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, we will continue to include all postoperative follow-up visits for up to 6 months after your surgery date at no additional charge.
After 6 months, any further visits will follow our out-of-network direct-pay rates.
We understand that every recovery is different. If you experience delays in healing or have a financial hardship, please contact us - we're happy to work with you to ensure you continue to receive the care you need.
As a courtesy during this transition, all UnitedHealthcare PPO patients will continue to receive discounted out-of-network rates 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 on or after October 1, 2025 (out-of-network): Your surgical fee includes all follow-up visits for at least 6 months after surgery, often extended to 9 months at no additional charge.
- For surgeries performed before October 1, 2025 (while in-network): We will also honor up to 6 months of follow-up visits at no additional charge, even though your original insurance benefit covered only 90 days.
After 6 months, any additional visits will follow our direct-pay out-of-network rates.
We know this transition can be confusing, so please don't hesitate to reach out if you're unsure whether your follow-up period is still covered - our team will gladly 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 UnitedHealthcare PPO network?
We are making this change to improve the quality, efficiency, and scheduling flexibility of surgical care.
By stepping out of restrictive insurance contracts, Dr. Sohn can provide a higher level of personalized treatment and operate at facilities best suited for each patient's needs-while maintaining transparency in pricing.
This change is also part of our long-term transition away from traditional insurance billing. Over time, insurance reimbursement models have made it harder for independent practices to provide the level of service and attention our patients deserve.
Our goal is not just to simplify billing, but to create a more sustainable way to deliver excellent care. By moving toward a direct-pay model, we can continue offering thoughtful, individualized treatment while keeping our focus on you-not the paperwork.
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