As I stand ontop of my soap box... I just don't understand

This is more of me just venting my frustration.... please no haters here.. I just need to get this off my chest once and for all so that I can move on.... LOL

I have worked in the health insurance industry for close to 25 years and my PS posed a rather intreaging thought in my head which makes complete sense, but I fail to understand how other PS's are getting away with this.... Here goes

If your dr participates with your insurance.... he has agreed to a) bill them for your services and can only upfront bill you any applicable copay/ coinsurance...... and b) has agreed to accept the insurance companies payment as payment in full for your services... excluding any applicaple copay/ coinsurance... SO HOW ON EARTH... if your doc participates with your insurance and is approved for a 'panniculectomy' how are they doing a TT or any other service, billing your insurance and balance billing your the difference. If your doc does a TT... he needs to bill for a TT.. if he does a BA then he needs to bill for the BA... etc... and in that case, the insurance would deny that the services rendered/ level of care billed was not authorized. This would be no different than your doctor billing your insurance for say....... and I realize this is extreme but I'm making a point here.... a heart transplant and actually giving you say a botox treatment.... Same difference... he's billing for an approved surgery and doing a 'cosmetic procedure'.. How are these participating docs billing the insurance for a panniculectomy, being paid for the panniculectomy but doing something other than a panniculectomy and balance billing you... a) their not billing for the service rendered and b) their not accepting the insurance payment as payment in full. In the insurance world we call that the F word... I won't actually say it, because maybe legally there's a way around it....

My PS clearly explained both surgeries and left it up to me... Had I only wanted/ could afford an insurance approved panniculectomy that's what he would have done..... solely the panniculectome (or) he clearly explained what he recommended, why he recommended it and left the decision up to me. I came home, discussed both surgeries with my DH and my mother and we made the decision that was best for me.

I just fail to comprehend.... how dr's are getting away this this... so if anyone could enlighten me I would so appreciate it.

I'm stepping off my soap box now... Thanks for listening... we now re-------- zume our regularly scheduled programming.. LOL

lemme ask this - are you also referring to when the doc gets the panni approved and the patient pays for the excess $$ to upgrade to a TT - so the doc bills for the panni from insurance and the insured pays for the difference to a TT?

I hate to answer for Lisa.. but I thinks he is referring to the insurance getting billed for a panni but the surgeon doing the pt a favor and just throwing in some muscle tightening for free... could be the patient and the doctor agreed upon a higher price for panni .. etc?  Not really sure how it is occuring but I myself had insurance pay for panni and paid the rest out of pocket for LBL and I do not think that is what Lisa is referring to.. more like you are paying for procedure that is billed to the insurance company (panni) and coming out with a full TT or heck I have ever heard of people going "I was surprised to see I got an LBL done". I was like WTH?!?!?!?!  how the heck?!?!?!?!

Lisa... I HAVE BEEN WANTING TO ASK THIS FOREVER!!!!! Thank YOU SOOO much for going there!! How are people getting around this?

My surgeon will ONLY do what he is paid for.  He wanted to do lipo with my LBL.. it was an additional 2500.  I chose not to go there as the bill was already steep for my DH and I before the lipo.  My husband heard me say about how ppl pay for a panni and get a TT on here.. he goes "well maybe he will just throw it in like the girls get on your OH PS board.." NO I said, not sure how they are getting that done, no way will he do that.  He didn't either.  

So really HOW IS IT people are getting around this... b/c I will say the "F" word.  It is fraud people!  They can loose their licensure over this unless you are right Lisa, there is a way around it? Not sure how there could be?  Crazy stuff...

But thank you for asking, I will want to know this answer!!!

I'm confused as to where the fraud is. Do you mean it's wrong for my surgeon to bill for the panni removal and do a TT or an LBL? I had, and paid extra for, an LBL and my insurance paid for the panni removal, which was done. So, are you saying they're not supposed to do more than what they bill for? Why not? I mean he DID DO the pann removal. I can see the fraud if you were approved for a panni removal and got a breast lift, but a panni removal is part of a TT or a LBL. So, maybe that's why I'm confused.

I think she saying that ppl are getting TT's when all they paid for was panni's... say insurance pays for the panni and YOU the patient does  NOT pay for the extra to have a TT but the surgeon does one anyways... to be nice.  I have seen it on here a lot.  "to my surprise i woke up with a full TT even though all I paid for was a panni, how nice".  That sort of thing.

Well, if THAT'S the case, I want the names of these surgeons so I can go to them!!! lol

Maybe i misunderstood her.. heck I donno.  I am sick this weekend and have a viral something or other... It may be the cold medicine talking but yeah, I want their digits too... bring it on! LOL

Here's some enlightenment:  I go to my dentist and I need a filling for a cavity.  My insurance only covers the cheaper amalgam (silver) variety and my dentist only does the more expensive composite (like porcelin) type which are $50 more per filling.  She bills for amalgam and I pay her $50 more and I get composite.  Where's the fraud?  Under the terms of my contract with them, I pay premiums and they are responsible for covering the cost of the filling (the cheaper one).  What do they care if I get a fancy filling?  Frankly it's none of their business. 

As for the panni vs TT issue you raise:   A TT is a panni plus muscle tightening.  It's a fancy panni, basically.  It's no different than paying a premium to get the composite filling rather than the silver one.   Why should the insurance company care?  They're still responsibile to cover the cost of the panni.  Your example would clearly be fraud if the surgeon billed for a panni and then performed a breast lift.  

I am in complete and total sympathy with those whose only hope is to get insurance to cover their plastics.  I have absolutely no sympathy for those poor, struggling health insurance companies, who, as I write, are throwing everything (cash in the form of your premiums) at congress to stop health care reform which attempts to offer a government option which would compete with them and offer more of the public better coverage. 

During the two years I have been active on this board, hundreds of women have upgraded to TT's, getting the panni covered by insurance and paying the balance to their surgeon.  If this were illegal, don't you think that the insurance companies would have pursued this "fraud" with all their lawyers and money and put an end to the practice?  It's not illegal.  These surgeons aren't criminals. 

And I'm not a hater.   I didn't use insurance (my government insurance covered TT and BR) but I fully support others who do.  After all, that's why we pay those big premiums! 

I think you are misunderstanding her... she is saying that you pay for a panni and the pt DOES not pay for the additional amount for a TT but the surgeon does it anyways.  Nobody is paying for the upgrade in other words.