Insurance Not Paying Portion of Medical Bill

I have to say that I'm REALLY upset with my insurance company right now.  My doctor used an assistant surgeon during my surgery, which is supposedly required for any laproscopic surgery (because there are 4 or 5 pieces of equipment and the doctor only has 2 hands, an assistant is required).  I was NEVER told by my doctor that an assistant would be used, and I asked ALL of the insurance-related questions to make sure that everything was covered.  Anyway the assisting surgeon just sent me a bill for $2,000, saying that my insurance (BCBSof IL PPO) will not pay for his services.  They are saying that a second  surgeon was not required as of June 30th, 2011.  I'm not really sure what to do now.  My doctor is insisting that ALL other insurance companies cover the assistant and that this is the first time he's heard of it not being covered. I guess that I now have to appeal, which TOTALLY sucks! 

And just to be clear, BCBS is paying for everything else, just not the assistant.

You need to contact your insurance and file an appeal. It sucks but that's the protocol that must be followed. I am a claims examiner for a health insurance company and we have an appeals form we send out when a member is requesting an appeal on a claim. Other insurance companies I have worked for will sometimes allow appeals by phone. So contact your insurance and find out the procedure they have for filing an appeal.

Thanks, leximama.  I'm in the process of doing just that right now.  But I'm very worried.  What are the chances that I'm going to get stuck with a $2,000 bill that I was not expecting?

Every insurance company is different but the one I currently work for and the former would allow appeal for 2nd surgeon when its out of the members control. Follow up on your appeal every few days or so. If the 1st appeal is denied, there is usually a 2nd appeal that can be which is usually reviewed by a different appeals committee. If your 2nd appeal is denied you can file a grievance with the insurance commissioner. Hopefully it won't have to go that far though. Don't stress out about it right now, I know easier said then done but you stand better chances when you're diligent on your follow through.

Thank you again!  This is great information.

Also, contact the provider, either the primary surgeon or the 2nd surgeon and ask for a letter regarding why a second surgeon was required. If you can, try to get one from each surgeon. The 2nd surgeon should give you the letter to submit with your appeal. I don't remember if you stated or not if the 2nd surgeon is contracted with the insurance. I assume no if they are billing you.

I hope it works out for you without too much hassle.

Hi!  Im sorry to hear about your situation. 

I have the same insurance provider for OH, but its with the Federal government. I still think alot of our coverage is similar.  I didnt know they charged so many copays for things.  My copays are: hospital (inpatient, $150), surgeon ($150), 2nd surgeon/assistant ($150), and technical assistant ($75).  My surgeon doesnt use a 2nd surgeon, but I think he used a tech. assistant (I think that may be a nurse or his PA...Im not sure).  Maybe call and see if these cost apply to you as well.  It is still money out of pocket but its not as bad as $2000. 

Good luck with whatever decision you make.

You should also check your Doc's paperwork. If your Doc is a participating physician, he and his practice should accept whatever is reimbursed.