Post op insurance nightmare

on 6/15/11 12:08 pm
 Had surgery and went great but also planned on having gallbladder and hernia surgery done at same time as WLS and now insurance has bundled all hospital bills as WLS instead of dividing out which would be a much much lower bill for me as my insurance only pays 60% of surgery and no out of pocket maximum.  Anyone else with this sane issue.  Was you able to appeal and get them to separate charges?  I will have to pay around 15,000 for this now after insurance since they lumped all 3 surgies into 1.  Should of only had to pay around 5,000.  Any help would be appreciated.
(deactivated member)
on 6/15/11 1:47 pm - San Jose, CA

How about asking your surgeon's office to RESUBMIT the claim properly, with each procedure broken out the way they are supposed to be?

Dave Chambers
on 6/15/11 3:04 pm - Mira Loma, CA
Ask your surgeon's billing person to examine how the surgery was billed.  I know my surgeon routinely tests for gallbladder issues and removes ones that exhibit issues.  I know he has repaired hernias also. Never heard any complaints from these people at support meetings, where I actually heard about all of these surgeries being done at the same time.  Medical necessity is probably the wording needed.  Maybe they coded part of this as elective surgery?  Call your surgeon's office ASAP. DAVE

Dave Chambers, 6'3" tall, 365 before RNY, 185 low, 200 currently. My profile page: product reviews, tips for your journey, hi protein snacks, hi potency delicious green tea, and personal web site.
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on 6/16/11 1:36 pm
 Thanks for all the advise, called surgeons office and insurance company and hospital and hospital states cannot separte charges, waiting on insurance company to review.

on 6/17/11 10:44 pm
It sounds like the WLS surgeon's office did not use the correct codes and modifiers when they billed the insurance.  If the correct modifiers are in place, the insurance will recognize the procedures as being separate and will not bundle them. 

Call your insurance company and find out what the required codes and modifiers are in order for these procedures to be paid separately.

Then call and talk to the billing manager at the surgeon's office and request the charges to be audited for coding issues, corrected and resubmitted to the insurance.