Preparing for surgery, \'90s style: caveat emptor.

by Jeff Siegel

You've been told you need surgery. The good news is that it will only take a day, and you won't have to spend the night in the hospital. The bad news is that it will only take a day, and you won't be allowed to spend a night in the hospital. Welcome to the brave new world of medicine in the '90s, where medical decisions are often based on what type of insurance you carry.

Lynne Kleinpeter had two shocks when her Ob-Gyn told her she needed surgery to remove a diseased ovary. The first was the news itself. The second was discovering how many decisions about her surgery would be made by her insurance company, not by her doctor.

"I didn't realize how much things had changed," says Kleinpeter, a Dallas travel agent. "The last time I had to deal with an insurance company, it was to send in the form and wait for the check. They just don't do it that way anymore."

Kleinpeter's discovery is one of the cornerstones of the brave new world of medicine in the '90s, where medical decisions are frequently made not for medical reasons, but by what kind of insurance you have. Whether that concept is good or bad is a subject for another time; what's important here is that you understand that the new system exists. And there are things you can do to make sure you get the best medical care possible. There are questions to ask, requests to make, and subjects to research.

What you shouldn't do, says Andy Lumpkin, the benefits manager at Southern Methodist University in Dallas and someone who has to explain these options daily, is to assume everything will just work out by itself.

"The days are long gone when you can lay back and let the doctor take care of everything," he says. "The patient needs to be more in charge and control of their medical decisions as they relate to insurance. Most importantly, you have to ask questions."

That's something that Kleinpeter learned as she went along. A host of issues that never occurred to her turned out to be important, including such seemingly innocuous subjects as where she filled her prescriptions and who chose her anesthesiologist. That's because everything that's involved with any kind of surgery is defined by what kind of insurance policy you have.

The traditional 80/20 plan, in which you made a claim and received a check for 80 percent of the medical bill less your deductible, is as much an anachronism as the blacksmith. Today, almost every medical insurance policy is either a PPO or an HMO.

A Preferred Provider Organization (PPO) allows you to choose a doctor from the list provided by your insurance company. You can select a doctor who isn't on the list, but your insurance won't pay as much of the doctor's bill. In a Health Maintenance Organization (HMO) your choices are even more limited. You choose your HMO, which then provides you with a primary care provider and other specialists.

Nevertheless, each insurance system operates in a number of similar ways. The most important revolves around what the insurance companies call cost "containment". With any surgery, containment begins with an insurance company review of your situation to see whether surgery is necessary, says James J. Unland, the president of the Health Capital Group in Chicago. Unland is the author of 15 books on the managed care industry, and a leading consultant in the field. Says Unland: "Some of this review is good, especially if it keeps doctors from churning out patients who don't necessarily need surgery. There's nothing wrong with transferring some of these medical decisions to a more rational mode."

Problems may crop up, however, if your doctor says surgery is necessary and the insurance company disagrees. Usually, say the experts, this happens when the insurance company wants to wait and see if the problem will clear up without surgery.

That wasn't the case with Kleinpeter's ovary. Her doctor and her insurance company were in agreement. A cyst had formed on the left ovary, and it had to come out. But that was only the first decision that had to be made.

"Don't assume that everything is going to happen magically and mysteriously because doctors are involved," says Lumpkin. "It's important to ask questions and to know what your options are."

The first thing you should do after the decision to have surgery has been made is to contact your insurance company or the insurance liaison where you work. Learn what is and what isn't covered by your policy. One of the advantages is that the major providers are more helpful in these situations than ever before. They will not only answer questions, but do so mostly in English and not in insurance-speak. In Kleinpeter's case, most of the paperwork was done ahead of time. All she had to do was show up and answer a few questions about her health.

The issues you need to be aware of are, say the experts, include:

You ask how much a car costs when you buy it, so why not surgery? This may be only an estimate from your doctor, but it's still better than waking up afterward to discover that your former gall bladder cost as much as a new luxury vehicle. Also, make sure to find out not only whether your deductible applies, but how much of the surgery insurance will pay for. Finally, find out when everyone expects to be paid. As a general rule, you will pay the hospital or surgery facility when you leave, and your doctors will usually bill you.

If you're the least bit mobile when your surgery is over, don't expect to spend a night in the hospital. That's one of the easiest, and most expensive, costs to contain. Kleinpeter, for example, went in at 8 AM and was home by 3 PM. If this bothers you, ask your health care provider about other options. For instance, your insurance may not pay for a night in the hospital, but it may pay for a nurse or home health aide to stop by and check on you that evening. At the very least, make sure your health care practitioner calls to ask how you're doing, and that someone else is home to talk to him or her to report on how you're feeling. You may be too groggy from pain killers to have a coherent conversation.

Two things are important, says Lumpkin, and they depend on whether you're in a PPO or an HMO. If you're in a PPO, make sure any specialist -- surgeon, radiologist, anesthesiologist, etc. -- that takes care of you is on your PPO's provider list. Otherwise, your insurance will pay less of the specialist's fee -- usually 60 percent instead of 80 percent. If you're in an HMO, and you don't like the specialist the HMO assigns, you can ask for another one. Really.

Don't expect anyone-- your health care provider or your specialist or your insurance company--to know anything about you unless you tell them. There are dozens of these sorts of items. Do you have dentures? If so, let the anesthesiologist know, because dentures can present a problem when you're being put under. Will you need prescriptions afterward? Ask beforehand, because you're out of luck if your insurance uses a mail-order company and you need something just hours after your procedure.

"What you have to realize," says Unland, "is that there have been so many legitimate advances in medical technology that many of the changes we're talking about, like day surgery, are good medicine. The damage occurs when these advances are used as a means to an end for the insurance company and its stockholders."

But that won't be a problem as long as you remember that it's your body, and you have the final say -- regardless of what kind of insurance policy you have.