Question:
Has anyone else received an unexpected bill 4 months post op?
Today I received a bill from my surgeon for $1400.00 that United Health Care won't pay them for having an assisting surgeon. When I was approved, my part of the bill was $150.00 and I paid that. Can they do this? No one asked me if I needed or wanted an assisting surgeon! I wasn't even aware one would be there. As far as I knew I was contracting the services of MY surgeon. Any suggestions? I feel ropped off and I do NOT have $1400.00 laying around. UHC paid approx $26000.00 for this surgery and I pay high premiums. I feel like I have been ripped off. — Peggy B. (posted on June 6, 2003)
June 6, 2003
I don't have any direct experience, but have seen posts about
"assisting surgeons" before. I'm sure they are in the archive.
Depending on your insurance policy - you probably don't have to pay. Call
your insurance and explain and have them take care of it. In particular,
with an HMO, the HMO has a contract with the doctor, and you only pay the
copay or whatever you are told your part of the payment is. That's how it
usually goes. Good luck!
— w8free
June 6, 2003
I am going through the same thing with Cigna. Cigna WILL pay an assistant
surgeon IF the doctor writes a letter explaining why (s)he needed one. I
am fighting because my assistant was out of network and I had no choice. I
am also filing an appeal. Good luck to you.
— Kendra S.
June 6, 2003
Hi ... This happened to me. I called the hospital's business office and it
was just something that had not been cleared between them and the insurance
company. With HMO's, you are only required to pay your amount (copay -
which looks like your $150) and the rest the hospital has to swallow. This
is what they agreed to when you were approved to have surgery there. They
should have a contract with your insurance company stating this. Call the
hospital and call the insurance company. It may just be an oversight that
they need to take care of. Best of luck, LisaD
— Lisa D.
June 6, 2003
Peggy, what type of policy do you have with UHC? I have UHC Choice, I
believe. When I called them I was told EVERYTHING would be covered 100%.
I'm going to call them later today to check that that includes the
assistant surgeon. I'm sorry you got shafted. But here's what I did when
this occured to me when I had my son (Through Blue Cross)...I got slammed
with a 700 bill for my epidural and 250 for my son's circumsision...why I
don't know. But I just called the hospital told them "I can't pay
this now...how about 10 bucks a month?" Granted, it took FOREVER to
pay it off, as long as you send SOMETHING you won't be attacked. Also,
call your insurance company and find out what the deal is and ask them what
you can do to get them to pay.
— Renee B.
June 6, 2003
This is probably an issue the claims payors need to resolve. Most likely
something was coded incorrectly or, it could have been human error. No one
is trying to rip you off! By the way, your employer is paying a whole lot
more than you are in the way of premiums. (I'm sorry, but I work for an
insurance company, and we hear that all the time. Insurance is a BENEFIT,
not an entitlement, so be glad you employer chooses to offer this to you at
a cost to you that is far, far less than if you had to pay for it
entirely. Sorry, end of rant1)
— koogy
June 7, 2003
Yup, happened to me too but over a year out from surgery. I had my surgery
May 9, 2002 and on May 23, 2003 I got a bill for the X-rays and endoscopy I
had in February, 2002. When I called to find out what was going on I got
nothing but run around from everyone. Turns out I have to pay the money. I
told them that since they decided to wait over a year to bill me that it
would take me at least that long to pay them and not to even THINK about
turning it in on my credit report. We worked out a $30.00 a month payment
plan and a written letter from them once they receive the last payment that
I owe NOTHING else. Good Luck.
— Vicki H.
June 7, 2003
I have a PPO and my insurance only paid out of network rates for the
surgeon and anasthesiologist. However, when I called their customer
service line and said that I had had NO choice in those doctors, they paid
in-network rates. It's worth a try. I had that happen a lot post-op
because the internists who saw me for every day of my various hospital
stays were also not in network. Saved me a bunch because I had a $2000
deductible for out-of-network care, had to pay 40$ of the maximum
allowance, and a $10,000 out of pocket maximum.
— garw
June 7, 2003
You are being squeezed by your insurance company as they do benefit by
delaying claims as long as possible (and I say this with no apologies to
insurance comp. employees-- I used to work in the law dept. of a major
insurer-- who feel the need to defend them). Understand that your insurer
has a contractual (read: legal) obligation to process your claim. If they
approved your surgery to be performed by your surgeon, then it is the
responsiblity of the surgeon and the insurer to determine the cost-sharing
for the asst. surgeon (the doctor and the insur. comp. have a lengthy
contract that addresses these issues). What you need to do is call
customer service and demand that they pay the asst. surgeon. If they deny,
then you are entitled to an expln. of why. Which you then need to forward
to your surgeon.
I had a lengthy problem with my insurer which I wrote about in my profile.
GOOD LUCK.
— SteveColarossi
June 7, 2003
I am the original poster and to the person who works for an insurance
company I just had to let you know that I ALSO work in the insurance
industry and THIS kind of crap is what gives us black eyes and also I pay a
HEFTY premium for my coverage, it isn't like they are giving me benefits
out of the goodness of their hearts. Yes the OWE me, because I pay THEM.
Now my rant is over. Thanks.
— Peggy B.
June 7, 2003
As a former surgeon's office manager, a major surgery like this absolutely
justifies an assistant. Patients are never asked if they want an assistant
- the main surgeon sometimes doesn't even remember to mention to them that
he will be using an assistant, it is just automatic, like expecting there
to be an anesthesiologist.
If the primary surgery was paid, your assistant surgeon's bill should be
paid also. All you need to do is look at your EOB to find out why the
claim was denied. The most common denial for an assistant claim is the
failure to add the -80 modifier by either the biller, or by the person
working the claim at the insurance company. I wouldn't fret, just work out
the details and get the assistant's office working WITH you to get the bill
paid - don't treat them like they enemy, the staff is just doing their
job.
— bethybb
June 7, 2003
I just reread my answer. I must have been half asleep. I didn't mean the
surgeon. I meant the surgical assistant is the one I didn't have a choice
about. My surgeon was in network (in fact, I changed my mind about the
surgeon I was originally going to go to because he doesn't take any
insurance). Also, I would have had to pay 40% (not 40$) of my insurance
company's maximum allowance, plus the difference between that and what the
out-of-network providers charged.
— garw
June 7, 2003
First I like to clear up a misconception. The hospital service is
completely separate from the surgeon service, anesthesiology service,
pathology service, radiologist service, ad nauseum. Every hospital has it
posted numerous places that services provided by these providers is
separate from the hospital. (Hospitals cover their butts that way.)
That said, my advice to patients is to call their insurance company and ask
"how do you view this claim". Ask them to specifically tell you
why the assistant surgeon wasn't covered. As the previous poster said, it
may have been billed without the modifier.
United Healthcare is one insurance I have very few complaints about,
working with insurances as I do. From many years experience, it is usually
an incorrect billing code given by the provider. I've even asked UHC to
call the provider and ask them to resubmit using the correct codes and UHC
will. (I also use to have them as my insurance and would go back to them
in a heartbeat if I could.) Good luck!
— Liz R.
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