xp - Post-op Insurance Problem Update #5 (I think)

For those of you who have been following the drama...here's the latest...

UHC called me this morning to let me know that my claim has finally been processed (as of Friday).  Of the $39,954.79 that my doctor billed for surgery, they paid $10,928.21.  My responsibility is $29,178.79 of which representative told me to NEGOTIATE, NEGOTIATE, NEGOTIATE!!!  2 of the procedures he billed for are NOT separately reimbursable services under the codes and they total $9,611.00 by themselves.  Many of you were right...talk about overbilling!!!

I called the doctor's office and told them it was processed and to expect an EOB sometime this week.  After the drama of last week, I really need a break from them for a few weeks.  I will start my negotiations in a few weeks.  I want to break down the bill, check out what self-pay patients have paid him and then go from there. 

For all of you who have read my rants and offered advice and support...THANK YOU a thousand times over!!!  I appreciate the simple fact that you fellow Oh'ers are willing to share and try to keep each other sane and supported.  I will keep you posted as to negotiations and any further harrassment from the doctor's office (if they dare).  As soon as I get the EOB I will post that too so those of you in the whole insurance process nightmare have some reference for what it's worth.

Thank you all again!

If the procedure was approved and the dr is a UHC provider doesn't he have to take what they pay?

Well, first my doctor is out-of-network.  Because I needed a revision, it was hard to find a doctor, let alone an in-network doctor, who would even see me.  Most won't touch another doctor's previous work.  Nice huh???  

Anyhow, as out of net-of-network, I have an out-of-pocket max for the year.  BUT...  that max. only applies to eligible procedures based on the average competitive rate for my geographic area (reasonable and customary).  So if Chicago area doctors on average charge $10K for an eligible procedure (ie. not a face lift), but my doctor charges $20K (over charges), they will only pay on the $10 K because that is the "going rate".  Most out-of-network benefits work this way.  Add on top of that that some of the procdures aren't even billable because they are considered part of the main surgery and not separate procedures (according to UHC).  I will have details on exactly what they paid for and didn't when I get the EOB.

Simplified...if my doctor charged a reasonable fee on billable procedures I would pay zero because my yearly max. was met.  But, because he charged a higher fee and charged for non-billable procedures, my bill is huge.  Like lots of people have mentioned on my previous posts...he WAAAAY overcharged.

Just a little advice. I do insurance claims for hospitals, and most of the time the 'inclusive' charges are a writeoff. The insurance is basically telling the doctor the inclusive charges aren't paid because they would not have exisited if it was not for the main procedure. Not to mention if this is an inpatient stay, insurance companies only pay a certain amount because they process accourding to DRG (they decide payment based on the diagnosis...no more no less) I would insist the doctor adjust the inclusive charges and only bill for patient responsibility which should be clearly indicated on the EOB. Throw out a couple of DRGs and make them think you have really done your research.

Hope this helps.

Breanna

Joyce imop he probably did other things while he was doing your surgery and insurance consider them an incidiential procedure and no additional allowance it allowed based on the surgery.  For instance if he is doing the lapband and sees your gallbladder is inflamed and needs to be taken care of he is already in the area and no additiona inscisions are made so they normally consider it an incidential procedure.  Some insurance will allow all and half of the 2nd procedure, but seems in your case they didnt allow.   As far as the previous poster talking about DRG 's those are only used by facilities(hospitals) and are paid based on a flat rate for the diagnosis but has no bearing on professional charges.   They have sepereate fee schedules for surgeons, and regular doctors.

I would ask for a total itemized from you physicians office and go ahead and neogiate a possible medium for both parties to agree on.

Hope you get things worked out

Vicki

much thanks to everyone