Question:
Can anyone help me with an appeal for the assistant surgeon....

This is a plea for help from my fellow Losers.... My insurance company is refusing to pay for the assistant he used during my lap RNY. They say she was medically unneccessary. I know I need to appeal, especially since I don't have $2,000. The problem is, I have no idea where to begin. Please, if someone out there has any advice, please email me at [email protected]. Thanks in advance!-- Jen    — Mrs. Rich (posted on August 27, 2003)

August 27, 2003
My UHC insurance also flat out refused to pay for my assistant surgeon. It was 1200. Medicare only paid 161. on it so I know I will have to pay the rest. I was told that it does no good to appeal but try it anyway. They most likely will set up payments for you.
   — Delores S.

August 27, 2003
It is very common for an assistant to be in a surgery, especially one of this serious of a nature. Heck there was an assistant on my LAP gallbladder removal back in 1994, which was covered. This is sort of nuts if you ask me. Get a statement from the surgeon why it was necessary for an assistant to be there. If he refuses to do it then tell him to pay the bill. <p>I had two full fledged bariatric surgeons do my surgery. They were both paid 50% of their fees, which is what they were expecting. They each billed $6000 and got paid $3000. So $2000 for an assistant sounds like a bargain. Is the issue that the assistant is not on your plan? If so, then the surgeon needs to explain why he chose someone not covered by your plan. <p>I would start with getting the letter and then sending in a claim appeal that indicates that it is common for an assistant to be involved in serious surgeries. Maybe you can find some info on NIH website so something or the AMA.
   — zoedogcbr

August 27, 2003
OK- first off- did you sign a piece of paper with yur surgeon saying that you would cover excess costs that insurance does not? If so, there may be a possibility you'd have to pay. But, you can negotiate the amount. The major thing to consider is this ---> Is your surgeon an IN NETWORK provider for with your health insurance co? If he is you may have a case with the Dr. because they are not supposed to charge excess fees to the patient, they are supposed to follow the rules of their agreement with the ins. company and take what they are paid as payment in full. Can you get a copy of the bill and payment info from the hospital and see how it was paid? If it was as in-network provider- You could then go back to the surgeon and tell him that it's his problem to negotiate with the ins co that he is a member of, not yours. He is responsible for knowing their terms and accepting their payment agreements. Just some 'food' for thought. I hope it helps!!! Most of all, try not to freak out too much. Even if you DO by some miracle wind up responsible for the charge, you negotiate it down with the billing department (plead poor, tell them you might go bankrupt, may never be able to pay if they can't negotiate with you and otherwise nicely carry on)and then make a LONG paymentent plan with them. That would be your worst case scenario. Some major bills I've had in the past, Ive negotiated down 50% and paid 25 bucks a month stretched over a long period of time. Good luck to you. Let us all know how it goes.
   — LMCLILLY

August 27, 2003
You know Jen- I have another thought. (sorry- my husband works for a major ins co in claims, so I hear a lot about this stuff from him) What have you received so far IN WRITING? Am I correct to assume that you have received a denial letter from your insurance that lists the fees they paid and the one they denied with a denial code? If this is all you have received so far, just IGNORE IT. Your doctors office should go back and re-submit either with a different code or whatever works for them. You ARE NOT responsible for anything yet. They Dr's office may in fact be well aware of the fact that they weren't getting paid for the assistant but billed it any way. Or they may have made a codeing mistake. Sometimes they do this in hopes of 'slipping it past' the ins co. It is a common practice. Unless you have received a BILL from your SURGEON or THE HOSPITAL, there is nothing to panic about yet. I only mention this, since you didn't specifically say that you have been billed by your surgeon. Sorry to babble- just hope some of this may help.
   — LMCLILLY

August 27, 2003
I'm pretty sure the issue is not her main surgeon's bill or HIS asssitant. But a bill from another doctor who assisted on the surgery, that is the problem.
   — zoedogcbr

August 27, 2003
I work in a hospital as a coder and I'm sure the doctors office would not have made a mistake on the codes-the code for Lap RNY is pretty simple and I doubt codes have anything to do with paying for an assistant surgeon. Also on major abdominal surgeries it is very common for surgeons to have another surgeon there to assist them. In our hospital a surgeon would never perform a gastric bypass surgery without an assistant surgeon. Your insurance company is being "fickle" they obviously want to get out of paying. Make sure you Appeal!! Have your surgeon write a letter explaining that it was medically neccessary for him to have an assistant! I hope this helps. Good Luck!
   — Kara J.

August 27, 2003
I have a friend who works in surgery. The "problem" actually lies with the assistant. They must be certified as a "first assist" (takes some special classes and certification) in order to bill the insurance company as a full assistant. If they don't have this certifcation the insurance company won't pay the extra fee for them. They are considered as hospital staff just like all the nurses. The assistant does not have to be a surgeon. It can be a nurse that works closely with the doctor. My surgeon's office explained this to us at our presentation. We were warned that if we chose the lap-RNY the assistant's fees would not be covered and we would be billed the extra $1000. They felt he did a much better job since he had helped the doctor do 100's of surgery. They haven't sent him to the training for the certifcation because it takes several weeks and need him too badly.
   — Kathy J.