advertisement
advertisement

Surgeon's Office Issues

My 2-level ADR surgery was finally approved after many months of appeals and issues. I want the surgery ASAP, August 1st or 2nd if I can. I want to run the surgery through my health insurance but my surgeons office wants their fees ($56k) on my car accident lien/some finance company they go through. 

Now I feel like I'm fighting with the surgeons office manager. She won't come out straight with me and explain why she doesn't want to run this through my insurance and I feel like I'm in a loss-lose situation. I don't want to piss her off and she sounds frustrated. Does anyone out there know why I might possibly have this issue? I have the money to pay my max out of pocket up front and told them that. 
advertisement

Comments

  • SavageSavage United StatesPosts: 4,299
    Hello...
    It is so difficult to sort these things out under the best of situations.
    Within my circle of friends and acquaintances, I have become personally aware of some health insurance companies going out of business....bankrupt.

    The State has picked up and will provide coverage for a precious few months.
    Within three months, the State expects the innocent/injured parties to yet again research for new health insurance companies, doctors' acceptance of that company, facilities acceptance of that company and be signed up with new found  health insurance company....begining again their cycle of deductible...(.as previous money to previous company's deductible is..just gone.)
  • Ellen625EEllen625 New Jersey, USPosts: 754
    I am not a lawyer however if your surgery is a result of an accident, the auto insurance may be picking up the tab as opposed to your health insurance. Can you call someone at the insurance company and ask them to explain it to you?
  • advertisement
  • Is your surgeon in or out of network?  If in network, then they have to take whatever your insurance company will pay them (which is less than $56,000, I'm sure) and you have to pay your share of the deductible.  If your surgeon is out of network, he can charge whatever he wants (which appears to be $56,000) and you submit it to your insurance company and they will credit a teeny portion of the actual charges to your out-of-network deductible. (I know this from experience since I used an out-of-network surgeon and ending up paying all cash for the surgeon's fee). The surgeon is not interested in cutting you a deal because he knows that eventually your are going to recoup all the money from the auto accident case.
  • jb3jjb3 OhioPosts: 1
    Hi Sara, I hate to impose on Y'alls conversation but it sounds to me like your Dr. might not want to get pulled in to a lawsuit issue. I don't know for sure but it seems that may be the reason.  IDK  I wish you luck, and if they are making you wait and you have nerve impingement those side effects can become permanent.  If they make you wait too long you may want to get a second opinion. I wish you all the best no matter what, I have been there done that ya know.
  • sara.gsara.g CaliforniaPosts: 43
    Yes, this is an auto accident case. But, I had a prior injury and my auto accident lawyer says my low-speed accident might easily not cover my medical expenses. 

    Its an an out of network Surgeon. So, if my max out of pocket for in network is $6,500 and my max out of pocket for out of network is $13,000, and I have both in network hospital fees plus the surgeon's fees, do I pay $19,500 or $13,000 for the surgery? This is where I am confused. I don't know if the max out of pocket fees are separated.
  • advertisement

  • sara.g said:
    Its an an out of network Surgeon. So, if my max out of pocket for in network is $6,500 and my max out of pocket for out of network is $13,000, and I have both in network hospital fees plus the surgeon's fees, do I pay $19,500 or $13,000 for the surgery? This is where I am confused. I don't know if the max out of pocket fees are separated.
    Yes, they are separated. You pay $19,500 and probably more. I used an in-network surgery center. My maximum in-network out of pocket is $4,000, so I had to pay $4,000 and the insurance company paid the rest. My surgeon was out of network and charged $10,000. My out of network maximum is $10,000, but the insurance company didn't care that I paid the surgeon $10,000 -- the insurance company credited less than $3,000 of his fee to my out of network out of pocket. The insurance company doesn't credit what the out of network surgeon charges -- instead it credits some teeny portion of that (or at least that is what my insurance company did, which I think is typical). I then also paid the out-of-network anesthesiologist out of pocket -- another $1,500 if I recall.

    The misassumption that you are making is that because your out-of-network maximum out of pocket is $13,000, you won't have to pay more than $13,000 for the surgeon. You not only have to pay what he demands because it is between you and him and not the insurance company, but the insurance company is only going to credit a small portion of that to your out of pocket, so you could end up like me not even having met your insurance out of network out of pocket even though you have already actually paid more than that in out of network fees.

    Artificial discs are expensive. Do you know if the disc itself is going to be on the network side or non-network side of the equation?  Obviously it would be preferable if the discs themselves were in-network. I think they are about $5,000 each, so that is $10,000 right there. Your surgical fees will also be higher than mine because you are having a two-level and also I think surgeons charge more for ADR than for ACDF.

    Anyway my sympathies. I tore my hair out before surgery trying to figure this all out. I don't regret going out of network. My philosophy is that you cut expenses elsewhere not on doctors, although unfortunately going out of network and paying high fees does not always guaranty a better result. In my case, it worked out because I had no pain, no swallowing difficulties and was back to work full-time in 6 days, so that was priceless to me.
  • Ellen625EEllen625 New Jersey, USPosts: 754
    My insurance has no out of network coverage and there was no way I could pay so I searched and researched and found an excellent surgeon who was in network.
  • Sara.g, have you investigated in-network surgeons?  Why have you chosen to go out of network?

    In my case, I live in a locality where most of the experienced spine doctors have either opted out of insurance entirely or opted out of the crummy insurance I am able to buy. If I had stayed in network, I did not have any well-regarded highly experienced spine doctors to choose from. Strangely, I'm having shoulder surgery soon and I am staying in network, because there are still a few good, experienced sports medicine doctors in my locality who accept my insurance.

    So I think it all depends on where you live and the type of surgery as to whether you will find a great surgeon in network.


  • sara.gsara.g CaliforniaPosts: 43

    L.A.Spiney said:
    Sara.g, have you investigated in-network surgeons?  Why have you chosen to go out of network?

    In my case, I live in a locality where most of the experienced spine doctors have either opted out of insurance entirely or opted out of the crummy insurance I am able to buy. If I had stayed in network, I did not have any well-regarded highly experienced spine doctors to choose from. Strangely, I'm having shoulder surgery soon and I am staying in network, because there are still a few good, experienced sports medicine doctors in my locality who accept my insurance.

    So I think it all depends on where you live and the type of surgery as to whether you will find a great surgeon in network.



    I feel like I'm willing to do whatever they need at this point because he is known to be a very good surgeon in this area. I want to get the surgery done very quickly too because it's been put off so long already, as is. I need the surgery badly at this point and hope we can do what they say so I can shoot for August 2nd or 3rd. The pain is miserable!
  • SavageSavage United StatesPosts: 4,299
    edited 07/23/2019 - 1:08 PM
    hello jb3 !
    Welcome to Veritas Health Forumplease click on link for helpful information!
advertisement
Sign In or Join Us to comment.