Well he has not had the surgery yet. He is scheduled for surgery on February 25.
What was explained to me from the insurance company (and followed up with a letter) is that because they do not have a PPO in the area and because this surgeon only practices at a certain hospital they will cover both the doctor and the hospital at the PPO level. Again at 90% vs 60% and yes that also includes the out of network fees.
They also said that because we did get a letter from them stating that it was medically necessary, we only have to cover the first $1000.00 out of pocket (due to family deductible) and that they will cover the rest 100%.
I have BC/BS of Ill. with a PPO. They have been extremely helpful, even suggesting the medical waiver. I was told if you find a nice representative make sure to get there name and always ask for them, or to have them call you back.
I hope some of this is helpful to you. Good Luck!