Question:
5months Post-Op battle with surgeon...

My surgeon is still sending me bills saying I owe him nearly $6000.00 My insurance company informs me that I am not to have to pay that because it is an "in-network discount" that he is to take. It has been a battle for months now and I need to have my blood work done (I haven't had ANY done sense surgery). Can I go to another Doctor maybe my GP or Gyno or Indo somebody else because I cant go back to my surgeon until this money issue has been taken care of (looks like never). Any help would be greatly appriciated. I live near Atlanta GA if anyone knows of a Doctor I can go to that will run the tests so my insurance will pay for it. HELP!!    — Sabrina Plunkett (posted on March 27, 2004)


March 27, 2004
Sabrina, go to your Primary Care Physician, they should do the bloodwork, no problem. If you don't have a PCP, there may be a clinic you can go to in the area. Unfortunately I'm not from around there, so I can't recommend anyone. Also, unless you signed a paper stating you would pay the difference of what your insurance did not cover for your surgery, then you do not owe your doctor anything. However, a lot of times surgeon's offices will slip a paper into a huge packet of papers needing signatures...a paper that states you will pay the remainder of what your insurance does not...and if you signed that, even unwittingly, you may be screwed. :0/
   — jenn_jenn

March 27, 2004
Be very firm with them. They had a a contract with the insurance company and agreement to payment from the ins co. They are committing fraud. In the meantime go to pcp for blood work. If they continue harassment let them know you will call the insurance comissioner for your state and report them. They will get audited! I had to do this with a dentist--and I got alot of my money back that they overcharged me for and they where billing for work not done and trying to collect for work not done. Keep your chin up.
   — Autumn

March 27, 2004
Even if you signed a paper stating that you'd pay what insurance does not, that only applies to your network negotiated portion of the bill (which is pre-established by the insurance company...eg 10%, 20% or whatever your portion is). That amount you are supposed to pay is 20% of the contracted rate. (I am using the 20% as an example below, and pretending your insurance company is Aetna). _____________________________________________- So let's say a procedure is $1,700, and Aetna's contract states the doc has to do it for $1,000 (Dr. signed the contract; his incentive is that Aetna will send him all their business aka network members). Aetna pays the Dr $800, you only pay $200, even though the original bill was for $1,700. That's exactly why your insurance company states that you are not legally required to pay it. This contract between the Dr and insurance supercedes any contract you have with the MD (ins company hires lots of lawyers to make sure of it), and that most certainly is fraud they are committing. Not only are they trying to fraud you, but they are also frauding your insurance company. Their contract is a promise that they will provide this service to you and the insurance company for a certain amount. Do follow through with the state insurance commission with a complaint(even if the Dr billing goes ahead and fixes the problem), but first speak with the highest supervisor at the billing dept, and tell him/her you plan to do this if you do not receive a "pd in full" receipt. Also let them know that you will report it to the MD you have seen. The docs do not want to lose surgical business over a poor business manager in the billing dept. And if thissurgeons office keeps it up and more people report them to the insurance commission they could end up losing some insurance company contracts. Also I recommend you hook up with members here who had the same surgeon. See if they had the same problem. If they did, there is power in numbers. Have them report it too. Chances are you aren't the only one who this has happened to. A lot of people get nervous by bills, and will just pay it. My husband had over $190,000 in hosp/medical bills when he had leukemia, so let me tell you I have been through all this insurance billing stuff before. Thankfully I never had anyone try and take advantage of me like that before. Good luck!
   — Transplant N.

March 27, 2004
I had a similar problem with a dentist and my insurance company, after many phone calls, specifically informed me that i did not need to contact the denist in this matter, that this dentist had tried to do this before, and that the insurance company would take it from there. after only 1 week the bill was taken care of and the dentist was made, by the insurace company, to write the amount off. he did, after all, sign a contract with the insurace company (he WAS a participating provider), stating that he would accept what they paid, and that they could NOT bill me or try to collect what he was suppose to write off. also, make sure that it was billed right, find out the CPT and ICD-9 code used. ask questions to the doctors office and the insurance company. in my case, i have a back ground in medicine and i knew that i didn't have to pay what he was suppose to write off so i stood my ground. after all it is YOUR money!!! not sure if this helps, but your not alone. huggs -keri
   — Keri P.

March 27, 2004
You should be able to go and see your regular doctor to run the blood tests. The important thing is to figure out what tests need to be run. If you take the list to your regular doctor, I am sure they can run them. Also, I would make an appointment to go and see the accounting person at your surgeons office and show them the discrepancy between your insurance records and theirs and see if you can simply get it cleared up. But if that doesn't work, my first suggestion probably will. Good Luck
   — Michelle S

March 27, 2004
Many years ago, I had a similar situation. There was a large amount of a bill that was to be written off by the hospital. Both the hospital and the insurance company were insisting that I call the other to get it resolved. At one point the hospital had resubmitted the bill, the insurance said they needed it again, etc..... They were both unwilling to call the other.It was very frustrating. So, what I did was I got both customer service reps together on the line with 3 way calling. I just sat there and let them talk and within 2 minutes it was resolved!!! You might try this. Good luck! Shelley
   — Shelley.

March 28, 2004
I would suggest that you get your insurance company involved in this problem. If this $6000 is, in fact, the in-network discount, the surgeon cannot "legally" bill you for it. He is bound by his contract with the insurance company and must write off the discount.
   — Bonnie

March 28, 2004
Yes, any doctor can order up the bloodwork and should know what you need to have run. If you need help, I recently had to move and find a new GP. My surgeon wrote a letter for me to give to him regarding the follow up care and testing that he recommends. I would be happy to share those recommendations with you if you care to e-mail me, if only for your peace of mind so that you can be sure and double check that your GP runs everything you need. Your surgeon, on the other hand, I'd tell to talk to the insurance company---or the lawyers! Good luck:)
   — christied

March 28, 2004
If you have an Explanation of Benefits (EOB) from the insurance company (and you should) it will show the contracted amount and how much YOU owe on it. I would send a copy of the EOB with the bill that you receive and tell them to check the EOB and that you do NOT owe $6000 as it was a discounted amount due to the contract they have with the insurance company. That should take care of it.
   — Patty H.




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