for different procedures. These guidelines may take into account things like past medical history and comorbidities. It's always wise to call your insurance company if you're unclear about coverage and ask what the steps are for a pre-determination before having the procedure done. 

You can always ask our Houston ENT & Allergy clinic to verify your insurance and draft up a price quote for you before you have the testing or procedure done. This is an estimate of what your payment responsibility would be and isn't a definitive price.




A few things to remember here include:

  • Learn as much as you can about your health insurance possible including your rates, covered services, deductibles, copays, coinsurance and out-of-pocket expenses.

  • If your doctor refers you to us or another specialist, be sure to check and if they’re in-network with your insurer.

  • You’ll have to meet your deductible before your insurance kicks in.

  • Check and see if your out-of-pocket expenses include your deductible.

If you are in need of a diagnostic test or procedure and have already contacted your insurance company about your coverage, call us here at Houston ENT & Allergy Services to set up your appointment. We’ll be happy to sit down with you and discuss your healthcare and insurance needs before your procedure.


Request An Appointment with Houston ENT & Allergy Today!