SAD ANGRY FRUSTRATED

First off, I realize that this is not the place to look for sympathy.  But I am so sad and angry that I am going to blow up!   I will try to make this short, but...........
No names.....Just Doc A, Doc B and Doc C.
Last summer, I had hoped to have RNY.   It was discovered that I had a LARGE hernia and my stomach was in my chest and part lying on my heart.  The Doc A didn't want to perform both repair and RNY due to the size of the repair needed.    OK,  I would trust this man with my life.  We discovered that he was the same man that saved my husband 28 yrs ago.   The surgery was alittle more than he had expected because my stomach had started attaching to the lining of my chest wall.     All of this was done lapriscopically   
  I drive a bus and had to go back to work, so RNY would be put off for a year
In this year, I had the opportunity to check into ALL of the WLS.  I went to  seminar......................Enter Doc B.      I was looking at the different types of WLS  that Doc A would not do.  Curious, I guess.     At this seminar, there was myself and 1 other person and Doc B.     Come to find out, Doc B assisted Doc A on my hernia surgery.  He does laproscopic and Doc A does not, so Doc B was called in.
I set up an appointment with Doc B to see what he had to say.  He informed me that a nisson was put in during last year's surgery for reflux.  Any pressure on the nisson would cause problems.  He recommended the DS and I was all for it until he and his nurse  annouced that they would not do this procedure under my insurance.  He wanted 12 grand up front.   I don't have it!      So I went to another seminar and met with Doc C.  He (finally) explained what a nisson was and that for VSG it would have to be undone and that more  than likely the reflux WOULD be worse.    hmmmm.
So I went back to Doc A and asked about the nisson and the RNY.  Doc A was quite upset that I had gone to the other 2 Docs.  He said that he had NOT done a nisson and why did I go to the other Docs.  I explained that I was looking at the other options  Doc A does not do laproscopic and only does open RNY and Band.  He wanted to know what I wanted from him.  And announced that since he knew how much scar tissue was there from last year, he would want money upfront over what  my insurance would pay.     Then he suggested that I go back to Doc B, maybe he would do it with just my insurance coverage!  I have an upper GI scheduled.  I asked him if he wanted the results to be sent to him.  He said NO and told me to send them elsewhere!  
I have always been told to look at all options and get more than 1 opinion.  Obviously, Doc A does not feel this way!
I am now out of time for ANY surgery this summer as I have to back to work in 1 month.       I am so sad and upset!  I couldn't even talk about this to anyone without crying.

Is it time to give up?  Everything happens for a reason.......Trying to figure out what it is.                      I am not looking for sympathy.  I am asking what do I do now!     The frustration is taking its toll on me and all around me    Did I do wrong by checking out other options

                                                                                         Sad and frustrated in Va,
                                                                                                           Diana.

Was Doc B Elariny?  He's the only one I know of in VA who does the DS, and he has an enormous "program fee" which I consider - well, I don't like it.

Now, let's take a step back: Doc A you kick to the curb - there is NOTHING to recommend him in the first damned place.  He's an asshole and he doesn't have the skills to give you ANY decent surgery AND he can't do it lap.

Now, let's move on to the surgery itself.  I of course think the DS is THE BEST WLS in the vast majority of cases.  I would move heaven and earth to get the DS over any other surgery.  So, let's just talk about that first.

Doc B thinks he can do a DS on you.  He was there - he said you have (because he gave it to you!) a Nissen fundoplication to fix the hiatal hernia, but that he thinks he can do a sleeve on you anyway(which you need for either the DS or as a stand-alone VSG).  I presume he's either going to take down the Nissen, and adjust things to make sure your hiatal hernia stays fixed, which I've heard of being done; or he's going to give you a "pork chop" shaped stomach, leaving the top a little larger to accomodate the Nissen (Walter Albert has this) and make the bottom narrow like a normal sleeve.  You should ask him how he plans to do this, just to be sure.

Doc C says he'd have to take down the Nissen to give you a VSG.  Obviously, he doesn't have Doc B's skills.  And if your BMI is over 45, I don't think you should settle for a ******up sleeve that he thinks will make your reflux bad again, AND still end up with inadequate weight loss.

Which brings us back to Doc B and his out-of-network charges and program fee.  Two possibilities here - the first is the one I would pursue.  Tell Doc B that you want to submit to your insurance FOR THE DS.  If your insurance says they don't cover it, then YOU APPEAL and FIGHT to get the DS under your in-network insurance rates.  You should be able to win.

That leaves just the @#$%^ program fee.  I don't know what to tell you about that, other than to (1) try to negotiate with him; or (2) get a loan to pay it.  You deserve the BEST surgery, and his fee is less than the price of a crappy used car.

Personally, if it were me, after I paid the fee and had surgery, I'd take him and his program fee to the state insurance commission as well as my insurance carrier, and to the local news as well, because he's using the program fee to collect more money than the contracted in-network rate and I personally think that's unethical.  MY OPINION, of course.

Oh and one more thing.  Just because this is elective surgery, in the sense that you could do it in a month or in two months, DOES NOT MEAN THAT YOU HAVE TO WAIT UNTIL NEXT SUMMER TO DO IT because of your job!  Would you put off getting your gall bladder out for 9 months?  Of course not - your health is at stake.  You will move forward to get your surgery planned, insurance authorization obtained, program fee paid, and when you have that in line, you tell your employer, too bad, so sad, I need surgery and you will have to find someone to temp until I'm ready to go back to work. 

Your life matters.

Thx for getting back to me so soon!  The doctor you speak of does his DS procedure under another company name than the rest of his surgeries.  One company is in network and the other is out network.  I called my insurance company and they verified that "HE" was in network and could not figure out how he could charge out of network fees.  The 12K was solely for out of network not his program fees.

My BMI is at a point that a DS is not covered unless I have the nisson.  It is 42.  I lost 32 lbs since the last surgery.    So if the nisson cannot be used as a problem with the other WLS, the DS is out now anyway.   I have the 6 mth thing done with the PCP.   It is good for 48 months, so at least that part is done.

And yes he was going to go under the nisson to create the sleeve, or as you put it, pork chop style.  But if no nisson, my BMI is too low for a DS

I WILL get there!  Somehow!

Not sure what you mean by "unless you have the Nissen" as a problem with the other weight loss surgeries - does that mean if Elariny can do a sleeve OR a DS, you can only get a VSG?  That doesn't sound right.

I would ask the insurance company to look into his billing practices.  I really hate this sneaky business, and I'm a lawyer (and while I'm licensed to practice in VA as well as CA, I only do patent law, so I can't help you with that). 

So is he going to charge you $12K PLUS his usual $4K or thereabouts program fee too?  Is he only going to give you a sleeve if you are in-network?  I am confused.

Diana,

I was under the assumption that they got away with these "program fees" by saying they were for post-op follow-up with NUTs etc...??

I paid fees to Dr Smith and to his surgical assistant in CASH which was the only way they would accept it.  But they didn't even try to pretend it was for some  kind of "program." 

~Becky

I'm not sure how they get away with it - other than that nobody has the balls to complain for fear of losing access to the surgeon afterwards.  I think the state Dept. of Insurance would be interested, as would their medical ethics boards and the insurance companies that have them under contract.  Probably the state attorney general too.

He has his Ds surgery under a different name because he is trying to double dip. He is cheating his patients and the insurance company.

It is unethical for him to not accept insurance for everything he does. He is essentially creating a "cash only" business for his WLS business so he can charge extra and not have to accept the amount the insurance co will pay.

I don't know what to tell you to do,but persionally,I would be hesitant to getinvolved with someone who is this unethical.

Have you considered going to Mexico? You can get excellent surgeons who are likely familiar with situations such as yours,for a frction of the cost on the US and some of them fund thru their offices.

good luck and don't wait till next summer...keep on moving thru it. You might have to go out of state...
Holly

Unfortunately, "Doc B" is the only DS surgeon in VA, and he is a good one (for the most part - I don't agree with all of his practices and I don't think he does revisions).  But this program fee thing sticks in my craw something fierce. 

And, there is another EXCELLENT DS surgeon who does the same **** and it makes me very unhappy about him, but I still recommend him because he has mad DS skilz.  And - I guess because he does this - he takes Medicare.  But he still requires the Medicare patients to come up with some significant amount of cash OUTSIDE of Medicare reimbursement.  I think that sucks.

It is illegal for this doctor to charge you extra money over what your insurance allows for payment.  This doctor signed a written contract with your insurance company to only accept what the insurance allows and the rest will be written off except for the (insurance company determined not doctor determined) out of pocket fees you would have.  If he is in network, he cannot charge you out of network fees.  He is bound by a contract!! 

I would confront him on this and warn him that you will be verifying this "extra" fee with your insurance company AND the insurance commissioner. 

In all honesty, at this point I would not trust Doc A to even touch me again.  But it's your body and your choice.

Good luck to you, I hope this all works out!

I'm thinking I may agree with Hazel here.  If your Doctor is a contracted provider, then he must accept the insurance allowable as payment.  However, if he is outside the network, the same rules would not apply as he is not under a contractual obligation to accept the allowable...