Dr Rabkin & Dr K, Insurance/Fees Confused

I had my heart set on a revision from Band to DS with Dr. Rabkin.  I have Medicare, but my BCBS Medadvantage plan is primary and since Dr. Rabkin doesnt contract with insurance, I coule use it as a non contracted insurance provider and get at least the hospital covered and then Pay Dr. Rabkin.  I was also prepared to be a Self Pay if necessary.  I just found out on Friday, I can not have Dr. Rabkin at all, not even as a self pay due to Medicare.  I am heartbroken and so confused.  According to Matt, in one of Dr. Rabkins other practices he accepts Medicare and Medicares policy states it doesnt matter how many practices you have if you are a contracted provider in one, you are a contracted provider in all.  So he would only be allowed to accept what medicare paid him and charge me no more.  So I figured I would just self pay and leave medicare out of it.  Matt told me because Dr. Rabkin was a medicare provider that he can not accept me as a self pay patient because medicare policy dictates that he can not accept self pay patients for severice medicare would cover and they would cover my revision and lap band removal.  So no self pay for me either.  Matt suggested Dr. K and I know he is a good surgeon and I may look into him again.  The last time I spoke with his office staff it left a bad taste in my mouth and I am not confused because I know Dr. K charges a program fee and I am dont understand how he can charge his medicare paitents anything extra when I couldnt do that with Dr. Rabkin.  So I cam very confused as to what the program fee is for, since medicare policy states he has to only accept what they give him.  Any one have any idea on this?  I do plan to ask his office if I choose to go that route with him.  Just feel discouraged and let down.  I never thought Dr. Rabkin would be out totatlly.

Last I heard, the fee was three grand for a virgin procedure and four for a revision.

Here's the deal.  Insurance does NOT pay enough for most surgeons to do the DS and feed their families and pay their staff.  Something has to give.

What MOSTLY gives is that most surgeons just do don't do it.  And, some who do, like Rabkin, make sure they are paid (most of their fees) up front and IF AND WHEN insurance pays them, they repay the overage back to the patient.  Crookes has been doing fewer and fewer DSs from what I've heard.  And that leaves Keshishian.  If he does not have a mandatory program and charge a fee, I'm pretty sure he couldn't afford to do this surgery, either.  (He could pump out two or three times the RnYs and make two or three times the fees in the same time it takes to do a DS.  It makes better financial sense for the surgeons to do the easier surgeries.)

I do know that even MediCal (medicaid) patients have to find a way to come up with the fee...so I imagine that Medicare people do, too.  (And my cousin just went through the thing you did about MediCare with her disabled son.  She just went to another doctor, didn't mention the Medicare and didn't mention the out-of-country insurance she has that will reimburse her if she pays herself.  My cousin's kid is HIGHLY insured...but Mom just pays cash and keeps her mouth shut and files for reimbursement later.)

****LIKE*****

I believe that what is happening is that the "program fee" that some docs charge is not considered a charge for medical services (though some docs do include such services in them, such as follow up appointments and the like) but more of an administrative charge for instructional materials and group support meetings. Dr. Rabkin doesn't charge a program fee, but wraps those services into his general surgical fees, so he can't afford to accept the discounted rates from the insurance networks or medicare. It is somewhat like the "admin fee" that the concierge doctors charge to keep their patient loads down and face time up while accepting discounted insurance and medicare payments.

Good morning. That happened with my sister. She is on diability and wanted to have Dr. Rabkin do her DS. She was willing to pay the difference. He doesn't accept medicare, My mom was willing to pay for the entire procedure, and they still wouldn't accept her.

I think it is a shame! Shame on our government too. If the patient is willing to pay, they (Medicare) should allow it. It's not any money out of their pocket. Even being a self-pay, they don't have to pay for anything - what is wrong with this scenario.

This post got my guts cause it hit right home.

I can only wish you the best and pray that you get the revision with Dr. K.

I am a revision from RNY with band to DS and I just love it. Life is so much better. No more throwing up with the band. The band should become obselete and removed from the market.

Hugs,
Lucy

Thank you for all your responses, it has given me food for thought.

Lucy:
I feel for your sister, I now how it feels.  My parents too were also willing to pay the self pay price and I was told no, because of Medicare. I think Medicare should be ashamed for taking such a good surgeon out of reach of people who want him and can afford the difference or to self pay.  I dont think Dr. Rabkin should have to worry about losing his medicare in his other practice beacuse he accepts a medicare patient in his wls practice.  I think medicare should be looking at it on a per practice basis and not just lumping them all under one.  I know Dr. Rabkin has been fighting for a long time with them but they wont let him around it.

I will be contacting Dr. K's office and looking into a revision with him.  I just hope I dont run into any issues with medicare and the program fee.