Not Covered by Insurance

Well I knew it was too good to be true. I received a call from my surgeon's office inquiring about a bill in the amount of $4000.00. I was pretty taken by such a request. The office person stated to me that the insurance company paid the claim to me in Dec 04. I immediately called to insurance company who claims to have paid the claim to me. Of course I informed them that they are mistaken and that I did not receive a $4000.00 check from anybody let alone the Empire Plan. Well in the midst of my investigation I found out that my surgeon was an out of network provider and that I would be financially responsible for the services rendered. Now my question is, why did my insurance company or my surgeon's office prior to providing service not inform me? Is that not what the pre approval process is for? There are plenty of surgeons in my network even some in the same office that could have performed the service without the financial responsibility that I must now incur. I have submitted an appeal on the claim to the insurance company in hopes that they will pay the entire claim as communicated to me. This has definitely skewed my perception of the Center for Obesity Surgery (Orchard Surgical) at the Hospital of Saint Raphael's. I definitely will edit my glowing comments about that organization. I have been contacted by so many in the Greater New Haven area about that facility and practice and have until now given such great comments and resounding recommendations to use that facility and that practice in particular. I surly would not feel comfortable now giving such a spectacular recommendation. It is a shame that such great work by a wonderful surgeon is over shadowed by this type of event, but that is a part of the complete package and what you will be faced with when selecting a surgeon. I will keep you posted on this terribly disheartening situation.

I am so sorry to hear of your trouble, but I too thought that's what the whole pre-approval process was for. Your heart must have hit the floor when you were told this. I hope everything works out for you, I'll keep my fingers and toes crossed that your appeal goes well. Patty

Oh, I can tell your stores about Empire BC! Dealing with them was one of the most challenging things I've ever done. Since my surgeon was out of network (it seems they usually are), I had to pay 20% of the cost out of pocket. It wasn't quite $4k, but it was at least half of that, not to mention all the co-pays for tests and other pre-op visits. The only positve financial aspect of this is that you can claim it on your taxes if you make under $70K or so a year. I would still have had the operation done. But when they preapproved me, there was no mention that they were pre-approving me for only 80% of the cost. Looking at it in a positive light, I guess this is still better than not covering it all. --Steve

Frenchy, I am so sorry you are going through this ordeal. I dont understand why your insurance and also your doctor's office is ridiculous. I mean if they knew that you would be responsible and there was others surgeon in the same office that could do this surgery without you having to pay anything. That is hogwash and someone should have explained this to you. I hope everything turns out because it would have been better for your surgeons office to tell u then to leave u in the dark. Toya

Dear Frenchy, I am very sorry that you have to deal with this type of BS. Excuse my language. I wonder though, you did mention that the Center was so wonderful and that there were doctors within the office that were on the list, if they couldn't submit the claim again slightly differently. Maybe someone doing the paperwork didn't do it properly. Oh gosh, I hope I do not aggrevate you more. I just don't want you to have to be burdened with this bill now. Best wishes to you...Kelly

Make an appointment with the Dr. and advise him of what has ahppened. Insist that he and the insurance company work out the details. I believe there is a process in place where a normally out of plan surgeon would be compensated the same value as an in plan surgeon. Don't give up yet. It is remarkable that an insurance company can negotiate with a Dr for services and they take what is offered, but when "private pay" They not only charge whatever they desire, but will take you to court if it is not paid OR will not perform the prodecure if full payment is not made before hand. Can anyone say "business"? Peter