Medical Insurance/Surgery Bill Question...

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RH

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Hi All,

Recently, my father had to have surgery to remove some cancerous spots on his skin. Before the surgery, he was asked about his insurance company, etc in the usual pre-op visit. He told them his comapny and then they gave him a multiple page release. Within that release, it mentioned that they did not accept his insurance. This may pass the legal requirements, but if they verbally ask about his insurance, I would expect a verbal reply as to if they take that or not.

Now, he has received the bill and, of course, the insurance company will not pay because it is out of their network. When he talked to the insurance administrator, the administrator mentioned that the surgeon also billed at double the acceptable rate outlined by the insurance industry.

Finally, my parents talked to the surgeon's office to see if they would accept partial payment. They have refused saying this wouldn't be fair to the other patients. This will go to a collection agency at the end of the month.

Is there any recourse my parents can take? They are both retired and this is a very big, unexpected expense. I appreciate any advise you guys might have.

Thanks,
Robert
 

cobb

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If this is blue cross and blue shield, bcbs, I have my own words for bcbs, but cant post them here, I am not surprised. I use to work for them and hated the way I had to treat the docs and nurses who called in.

First off, its my understanding plastic surgery is not covered under any plans. If you were in a horrible car accident, they would pay to fix you to heal, but not to make you more human like or pretty. This is usually the genetic insurance clause for plastic surgery, which is what this sounds like it fell into.

Now, did you get an authorizantion from the insurance co? Did they say anything in regards to this being covered?

Otherwise, I am not sure you would like the news. You really need to read stuff before signing it. I guess you can try your local attorney general, bbb, or a lawyer depending on the amount.

Insurance aint all it is cracked up to be. I sprained my ankle one friday evening when I was 14. Since it was not life threatening, insurance would not cover the er doc, xrays or ace bandaid. I was expected to wait til Monday morning, get a docs appointment and have him look at it, then get x rays, cast, etc, etc.

Furthermore, I was given pain killers and wheelchairs by the docs for my muscular disease. After a few semesters of biology and a few trips to GNC, I got out of the wheelchair.
 

Hookd_On_Photons

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You mentioned your parents are retired. Are the covered by medicare? Is their health insurance carrier a Medicare HMO? If neither, what type of health insurance coverage is it? (PPO, HMO, etc.) (Note: MediCARE covers the elderly and disabled. MediCAID covers persons below the poverty line, regardless of age. Note that it is possible to be eligible for both Medicare and Medicaid. People often assume that MediCARE and MediCAID are the same, but there are important distinctions when billing issues arise.)

If it's not Medicare, your parents might be screwed. While it is ethical to inform you whether or not the surgeon accepts your insurance, the office is under no legal obligation to confirm that for you. The burden is upon the patient to check insurance eligibility. And you can bet the insurer is not going to stick their neck out for you. Sorry, but let the buyer beware.

Also, when the insurance administrator tells you the damn surgeon is charging twice as much as he should, I wouldn't automatically assume that the surgeon is trying to gouge you. Health care providers (physicians, hospitals, therapists, etc.) negotiate with health insurers, and present a "usual and customary fee" for a given service. This is the equivalent of sticker price on a car. Nobody really pays sticker price on a car, do they? The insurer negotiates a discounted rate, which is a certain percentage of the customary fee, and may be pegged to the Medicare reimbursement for that service.

Medicare reimbursement varies from region to region, but it's usually around half of the customary fee. Medicaid pays around 15-25% of the customary fee. Private health insurance carriers will usually negotiate a fee schedule that is around 80-130% of the Medicare reimbursement (i.e. 40-65% of the customary fee).

The only people who pay the customary fee (i.e. full rate) are people without any medical insurance, who have too much income to qualify for Medicaid, and who are not old enough or disabled enough to qualify for Medicare. In the business, they are known as "self pay".

If part of the bill is owed to the hospital, you can negotiate a payment plan with them. They are usually fairly reasonable in this kind of circumstance.

You are on your own negotiating with the surgeon. Please note that under Federal law, he cannot charge *less* than the Medicare rate for his services. Yes, that's right. The Federal gov't establishes a minimum rate for health care services to ensure that Medicare will never be low-balled.

On the other hand, if your parents are covered by Medicare, under Federal law the surgeon is not supposed to bill you for any *more* than the Medicare rate.

Also note that any care rendered in the 90 day period following a surgical procedure (the "global period"), including office visits but not including medications or other consumables, is generally considered to be included with the surgical fee. In other words, there should be no professional charge for office visits for follow-up care after the procedure (though you *can* be billed for goods used as part of the care rendered).

Do not be angry or hostile when talking with the billing manager. He or she deals with angry, hostile people all day, and will be more responsive if you are polite. Do not try to persuade them to discount their price and write off the difference on their taxes. I don't know where that myth came from, but there is no tax write-off for uncollected payment for health care (if there were, no doctor or hospital in the country would pay any income taxes...), unless you consider that decreasing income decreases the practices' tax burden.
 

BIGIRON

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Good responses. I'm really surprised that a doc would provide services without some type of prepayment or charge card or something, or at least doing a financial workup to determine ability to pay.

If your parents are low income, there may be some type of legal assistance available at little or no cost. Just about every city has a social services hotline or referral system. That might be worth checking into.
 

WildRice

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This thread was brought to my attention by Jeff Rice, my husband. As a medical billing resolution specialist at a major heart hosptial, I see all kinds of denials. However, it is especially bad PR for a physician's office to not check with the insurance to see if they par with the physician.

First and foremost, does your father have medicare? If so, did he sign an ABN, or Advance Beneficiary Notice? This document says, that in the event certain tests, procedures, and even diagnosis are not covered by medicare, the patient accepts liability for any and all services rendered which are not covered.

Secondly, were the cancerous spots benign or malignant. Hint: if this was a scheduled removal, there was ample time for the physician's office to verify eligibility for the procedure. As well as the pt to check too.

Thirdly, if the insurance is advising that the physician is charging 3 times the usual and customary amount for the procedure per Dx, this is a red flag! I would call the OIG, Office of the Inspector General to AUDIT this office. These are the BIG WHIGS of the medical insurance industry. They will enter unannounced and ARMED then SEIZE every shred of documentation after a brief and complete investigation. This usually RUINS a practice and can even result in the physican loosing his licence to practice in that state if he is involved in the least of offenses. http://www.oig.doc.gov/

Depending on how eager your father is for the lime light, you can call a local news station that has an investigative reporter to expose this practice, or at least make others leary of going to this practice from the emense amount of terrible public relations. This office perhaps does NOT want to give insurances discounts (that they KNOW they are entitled to) so they deliberately (in some cases) code a Dx that would not be covered. Perhaps order tests not totally nessasary. And in this case, jack thier prices to the highest allowable rate by a few insurances.

Personally, I would NOT threaten or make known 'who' started an audit. It's the equivalent of the biggest "F" word in the industry.

Also, I'm somewhat surprized that your father's insurance does not even have out of network benefits. I can't stress enough to people, as boring as it is---READ YOUR POLICY! Or have an insurance rep READ IT TO YOU and explain your questions, after all you are their boss, you pay them, you can always pick a new carrier.

BTW, all the other responses were very good esp HOP's suggestion that your father applies for medicaid. However, land assets (no matter if they yield a crop or not) can keep him from utilizing this benefit. Plus, it may not be retro active coverage for a benign removal.

If this goes to collections, whether or not Dr's office is audited, your father will owe the collection agency and that will be the debtor not the doc. If an audit is what you feel the best course of action is, do it quickly as this will hang up your father's debt (perhaps indefinatly).

I hope I had not rattled on too long. I see the paragraphs stacked up.
 

RH

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Hi All,

Thanks all for your replys. My parents insurance is POMCO so I think that is like a PPO or something along those lines. I will talk to them this weekend to get more info regarding benign, malignant, stc.

The bottom line is that the responsibility was with my parents to call the insurance company ahead of time and get the procedure authorized. I really don't want to drag the doctor through the mud. He provided a very specialized service and should be compensated for it. Unfortunately, there was a doctor 40 miles away that was in network they could have gone to. I'll call the billing manager on their behald later this week and see if they would be willing to negotiate a little.

Thanks,
Robert
 

Hookd_On_Photons

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RH, see if your parents can talk to the doctor about this, if the billing manager or practice manager won't cut you any slack. (Unfortunately, people who do medical billing/collections for a living tend to develop a callous attitude over time. Getting burned by a few deadbeats tends to harden your heart, I suppose.)

In many practices, the billing/practice manager has to be hard-nosed about collections because most doctors are terrible businessmen, and are usually more willing to write something off than engender a conflict with a patient over finances. Admittedly, there are a few bad apples who view their patients primarily as a revenue source, but the majority are halfway decent people who are willing to work out some sort of arrangement.

It's possible to find out what the Medicare reimbursement for the surgical procedure is, if you know the CPT codes that the doctor charged for. That way, you know a reasonable price point to begin your negotiations.

http://www.cms.hhs.gov/physicians/mpfsapp/step1.asp
 

James S

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While I cant tell you exactly what you need to do, I can also make a couple of general suggestions.

First off, call your PPO again and ask about out of network payments and see what they will do. If you haven't spoken to several different people there on several different days you dont really know what their policy is as you almost certainly got incorrect info. The people on the phone can't possibly understand the ludicrously complicated paperwork and policies of an insurance company, they are just following a cheat sheet and some of them are better at that than others.

same thing for the doctors office, keep calling to chat. It is stupid for them to send it to a collection agency, they will collect pennies on the dollar if anything at all. By allowing you to make payments against the bill they will ultimately recover much more of the expense. So ask them about that again too. You may get a different answer from a different person there.

The 3 times the price thing is stupid for the insurance company to say. All billing is at least 3 times what the insurance company agrees to pay for. Thats how it works, they pay the doc what they think the procedure is worth and the doc has to take it if he wants to stay in their network. The bill may be $1000 but the collections only $300 from the insurance company. So somehow the doc will be making up the rest of the $700 from the volume of patients that the insurance company sends to them. This is not a problem and it's not that they are gouging the price necessarily. So that is confusing.

I dont know a single doc or hospital that wont accept payments against a bill. That is just stupid. As long as you're making payments I think there are rules about what they ann do as far as collections too.
 

bwaites

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I usually just avoid these threads, but...

As a Physician Assistant who works in a private office, after 5 years of working in a hospital in the billing department, and 10 years selling health insurance, I might bring a thing or two to light.

First, for the Surgeons office to have not given BOTH written and verbal confirmation of the coverage is rare. Doctors want to get paid, our staffs are generally pretty well trained to make sure that patients understand that they are or are not covered by their current insurance plan. To not have cleared it with the insurance company before the surgery is rare, especially if there was time between the diagnosis and the surgery.

Second, if they are in a PPO or HMO situation, where was the gatekeeper? Their primary provider should have been the one to refer them to the specialist, unless your parents chose to go to someone outside the network. Most specialists in Washington State won't take self referrals for this very reason.

Third, you stated this was for removal of cancers, so I am going to assume that the lesions were indeed cancerous. There are NO benign cancers. Some are more dangerous than others, but there are NO benign cancers. That being the case, this is NOT cosmetic surgery, it is medically necessary and do not allow the insurance company to invoke the cosmetic surgery part.

Fourth, to clear something up. Most, (by law in Washington State, all companies MUST) insurance companies DO cover cosmetic surgery to repair damage secondary to an accident or illness. They DO NOT cover cosmetic surgery to correct some supposed fault, like small breasts, big nose, etc.

Most offices WILL allow you to make payments, if the payment is reasonable. We sometimes allow $5 monthly payments, when we are aware of the circumstances. We are liberal in our policies, but some offices aren't. Talking to the doctor, as tough as that may be, IS more effective than talking to the billing people, we are softer! They have directives, but we can modify those when the circumstances warrant it from our viewpoint, they can't.

Reasonable and Customary charges really don't even exist any more, they were a charge decided upon by the insurance companies after polling all the offices in the geographic area that performed the service. With Medicare dictating charges, they don't need to do that any more, they just take the Medicare allowable charge and adjust by some unknown factor. (They won't tell us what that is, so we are always guessing!)

As for advice:

Go in and sit down with the doctor and your parents, tell the front desk it is a surgical followup.
Talk with the doctor about the situation, tell him you would like to make payments for his services, and that your parents were not aware of the insurance coverage. (We all realize how confusing it is, we have nurses and staff that do NOTHING but deal with it all day, every day!)
Explain that you understand he provides a valuable service and that you understand your obligation to pay for that service, you just need time to do so.

Talk with your parents insurance company, there SHOULD be SOME out of network coverage, if only at 40 or 50%.

Try to get them to at least pay what they would pay in the network.

Hope that helps!

Bill
 

RH

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Thanks for all the advice guys. I will know more this weekend.

In response...yes they were cancerous. My dad went to an in network doctor who referred him to this out of network surgeon even though an in network surgeon was only about 40 miles further away. Neither the referring doc or the surgeon's office mentioned the out of network part. It was in the documents I guess, but my mom didn't read them as she should have.

Thanks,
Robert
 

Jumpmaster

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RH said:
In response...yes they were cancerous. My dad went to an in network doctor who referred him to this out of network surgeon even though an in network surgeon was only about 40 miles further away.

While it's true your folks should've gotten a referral first, there may be hope...when I had my ACL surgery, there were NO anesthesiologists in the area that were in the BCBS network (thankfully, I don't have BCBS anymore!)...I'm not sure how your parents' insurance works, but with my old plan in BCBS, if there were no docs of the type needed in the area that were in the network, they covered it anyway.

I personally wouldn't necessarily consider 40 miles away as "in the area". YMMV and their policy probably states what *they* consider as in the area...I do hope it works out for y'all.

JM-99

p.s. I also learned that it is illegal for doctors to withhold your medical records pending payment of fees -- so if they try this, make sure they understand what they're doing is illegal and they'll straighten out in a hurry. They know it's illegal to do that...they're just counting on us not knowing that. :rant: (This happened to me upon trying to enlist...I had to type up a demand letter before they'd budge!)
 

bwaites

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Robert,

If an "in network" doctor referred your parents, you have some more leeway with the insurance company, as "network" doctors generally have a contractual obligation to refer to other "network" doctors.

That means that when a PPO or HMO doctors office refers you, you have a reasonable expectation that they will follow the rules and refer you to someone who is also in the network, and that they have an obligation to tell you if they do otherwise.

If the paperwork was ambiguous, "if your insurance company doesn't cover this procedure, you will be responsible for payment" vs. "you understand that this office (or doctor) is not a network provider for your network and you accept responsibility for the charges and reimbursement through your insurance provider" or something similar you also have some leeway to discuss deceptive or unfair practices.

Lots of wiggle room for all involved in the story so far. Make sure YOUR parents get to use their share of the wiggle room!

Good Luck!

Bill
 
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