Insurance question for those who had out-of-state surgeries

Hi all! So, a short FIVE WEEKS after Dr. Hepworth sent the referral, I am finally scheduled to see Dr. Fargen in North Carolina for possible stenting. And now I have to worry about how it’s going to be paid for.

Those of you who have traveled out of state for surgery, how did your insurance coverage work? A doctor in North Carolina is obviously WAY out of network for me. Dr. Hepworth told me it would be no problem, that he and Dr. Fargen would both write letters and it would all be fine. Well, now Dr. Fargen’s office is telling me that they don’t get involved in insurance issues, and the girl I talked to at Dr. Hepworth’s office said “I guess you would just have to self pay.” To the tune of 100K+? Nope.

So I’m going to call Jenna at Dr. Hepworth’s office on Monday. But in the mean time, I’d like to hear how others did it. Did your insurance cover an out of state procedure? Was it a hassle to get it covered? Was it treated as out-of-network and subject to a different deductible than your in-network coverage? Did the doctor’s office handle it, or did you have to personally coordinate? I really can’t imagine trying to make something happen with Anthem, given that the only phone numbers I have go to very not helpful off shore call centers.

Thanks – don’t know what I’d do without this community!!


I haven’t had to deal w/ insurance out of state but I did work for a doctor’s ofc in the past. I think it’s awful that Dr. Fargen’s ofc has the “we don’t get involved” attitude about insurance. That’s wrong in my book! It may be that Dr. Fargen will be willing to write a letter to your insurance despite what his front ofc staff told you.

Often insurance will cover out of network care if the procedure you’re having done isn’t done by someone in your state. Since the type of stenting you’re getting done may not be done there, you have every reason to pursue a doctor elsewhere. Otherwise, you’ll need to rely on Dr. Hepworth & Dr. Fargen’s creative writing to justify your need to travel to NC for the surgery.


I’ve been speaking with both offices. Today Dr. Hepworth’s office told me he would write a letter. Meanwhile I spent the better part of an hour getting the run-around from Wake Forest, and have made no progress on that side beyond a vague promise that someone who knows more about this will call me. Right now I feel like the odds of my actually being out there in January are about 50/50/

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@ Bopper - I’m sorry the runaround continues!! Obviously the employees at these offices have no clue what it’s like to be debilitated by a health issue & how wonderful it would be to have the insurance & other issues w/ records transfers, etc., be straightforward. Maybe they are understaffed, but if that’s the case, they need to be honest about the time frame in which a person can expect to be contacted rather than giving a vague answer or a false promise.

I had surgery done out of state. My insurance has an “out of network” piece where I was able to call and speak to the billing department at the Drs office and then subsequently with the hospital that I had the surgery with. I was able to get it covered. We have high deductibles but was able to set up a reasonable payment arrangement. My surgery cost close to 90000. I had to pay 7000. And that’s only because I had moved prior to my surgery to a new state, had to start new insurance unfortunately and therefore start a new deductible. Hopefully this all makes sense. If not please feel free to reach out to me. Did it take a lot of phone calls and time, yes. But so did everything else that had to do with with getting to this point. Where there is a will, there is a way my friend. Best wishes to you.



First does your insurance allow you to go out of state? There should be a little suitcase on the lower right corner of your insurance card. This indicates you can travel. I would suggest you call your insurance company to confirm this as they like to change rules on Jan 1st.

This all depends on your insurance and whether you are in a PPO or HMO? If you are in a PPO and this doc isn’t in network it usually pays what insurance company considers to be “customary & reasonable” within the zip code the procedure is done in. ie: almost always will result in a higher copay or coinsurance amount.

You need to get the diagnosis codes and what is called CPT codes from he doctors office performing surgery then call your insurance company and see IF they will tell you how much they will pay (R & C). The hospital or surgery center will be a separate billing and likely anesthesiologist. Are these in-network or not. Some docs offices have great staff that knows the ins and outs of this but you likely need to do the leg work because with short staffing everywhere, some just are not plain motivated to help you. I would call back to Fargen’s office and ask to speak with Insurance Biller or office manager.

Dont trust anything front office staff tell you! They are notoriously lazy and ill informed and likely new. keep that in mind.

I can probably walk you thru this more if you need help. Just message me privately.


Thanks. It’s an HMO (there are zero PPO’s available in Colorado for individuals). There is a suitcase on my card. Right now Dr. Hepworth’s office is appealing to Anthem. But in the mean time, there has been a new development. Dr. Hepworth has identified a neurosurgeon in Denver who is starting to do jugular stenting. I am waiting for an appointment with him. If it worked out, it would be SO much better. He is actually in network for me.

I know – “Really, a guy just starting to do it?” But a) Dr. Hepworth trusts him. And b) he’s a very experienced neurosurgeon who’s apparently very proficient at brain stenting. So I wouldn’t think jugular stenting would be too far out of his wheel house. But we will see once I meet with him.


That sounds promising! :crossed_fingers:

Gotta love Dr. Hepworth & how well he takes care of his patients!! I’m really glad for you @Bopper & hope the more local surgeon is a go for you.

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