Question:
Out of pocket fee's for assistant doctors is bull
I have been looking into the WLS for a long time, My husband finally got good insurance and I wanted to make a appointment with Dr. Capella in New Jersey for the first week of July when my insurance takes affect, but to find out I would need $2,000 for his assistant because he doesnt take my insurance, but I cant afford to do that because I have a out of pocket fee for the hospital of 2500, well I have now looked all morning on just about every web page to find a doctor who takes my insurance and his assistant and found that EVERY doctors assistant doesnt take the same insurances as the head doctor or partner, how odd is that. how well planned are these doctors, I am sure they split the cash, and say they dont cause the insurance pays the other which I'm sure the assistant get a dib of that as well. the doctors that dont take this extra fee are the ones that have high mortaility rates. it sickens me that I want Dr Capella so bad and I have to pay his assistant 2000 to learn what dr. capella would be doing to me. shouldnt it be a law that 2 or more doctors in the same office should have to accept and particapate in the same insurance?, I think so — kellisobo (posted on June 1, 2006)
June 1, 2006
Is this a hospital with a Bariatric clinic? If not, maybe look for one of
those. That is indeed CRAZY! What does this assistant do? If the
assistant is not an MD, the Dr. Capella should be paying the assistant,
especially if this assistant works with Dr. Capella on all of these
surgeries. Sounds like just another way for somebody to make money.
Thanks for the info, that is one thing I'm going to ask my surgeon when I
see him next month.
There is a physician here in the Washington, DC area and I would like him
to do my procedure, however, he doesn't accept CIGNA. Oh well, there are
others.
Check your insurance companies website and see what the requirements around
the surgery is going to be. You shouldn't have to pay an out of pocket
hospital fee either if the insurance is going to cover the surgery.
Insurance companies are starting to certify Bariatric clinics and the
insurance you and your husband are finally getting may do just that. I'd
check the insurance website before putting any money out and check for
Hospitals in NJ that have Bariatric Clinics in them. This way, the clinic
is part of the hospital and the surgeons and staff work for the hospital.
— the7thdean
June 1, 2006
Hi Kelli - I just experienced this myself. I received a notice from my
insurance telling me that the surgeons's assistant was not a designated
provider. I called my doctor's insurance coordinator immediately. She
said that it was wrong - that in the state of California a doctor in
REQUIRED to have an assistant surgeon in the operating room or else he
can't operate. Basically she said that they come as a package deal and
insurance companies cannot single out one and not pay the other for the
exact same procedure. She told me not to worry, that she would handle it
and that if my insurance persisted in denying payment that my doctor would
write it off rather than stick me with an extra bill that I shouldn't have
to pay. Call your surgeon's insurance coordinator (all offices have one
and they are experts) and ask if New Jersey has that same law, and if so
the lead surgeon and his assistant cost should both be covered if your
procedure was authorized and your surgeon is a designated provider. Hang
in there! This is something you can fight and probably win. I had to
fight my insurance just to get my surgery covered at all. I was persistant
and wouldn't take no for an answer. My health was at stake! Six months
later I had the coverage and not only for me. They changed their policy,
so I paved the way for others, too. What a thrill that was! Fight this,
Kelli. I bet you'll win. I had my surgery 3-8-06 and am already down 70
lbs.!! WOO HOO! This is the best thing I've ever done for myself and I'b
be willing to bet you'll feel the same way, too.
— Catrina
June 1, 2006
Sometimes, depending on the type of insurance you have (plan) you have to
meet deductibles, like for prescriptions and/or hospital, once you meet
that deductible then the insurance picks up the rest. For example, I had a
$2,500 deductible for hospital overnight stays, when I had my 3rd child I
had to pay the hospital $2,500, then the insurance picked up the rest. With
having deductibles with your insurance, the higher your deductible the
lower your monthlty premium. We recently switch, to a plan so we don't
have to meet any deductibles. But we pay a very high premium every month
for it. Hope this helps....Marcy
— need2loose4me
June 1, 2006
I thank everyone for all the emails, My most recent one someone explained
about the premiums and deductibles, but I couldnt email them back, but in
regards to that email, I do have Great insurance thats why I was so excited
that I can get the doctor I wanted and it covered everything, NOTTT the
assistant : ( I pay a very high premium every two weeks to get low
co-pays, as far as the deductible I have a 200.00 which is low and great
and the $2500 I do have to meet the 1 time hospital stay deductible like
you had stated but after that I am covered 100%, I did pick the best plan
my husbands company offered.
Another email was that I should look into seeing about the insurance paying
one doctor in the surgery room, with that said the head surgeon should be
paying HIS assistant. I will now look into this with great depth, and seek
council and see what can be done and or how it should be or is, if this
makes sence. I am now on a search for a another doctor and am trying now to
keep closer to my home in Sayreville, NJ which is Middlesex County, I do
have some doctors around but didnt want to just settle on any JO. also I
see some doctors are making people become a member for 700.00 and up to
2000 to there group what is this, this is all so crazy, someone needs to
Tame these doctors. our insurance is covering these WLS's and they are
still getting cash from us in sneaky little ways. well wish me luck because
I will be on the phone most of the day trying to find out as much law as I
can that pertains to this
— kellisobo
June 2, 2006
Kelli, it is becoming more and more common for surgeons to charge a program
fee. It's not that they aren't making money, but you have to remember, the
surgeon is paying rent for the office, utilities, paying the office staff
(and if they work after hours, or overtime to teach classes or run
informational meetings or support groups, that costs money, too.) They have
to process a tremendous amount of paperwork and keep it all straight with
multiple insurance companies. If you get printed materals, that costs
money, too. Last, but not least, what you see on the bill as "billed
charges" for the surgeon, is nowhere near what he actually gets paid
from the insurance companies that he contracts with. I do agree with the
poster that said the assistant surgeon should be covered under the fees.
And I also believe there is an assistant surgeon on most cases. (I'm in
Ohio and I know there was one there when I had my lap RNY.) The assistant
surgeon may also be covered under the hospital fee portion of the surgery.
— koogy
June 2, 2006
Kelli,
I have been in healthcare billing and collections for over 20 years and am
quite a pain when it comes to my own bills and coverage. I've learned that
the squeakest wheel definitely gets the oil when it comes to dealing with
insurance, appeals, etc...and that if you don't get the answer you want
from one rep, go to another, then go to a supervisor, manager, etc.
Utilize the appeals departments because on average, 50% of initial
submissions over $2000 get denied or only partially paid for various
reasons (giving the insurance industry the opportunity to 'float' the funds
to obtain more interest until an appeal is made/paid, or hope that people
take their determination as 'gospel' and never bother pursuing additional
payment.
With that said, the best approach is to let your insurance provider know
that you have no say in your doctor's choice of an assistant...just as you
have no say in your anesthisologist, or any other consulting doctors on the
case. In 95% of the cases, the insurance companies will consider the
'other' doctors 'in-network' if you have chosen a hospital and your primary
surgeon that are in-network with your insurance company. Most claims are
processed automatically when submitted electronically and if the numbers
don't match their provider data base then they get paid at out-of-network
rates. This will probably happen even if you do get approval prior to your
surgery to have it processed in-network. Just call and contest it. It
will then have to be manually reprocessed. You can also ask to have a case
manager assigned to your case since it is elective (and expensive) surgery.
Sometimes the insurance companies will do this for chronic care patients,
or high dollar surgeries/therapies. This will be a nurse (ususally) that
works for the insurance company and is assigned to your case. She/he will
negotiate rates with non-contracted providers. Good luck...and don't give
up (or in). I'm from NJ and heard Dr. Cappella is very good. I had my
surgery by Dr. Elliot Goodman at Holy Name Hospital in Teaneck. If Dr.
Capella doesn't work out for you, you may want to try Dr. Goodman. He and
his staff are excellent, very professional, timely, as well as the staff at
Holy Name Hospital. He has a tremendous amount of experience, and many of
his nursing/office staff are former gastic by-pass patients...so they have
intimate knowledge of your fears, concerns, etc. They were also very good
at handling all the insurance approvals. Good luck and please feel free to
email me if you have any questions.
— angelav
June 4, 2006
I have a question for you, would you work for free? So why do you think the
assistant surgeon should? All surgeries always have at least 1 surgeon to
assist, it always helps to have extra sets of hands especially with
morbidly obese patients, everything from positioning them to inserting
instruments is more work because of their extra bulk and weight. Each
surgeon is independent and they don't work for each other, one is not the
boss of the other, so they don't split any fees. Doctors aren't mandated to
accept insurances. The decision to accept or not accept insurance is
decided between each insurance co. and each individual doctor, they have a
contract. Just because the doctors share office space means nothing other
than they share space, no payment sharing or insurance reimbursement is
implied. As you are aware of increasing costs and lack of reimbursement
more and more doctors will not deal with any insurance companies and you
pay the doctor yourself. Your best choice
is to start saving your money because you will probably have at least 6
months until you can be operated on, you will need visits with dieticians,
psychologist, surgeon, medical doctor, maybe a sleep study and hopefully a
cardiologist and pulmonary doctor, and you may need 6 months of physician
supervised weight loss attempt before your information can be submitted to
the insurance company for approval. As you have discovered having health
insurance is not a free ride anymore and patients are expected to pay for
more of their health care costs than ever before and this will only
increase as time goes by. You may not like that you have to pay, but its
how it is, and there is no way around it. Honestly if your finances are as
bad as you indicate you may honestly not be able to afford to have WLS and
may need to rethink this. It's just not the surgery costs, but you will
always have doctor visits, copays, prescriptions, vitamins and supplements,
deductibles ,healthy high protein food choices, gym memberships to pay for
the rest of your life, all of these are costs associated with WLS. As
someone who has worked in healthcare finance & nursing for close to 20
years I've seen alot and learned alot about how the healthcare system
works.WLS is alot of work and it's not magic, your weight loss and
continued weight loss maintanence depend on how hard you are willing to
work at it, eat properly, exercise and be concious of and change the
behaviors that made you MO in the first place. I'm not trying to be mean
to you but I think you should be aware of the facts as they really are.
Its alot more work to go through WLS and be a sucess long term than it is
to remain MO, unfortunately not everyone realized it and is up to the
challenge. Can you get a part time job to save some $ for your surgery
fees?
Best of Luck
— goldroses
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