A Notice to Our Patients with UnitedHealthcare PPO Insurance
Effective October 1, 2025
Dr. Sohn and his team will no longer be in-network with UnitedHealthcare PPO plans. However, we are still happy to care for patients with UnitedHealthcare PPO insurance and will work with you to submit claims for reimbursement under your out-of-network (OON) benefits.
UnitedHealthcare PPO – Frequently Asked Questions
Q: Are you still seeing UnitedHealthcare PPO patients?
Yes. We are happy to continue seeing patients with UnitedHealthcare PPO. However, as of October 1, 2025, we are no longer in-network providers with UHC PPO.
Q: Will this increase my out-of-pocket costs?
Possibly. Because we are now out-of-network, your out-of-network deductible and coinsurance will apply instead of your in-network benefits. This often means higher out-of-pocket costs.
Some patients are surprised to learn they have separate in-network and out-of-network deductibles, and both may need to be met before reimbursement begins.
We strongly encourage you to call UHC before your visit or surgery and ask:
- "What is my out-of-network deductible?"
- "How much of it have I already met?"
- "What is my coinsurance rate for out-of-network services?"
Even with higher deductibles, many patients find the transparency and extended follow-up care we provide valuable. And whenever possible, we continue to use in-network hospitals and surgery centers to help lower your overall costs.
Q: What does this mean for my visits and surgery?
Clinic Visits
- All clinic visits (new and follow-up) are now billed as out-of-network.
- We collect payment in full at or before your visit.
- If your insurance allows, we will submit a claim on your behalf.
- If the insurer sends payment to you → you keep it.
- If the insurer sends payment to us → we refund you within 30 days, up to your PRA (Patient Responsibility Amount), minus any discounts or balances. Our office keeps any payment above your PRA.
If your plan does not allow us to submit claims - or if you prefer - we will provide superbills and itemized receipts for you to submit yourself.
Surgery
- We collect the Patient Responsibility Amount (PRA) - your contracted fee with us - in full before surgery. This is your maximum financial responsibility for Dr. Sohn’s surgeon’s fee.
- We will submit your claim to UHC whenever permitted.
- If UHC pays you directly → you keep the entire payment, even if it’s more than your PRA.
- If UHC pays us → we refund you within 30 days, up to your PRA, minus any discounts or balances. Any amount above your PRA is retained by our office.
Important: Prior authorization is required for many procedures but is never a guarantee of payment. Please see this page for more information about common patient responsibility (PRA) amounts for our services: https://www.sohnortho.com/direct-pay-and-out-of-network-care-shoulder-upper-limb-specialist-san-juan-capistrano/
Q: What if I had surgery with you while you were still in-network with UnitedHealthcare?
If your surgery took place while we were still in-network with UnitedHealthcare, your 90-day postoperative global period is fully covered under your prior in-network benefits.
After that 90-day period ends, any additional visits are considered follow up visits and will be billed under our out-of-network (OON) policy.
We understand this transition may feel frustrating, especially if your recovery extends beyond 90 days. We remain committed to supporting you through your full recovery - and we'll always be transparent about your visit costs before scheduling.
As a courtesy during this transition, UnitedHealthcare PPO patients will receive a discounted out-of-network rate through December 31, 2025.
(Please note: imaging, braces, or other supplies may still carry a separate fee.)
Q: How long are my follow-up visits included after surgery now?
- For surgeries performed after October 1, 2025 (out-of-network): Your surgical fee includes all follow-up visits for at least 6 months, often extended to 9 months at no additional charge.
- For surgeries performed before October 1, 2025 (in-network): Your follow-up visits were covered for 90 days after surgery. Once that period ends, any further visits will follow our out-of-network direct-pay rates.
As a courtesy, UnitedHealthcare PPO patients will continue to receive our discounted out-of-network rates through December 31, 2025.
We know this change can be confusing, so please reach out if you’re unsure whether your follow-up is still within the global period. Our team will confirm your status before your next visit.
Q: What parts of my care might still be covered by UHC?
Even though we are out-of-network for the surgeon’s fee, many aspects of your surgical episode may still be billed in-network, including:
- Hospital or surgery center facility fees
- Anesthesia services
- Many implants and surgical supplies
- Intraoperative imaging
Q: Does this change affect UnitedHealthcare HMO plans?
No. This change applies to UnitedHealthcare PPO plans only. If you have a UHC HMO plan and we are a participating provider, nothing changes - you remain in-network with us.
Q: Does this change affect patients with Medicare and UnitedHealthcare secondary insurance plans?
No. If Medicare is your primary insurance and UnitedHealthcare (or a subsidiary such as AARP) is your secondary insurance, nothing changes. We will continue to bill Medicare first, and any remaining balance will automatically be processed by your UnitedHealthcare secondary plan.
Q: Will you bill UnitedHealthcare for me?
Yes. We collect our fee at the time of service. When allowed by your plan, we will submit claims to UHC on your behalf.
- If UHC sends payment to you → you keep it.
- If UHC sends payment to us → we refund you within 30 days, up to your PRA (minus discounts and balances). Our office retains any amount above your PRA.
Q: How do I know if I’ll be reimbursed?
We recommend calling the number on the back of your insurance card and asking:
- "What are my out-of-network benefits for orthopedic care?"
- "What's my reimbursement rate for an office visit or surgical procedure?"
- "Will reimbursement be sent directly to me, or to my provider?"
Q: Why are you leaving the network?
UnitedHealthcare PPO’s reimbursement rates are not sustainable for our practice. This shift allows us to continue delivering excellent care, maintain transparent pricing, and reduce administrative delays for our patients.
Claim Form Resource
If you prefer to submit claims directly yourself, you can use the UnitedHealthcare Medical Claim Form:
https://member.uhc.com/myuhc/content/dam/myuhc/pdfs/claim-forms/CMS1500ClaimForm010402.pdf