My surgeon's office is trying to rip me off!

I am 5 weeks post op. I am now getting to all of the fun financial stuff. The office I have gone to gave me an initial estimate with insurance of $4600 for my LapBand procedure. The deal was that you had to pay the $4600 up front before they would do the surgery. I paid the money, and now they are saying I owe an additional $4500!! I didn't have anything out of the ordinary happen during my surgery. Nothing that would cause them to have to charge more.

I am really stressed out about this and I don't know what to do. I have talked to the billing cordinator at the office and he general response has been 'sorry, I can't help you'. I just can't understand how they can give me an estimate and expect me to be okay with having to pay double the estimate. Isn't the point of an estimate to come as close as possible to the actual cost?

I am thinking of pursuing a lawyer in this matter. Does anyone have any suggestions of where I should start with this? Should I go a different route before engaging a lawyer?

First, let me offer you a congratulations on a successful surgery.  I am glad you are on the losing end now. Second, can you provide information on your health insurance?  Did your insurance pick up any of the costs?  Are you paying out of pocket?  Do you have a high-deductible plan? A little more information would be helpful.

Thanks for your response. The office I went to used two surgeons - one in network and one out of network. I have United Healthcare - my insurance was to pay 90% for in network services and 70% for out of network services. The office billed my in network doctor $7500 and recieved payment of the contracted amount (around $2000). However, they billed for my out of network surgeon $10,000 - and since the doc was out of network - the insurance paid the 70% based on "reasonable and customary" charges. Reasonable and Customary (in case you don't know) is the amount the insurance company says the doctor should charge for a service based on what other doctors in the zip code charge. The R&C was ALOT lower than $10,000 (more like $5000). So - the Doctor's office is telling ME that I owe the difference between what my insurance paid (approx $5000) and the $10,000 price tag they billed for.

Sorry for such a long winded explaination - but that is just the half of it. They also billed my out of network surgeon for a hernia repair that was only supposed to be billed for the in network surgeon because there was only one surgeon performing that part. Also - they billed my out of network 2 line items for the laproscopic procedure. They billed my in network doctor like 6 line items for the laproscopic procedure. They told me ahead of time that both doctors performed the same percentage of the lapband surgery - so what gives? I think they are trying to scam my insurance and scam me! The funniest part is that I have a few friends that are patients of the same office and are having the same games played with them as well! They also have 3 claims with the Better Business Bureau - I am assuming concerning the same problems.

I am super frustrated and need some advice - thanks to anyone *****sponds.

All right.  Thank you for clarifying the matter. Since one of your surgeon's was participating, the insurance company reduced the billed amount to $2,000, of which you would have been responsible for 10 percent, which would have been $200. For the non-participating surgeon, this is how it works out: Nonpar billed amount:  $10,000 Reasonable and customary charges:  $5,000 Insurer's nonpar responsibility:  $3,500, or 70 percent of the reasonable and customary charges Patient's nonpar responsibility:  $6,500 ($1,500 + $5,000) Please note that for out-of-network services, you will be responsible for all costs not paid for by your insurance company.  So, while your insurance company mitigates its costs by paying based on usual and customary charges, it cannot constrain the out-of-network provider from charging exorbitant fees and passing those fees on to the patient. The actual amount that you currently owe is $2,100 ([$6,500 + $200] - $4,600).  The amount that they are telling you is simply erroneous unless there are other charges that you might have escaped your memory. The office will not be able to scam the insurance company mainly because in the cases of both the in-network and out-of-network surgeon, it was going to pay a specific amount and nothing more, regardless of whatever is billed.  If anything, the office might be trying to scam you since you are the one who will responsible for all excess non-participatory charges. If you believe that the office is attempting to bill what should have been participatory services (meaning services that should have been rendered by the participating surgeon) as non-participatory, then you should consider reporting that information to the Better Business  Bureau or to your state's governing insurance entity.  Doing so will require a time commitment on your behalf due to the level of bureaucracy that you might encounter, so you will want to keep in mind that your credit rating might be affected while you are waiting for the matter to be resolved. You can also consider speaking with an attorney about the matter.  Bringing legal action against the office should be able to stave off any attempts of damaging your credit profile while you work to resolve the matter legally. I am sorry for the issues that you are experiencing and hope that you are able to amicably resolve them.

Thanks for your response. I think where I really feel like I am being scamed is because I was originally given quote "estimate" of what I would end up paying out of pocket. The estimates said I would be paying the $4600. But now - like I said I am owing another $4600 ($1000 from the hospital and $3600 from the office). The original estimate included the hospital amount. I just don't understand how they can expect me to pay double of the estimate. Isn't the purpose of an "estimate" to give you a closest to exact amount that will be due based on services rendered?



For example - if I hire someone to come in to clean my house and their estimate for the job is $200. I don't expect them to come to me after the job is completed and tell me I owe them $400. If they said to me, "we had to use a special cleaner on a certain area of your house - so we will need to charge a bit more" - and then charge me $220 - then I find that acceptable means outside of an estimate.



This is where I really feel they are in the wrong. When I ask them about this estimate that was given to me, they say "sorry, but we cannot give you a fair estimate due to insurance reasons". Also, they told me the estimate that was given to me was for a cash patient - not for an insurance paying patient. Why would they give me a cash patients estimate? Why didn't they tell me that when they gave me the estimate - not after everything was said and done.



I really feel like I was mislead - if I would have know I was going to end up paying a total of $8000 - I probably would have thought a little harder before jumping into the surgery - or went to a surgeon that was strictly in-network.



Thank you for your input.

Your thinking is right in the whole process.  Estimates are usually given to cash-paying patients, not to patients with insurance.  For those with insurance, even out-of-network costs can narrowed down to a close figure.  Most insurance companies have no issues providing information on usual and customary charges to providers or members.  They do that because they want to provide people with as much information as possible before they choose to have out-of-network services. The office that you are dealing with sounds shady to me and were probably preying on the fact that you were eager to get the surgery and trusted their professionalism.  While not all offices are like this, I am starting to see a common trend in this with offices specializing in bariatric surgery. You might want to consider pursuing the matter further.

Estimates are to be off by 10% either way.  I forgot where I read it, but it was a legal document.  If I find it i will let you know.

Sounds fishy to me too.  Why did the in-network doc to all the work?  They knew the situation, but still billed it the way they did.  They are trying to makeup for what the ins did not pay.

That is exactly what they are trying to do. The funny thing is that my insurance has now come back and issued a check for the WHOLE out-of-network bill! So - the office is getting, (I think) alot more money than they should. It's crazy.

I know with some insurance companies the doctor can refuse to accept U&C and are either paid in if it was in facility or paid at a hihg co-insurance. This is just from my experience working at an insurance company. Not sure if it's the same with all of them.