Most Empire Plan enrollees know that surgery is covered by the plan when it’s medically necessary. You may not know, however, that there are limitations to what the plan will pay if your doctor does more than one surgical procedure during the same operation.

United HealthCare’s (UHC’s) payment for multiple surgeries follows Medicare guidelines and is considered standard practice in the health insurance industry. When multiple or bilateral surgical procedures that add significant time or complexity to your care are performed during the same operation, UHC will pay 100% of the allowance for the primary procedure (the more complex procedure) and 50% of the allowance for each secondary (less complex) procedure. There are a small number of surgical procedures where UHC will pay 100% for both, but these are the exceptions rather than the rule.

A secondary procedure that does not add significant time or complexity to your care, or which is considered an integral part of the primary procedure, is referred to as an incidental procedure. Examples include an incidental appendectomy, loosening (lysis) of adhesions, excision of previous scar, or puncture of a cyst. When an incidental procedure is performed, UHC will pay for the primary procedure only. No payment will be made for the incidental procedure.

Surgery is billed and reimbursed using a “global” fee. This means that the surgeon’s charges for normal, uncomplicated pre- and post-operative care are included with the charge for the surgical procedure itself. In turn, UHC’s allowance for the surgical procedure includes payment for all three components. Usually, surgeons will charge less for a secondary procedure because of the following: 1) little or no additional time is spent on pre-operative care and preparing the patient for a secondary procedure; 2) the surgeon spends less time on a secondary procedure if it’s performed through the same incision as the primary procedure; and 3) little or no additional time is spent on post-operative care for a secondary procedure. Consequently, UHC reduces payment to 50% of the allowance for a secondary procedure.

The benefit limitations for multiple surgeries will only affect you if your surgeon does not participate in the Empire Plan. If you plan to use a non-par surgeon for elective, non-emergency surgery, we strongly encourage you to submit a predetermination request to UHC so that you will know how much you will have to pay out-of-pocket before you actually have the surgery. You may call UHC at 1-800-942-4640 to request a predetermination form.