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

Ok- after rereading this.. maybe *I* did misinterpret.

I had a LBL but paid for panni.  They bill it separately... the panni goes to insurance and the rest is billed to me.  How they can do this? not sure but it is legal.  That I do know.  

I thought you meant when the surgeon throws in additional work and all that is paid for is a panni but during surgery the surgeon does more. 

Sorry if I misinterpreted.

My doctor told me up front that insurance would not pay for lipo under any cir****tances, so that IF I wanted to have that option, it would cost me $3500.  In my mind that was a small price to pay to get done what I wanted.  He did say he could do the procedure without lipo, but the results would not be as good.  So he billed my insurance company for a thigh lift, and he billed me for lipo.  I also had to pay my co-pay to the facility.  I am not sure where or why you say this is fraud, to me it was open honest communication with my surgeon.  I had also consulted with another surgeon who said that he would take what ever the insurance paid on a panni removal, and then bill for the muscle tightening if needed....again open honest communication, not fraud, he did not bill the insurance company for a TT, he billed for a panni removal.

OUCH.... sorry to have stirred up so much fire today... Sorry everyone....

I am specifically referring to when a dr. has a medically necessary Panniculectomy approved, billed the insurance for the covered procedure, but does a different procedure such as a tummy tuck and then balance bills the patient for the higher more extensive procedure. The issue is not wether or not you have the right to choose a more extensive procedure... the issue is the billing practices of the 'participating' (which may I add is the key word here) provider will the insurance.. When a dr. participates with an insurance they have agreed to accept their payment as payment in FULL... and therefore can not balance bill the patient. And, when they bill the insurance this is a legal binding document stating this is what I performed.... Not this plus more...

What it comes down to in most (but never in all) instances is that the panniculectomy which is ONLY the removal of the excess skin of the pannus.... Not the entire abdomen.. is often seen as a Medically Necessary procedure... A tummy tuck..... in most instances as seen as a purely cosmetic procedure and that is why it's not covered... So how are they billing for a covered procedure but doing a non-covered procedure. Everything when submitted to the insurance company has a separate code.... therefore a panniculectomy would be coded 15830 and the TT 15847... so how are they billing 1 procedure and doing another...

And Yes. if the insuranace company I work for found out that a participating dr... was performing and billing for services other than what was rendered, yes, we would investigate that provider's practices and re-review their participation with our organization.

Yes, it IS insurance fraud. I have no idea how they get away with it. 

What I want to know is how a PS who is paneled under a PPO or HMO can REFUSE to do a panniculectomy that has ALREADY been approved As MEDICALLY NECESSARY by the insurance company simply because they don;t want to accept the amount of money the insurance will pay.  They have a CONTRACT with the insurance company, and if the insuracne company says it's medically necessary, how can the surgeon say it's not?!?  All of the PS's in my area have banded together and are refusing to do panniculectomies unless the pateint pays full fee and then the patient submits it for insurance reimbursement.  Which is NO different than the surgeon balance billing the pateint for what the PPO/HMO does not cover... whihc is a violation of their contract.  Yet every flippin' surgeon in this town is doing it!  And the insurance company  (Aetna) doesn;t seem to care because patients ae not able to have it done because they cannot afford to pay full price out of pocket. ( I got lucky and found a surgeon who had just opened a new practice and needed patients...)

Lora

I'm with you Lora......

the first surgeon I saw... was going to do the whole balance bill thing and the least complicated procedure he will do is a TT... He WILL NOT and DOES NOT do an insurnace billed panniculectomy only.

the 2nd surgeon was one or the other... but he could not 'legally' upgrade the procedure. it was either what the insurance approved and was going to pay... or 100% self pay... He told me flat out... he is only 1 of 2 doc's in the area that will do an insurance billed panniculectomy because there are so many patients out there that NEED the surgery and can not afford any more than what the insurance paid.. however, if he were not do nothing but insurance billed PE's all day he couldn't afford to keep his practice open because it pays so little...... That's why he does a few a month....

he's my thing... We can use me as an example.. My surgeon charged 5K + for my WLS and was paid approximately $1600 by the insurance company.. That other 3,400 was a provider write off and he could not balance bill me... Same goes for a plastic surgeon..... Ok.. so normally he would bill 5K for the PE... be paid $1600 by the insurance company... When in actuality he did a TT, charged you 10K, was paid $1600 by the insurance complany and balance billed you $8400.... in reality... the only difference was 5K. not the $8400 he's billing you.. That $3400 is a write off, can not be balance billed and they are getting away with charging you  because they either won't do an insurance billed PE or you have upgraded your procedure.

I just don't understand it.

So we as the patient end up paying more than they would normally get as reinbursement from the insurance company? this stuff gets so downright confusing.

I also wondered if I had a problem with the actual LBL and not so much with the panni portion (how do u differentiate really) who would be responsible for the complications? Me or the insurance company? It really is sorta scary isn't it?

My guess from my own experience would be... if you had complications........ and the insurance company found out about it, they would  take back what they paid and it would all become self pay.....

yep.... any write off now becomes your responsiblity.. that's why I don't understand how these dr's are doing this because they have a legal binding contract with your insurance company that you will not be balance billed. But upgrading your procedure you are being balance billed.

Confusing is not the word for it.

Amen Amen Amen....great post and I too worked for insurance and it was my job to audit these procedures.  But it is a shame when the patient is unaware of the shady billing practices of the doctor.  Because ultimately the patient will pay more and think they are being screwed by insurance.

~Maxine