Question:
Tricare approved LBL, now surgeon won't perform

Tricare approved my LBL and my surgeon called me with the 'good news/bad news'. Seems Tricare hasn't paid them for several procedures over a several month period and even though the surgeon's office is a participating provider for Tricare, Tricare's reimbursement is so minimal ($660 on a $7500 surgeon's fee) that it isn't worth their liability for this kind of payment. Can't say I blame them at all! Any recourse for me that you know of?    — Vicki S. (posted on November 9, 2003)

November 9, 2003
Your doctor is in violation of his contract with the insurance carrier. Payments are negotiated. He must have agreed to that reimbursement. You need to contact your insurance carrier and tell them that the surgeon will not perform the surgery due to the low reimbursement he had contracted for. They should contact the Provider rep and they should try to resolve the issue with the doctor office for you. If they can't, they should give you information on how to file a formal grievance. If the doctor didn't like the reimbursement he shouldn't have signed the contract. Good Luck! Lisa open rny 4/26/02 -155lbs
   — LisaTaz

November 9, 2003
Hi Vicki: If you don't feel like waiting while they work this all out, you can also ask for another preferred provider and have tricare switch the approval to that doctor. Talk to the people at Tricare and tell them you want the approval to be transferred and how it wouldn't be fair for them to have you wait while the new surgeon has to completely resubmit the preapproval. I switched surgeons and thought they'd transfer and they won't. I am waiting the three weeks it'll take to be approved again, and that's ok since this was my choice. But since this is a provider who isn't following the agreement, then tricare should be willing to transfer so you get to have the surgery close to the time you would have, had things gone as it should have. I hope that makes sense. :o) Sherry
   — sherry hedgecock

November 9, 2003
Makes you wonder why they even submitted to insurance if they had no intention of accepting it????! Like someone else said, they already KNEW what they were going to get paid - its contracted with the insurance company.
   — Shelly S.

November 9, 2003
I had my tt approved under one doctor and then switched to another doctor. All I had to do was call the insurance company and tell them to change the doctor's name. You don't have to go through the approval process again. However, it seems this provider is only in it for the money. I would be more concerned about the type of work he does if all he cares about is his reimbursement level. I'm sure you'll probably need more work done by him that won't be covered by the insurance. Therefore, he will have a repeat customer and he gets the FULL price that he charges on those procedures since the insurance won't pay for it. I don't feel real sorry for plastic surgeons. The majority of the time, their ENTIRE charge is paid in full to them by the patient before the surgery even takes place. Trust me, I've seen how much they make and there making a bundle!!
   — Patty H.

November 13, 2003
Sorry to sound stupid, but what is an LBL? It sounds like a plastic surgery. I also have Tricare. How did you get it approved and what were their requirements? Thanks so much for your time. Sorry that I didn't have an answer. -Kristi
   — Kristi B.

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