Question:
Out of pocket fee's for assistant doctors is bull

I have been looking into the WLS for a long time, My husband finally got good insurance and I wanted to make a appointment with Dr. Capella in New Jersey for the first week of July when my insurance takes affect, but to find out I would need $2,000 for his assistant because he doesnt take my insurance, but I cant afford to do that because I have a out of pocket fee for the hospital of 2500, well I have now looked all morning on just about every web page to find a doctor who takes my insurance and his assistant and found that EVERY doctors assistant doesnt take the same insurances as the head doctor or partner, how odd is that. how well planned are these doctors, I am sure they split the cash, and say they dont cause the insurance pays the other which I'm sure the assistant get a dib of that as well. the doctors that dont take this extra fee are the ones that have high mortaility rates. it sickens me that I want Dr Capella so bad and I have to pay his assistant 2000 to learn what dr. capella would be doing to me. shouldnt it be a law that 2 or more doctors in the same office should have to accept and particapate in the same insurance?, I think so    — kellisobo (posted on June 1, 2006)

June 1, 2006
Is this a hospital with a Bariatric clinic? If not, maybe look for one of those. That is indeed CRAZY! What does this assistant do? If the assistant is not an MD, the Dr. Capella should be paying the assistant, especially if this assistant works with Dr. Capella on all of these surgeries. Sounds like just another way for somebody to make money. Thanks for the info, that is one thing I'm going to ask my surgeon when I see him next month. There is a physician here in the Washington, DC area and I would like him to do my procedure, however, he doesn't accept CIGNA. Oh well, there are others. Check your insurance companies website and see what the requirements around the surgery is going to be. You shouldn't have to pay an out of pocket hospital fee either if the insurance is going to cover the surgery. Insurance companies are starting to certify Bariatric clinics and the insurance you and your husband are finally getting may do just that. I'd check the insurance website before putting any money out and check for Hospitals in NJ that have Bariatric Clinics in them. This way, the clinic is part of the hospital and the surgeons and staff work for the hospital.
   — the7thdean

June 1, 2006
Hi Kelli - I just experienced this myself. I received a notice from my insurance telling me that the surgeons's assistant was not a designated provider. I called my doctor's insurance coordinator immediately. She said that it was wrong - that in the state of California a doctor in REQUIRED to have an assistant surgeon in the operating room or else he can't operate. Basically she said that they come as a package deal and insurance companies cannot single out one and not pay the other for the exact same procedure. She told me not to worry, that she would handle it and that if my insurance persisted in denying payment that my doctor would write it off rather than stick me with an extra bill that I shouldn't have to pay. Call your surgeon's insurance coordinator (all offices have one and they are experts) and ask if New Jersey has that same law, and if so the lead surgeon and his assistant cost should both be covered if your procedure was authorized and your surgeon is a designated provider. Hang in there! This is something you can fight and probably win. I had to fight my insurance just to get my surgery covered at all. I was persistant and wouldn't take no for an answer. My health was at stake! Six months later I had the coverage and not only for me. They changed their policy, so I paved the way for others, too. What a thrill that was! Fight this, Kelli. I bet you'll win. I had my surgery 3-8-06 and am already down 70 lbs.!! WOO HOO! This is the best thing I've ever done for myself and I'b be willing to bet you'll feel the same way, too.
   — Catrina

June 1, 2006
Sometimes, depending on the type of insurance you have (plan) you have to meet deductibles, like for prescriptions and/or hospital, once you meet that deductible then the insurance picks up the rest. For example, I had a $2,500 deductible for hospital overnight stays, when I had my 3rd child I had to pay the hospital $2,500, then the insurance picked up the rest. With having deductibles with your insurance, the higher your deductible the lower your monthlty premium. We recently switch, to a plan so we don't have to meet any deductibles. But we pay a very high premium every month for it. Hope this helps....Marcy
   — need2loose4me

June 1, 2006
I thank everyone for all the emails, My most recent one someone explained about the premiums and deductibles, but I couldnt email them back, but in regards to that email, I do have Great insurance thats why I was so excited that I can get the doctor I wanted and it covered everything, NOTTT the assistant : ( I pay a very high premium every two weeks to get low co-pays, as far as the deductible I have a 200.00 which is low and great and the $2500 I do have to meet the 1 time hospital stay deductible like you had stated but after that I am covered 100%, I did pick the best plan my husbands company offered. Another email was that I should look into seeing about the insurance paying one doctor in the surgery room, with that said the head surgeon should be paying HIS assistant. I will now look into this with great depth, and seek council and see what can be done and or how it should be or is, if this makes sence. I am now on a search for a another doctor and am trying now to keep closer to my home in Sayreville, NJ which is Middlesex County, I do have some doctors around but didnt want to just settle on any JO. also I see some doctors are making people become a member for 700.00 and up to 2000 to there group what is this, this is all so crazy, someone needs to Tame these doctors. our insurance is covering these WLS's and they are still getting cash from us in sneaky little ways. well wish me luck because I will be on the phone most of the day trying to find out as much law as I can that pertains to this
   — kellisobo

June 2, 2006
Kelli, it is becoming more and more common for surgeons to charge a program fee. It's not that they aren't making money, but you have to remember, the surgeon is paying rent for the office, utilities, paying the office staff (and if they work after hours, or overtime to teach classes or run informational meetings or support groups, that costs money, too.) They have to process a tremendous amount of paperwork and keep it all straight with multiple insurance companies. If you get printed materals, that costs money, too. Last, but not least, what you see on the bill as "billed charges" for the surgeon, is nowhere near what he actually gets paid from the insurance companies that he contracts with. I do agree with the poster that said the assistant surgeon should be covered under the fees. And I also believe there is an assistant surgeon on most cases. (I'm in Ohio and I know there was one there when I had my lap RNY.) The assistant surgeon may also be covered under the hospital fee portion of the surgery.
   — koogy

June 2, 2006
Kelli, I have been in healthcare billing and collections for over 20 years and am quite a pain when it comes to my own bills and coverage. I've learned that the squeakest wheel definitely gets the oil when it comes to dealing with insurance, appeals, etc...and that if you don't get the answer you want from one rep, go to another, then go to a supervisor, manager, etc. Utilize the appeals departments because on average, 50% of initial submissions over $2000 get denied or only partially paid for various reasons (giving the insurance industry the opportunity to 'float' the funds to obtain more interest until an appeal is made/paid, or hope that people take their determination as 'gospel' and never bother pursuing additional payment. With that said, the best approach is to let your insurance provider know that you have no say in your doctor's choice of an assistant...just as you have no say in your anesthisologist, or any other consulting doctors on the case. In 95% of the cases, the insurance companies will consider the 'other' doctors 'in-network' if you have chosen a hospital and your primary surgeon that are in-network with your insurance company. Most claims are processed automatically when submitted electronically and if the numbers don't match their provider data base then they get paid at out-of-network rates. This will probably happen even if you do get approval prior to your surgery to have it processed in-network. Just call and contest it. It will then have to be manually reprocessed. You can also ask to have a case manager assigned to your case since it is elective (and expensive) surgery. Sometimes the insurance companies will do this for chronic care patients, or high dollar surgeries/therapies. This will be a nurse (ususally) that works for the insurance company and is assigned to your case. She/he will negotiate rates with non-contracted providers. Good luck...and don't give up (or in). I'm from NJ and heard Dr. Cappella is very good. I had my surgery by Dr. Elliot Goodman at Holy Name Hospital in Teaneck. If Dr. Capella doesn't work out for you, you may want to try Dr. Goodman. He and his staff are excellent, very professional, timely, as well as the staff at Holy Name Hospital. He has a tremendous amount of experience, and many of his nursing/office staff are former gastic by-pass patients...so they have intimate knowledge of your fears, concerns, etc. They were also very good at handling all the insurance approvals. Good luck and please feel free to email me if you have any questions.
   — angelav

June 4, 2006
I have a question for you, would you work for free? So why do you think the assistant surgeon should? All surgeries always have at least 1 surgeon to assist, it always helps to have extra sets of hands especially with morbidly obese patients, everything from positioning them to inserting instruments is more work because of their extra bulk and weight. Each surgeon is independent and they don't work for each other, one is not the boss of the other, so they don't split any fees. Doctors aren't mandated to accept insurances. The decision to accept or not accept insurance is decided between each insurance co. and each individual doctor, they have a contract. Just because the doctors share office space means nothing other than they share space, no payment sharing or insurance reimbursement is implied. As you are aware of increasing costs and lack of reimbursement more and more doctors will not deal with any insurance companies and you pay the doctor yourself. Your best choice is to start saving your money because you will probably have at least 6 months until you can be operated on, you will need visits with dieticians, psychologist, surgeon, medical doctor, maybe a sleep study and hopefully a cardiologist and pulmonary doctor, and you may need 6 months of physician supervised weight loss attempt before your information can be submitted to the insurance company for approval. As you have discovered having health insurance is not a free ride anymore and patients are expected to pay for more of their health care costs than ever before and this will only increase as time goes by. You may not like that you have to pay, but its how it is, and there is no way around it. Honestly if your finances are as bad as you indicate you may honestly not be able to afford to have WLS and may need to rethink this. It's just not the surgery costs, but you will always have doctor visits, copays, prescriptions, vitamins and supplements, deductibles ,healthy high protein food choices, gym memberships to pay for the rest of your life, all of these are costs associated with WLS. As someone who has worked in healthcare finance & nursing for close to 20 years I've seen alot and learned alot about how the healthcare system works.WLS is alot of work and it's not magic, your weight loss and continued weight loss maintanence depend on how hard you are willing to work at it, eat properly, exercise and be concious of and change the behaviors that made you MO in the first place. I'm not trying to be mean to you but I think you should be aware of the facts as they really are. Its alot more work to go through WLS and be a sucess long term than it is to remain MO, unfortunately not everyone realized it and is up to the challenge. Can you get a part time job to save some $ for your surgery fees? Best of Luck
   — goldroses