I had emergency surgery (scheduled a day in advance) on my ankle in November, and I thought I’d paid everybody (hospital, surgeon, anesthesiologists) at this point. Actually, my insurance company paid most of it; I forked out less than a grand overall.
But I just got an insurance statement that indicates I’ll be owing another $1000+ to the Assistant Surgeon. She’s out-of-network, so my insurance only covers 50%.
My question, is it ridiculous that I went in with the expectation that everyone involved would be in-network? Is there any way I can take this up with the hospital, or is this just a rookie surgery mistake that I have to chalk up as a lesson learned? And is there any way to make sure any future surgeries (such as the removal of all my ankle hardware) only involve in-network docs?
You could call the billing department, explain the situation, and offer to pay what you normally would if the AS were in-network, and ask them to write off the rest. The worst they can do is say no. If they do say no, call a patient advocate provided by your insurance company and see what you can do, or file an appeal with the insurance company if that’s an option. If it is an option, the process should be explained on your explanation of benefits letter regarding the surgery.
This is an interesting question. I do believe that any reasonable person would expect that having surgery at an in-network hospital would mean that all persons immediately involved in that surgery are in-network. You couldn’t be expected to check out each and every person who assisted in the surgery, right down to the technicians to see if they were in the network, could you?
I hate to recommend that anyone call an insurance company because I know what you get nine times out of ten, but I suspect that anyone assisting in the surgery that was in-network is in effect waiving any out-of-network charges. In other words, the assistant surgeon was operating under the surgeon and so is subject to the limitations of billing for that surgeon. I don’t know if I’m being clear. This is something your insurance company should be able to tell you.
I’m so glad you’re not blindly paying the charge. I’ve had several surgeries and I’ve examined the bills for each one. There was never a bill that was entirely right, and one outpatient surgery was inflated by about three times what it should have been with charges for things that hadn’t happened. I got those charges removed even though a lot of them had already been paid by insurance, because we all pay for bogus medical costs.
In your case I think you do need advice from your insurance company. You had no control over which assistant surgeon was at your surgery, so I fail to see how you can be held liable for out-of-network charges in regard to that surgeon.
If the surgery had been planned a ahead of time then the insurance company would have worked with the billing office of the hospital and re-approved the expenses. If they were not going to fully cover a medical provider it would have been known before hand and then a replacement might have been located that was covered or they could have let the OP know that provider X was only being covered for half.
Since it was an emergency surgery and there was no time to have the insurance review the paperwork then as Alice the Goon stated your best bet may be to contact the billing department and explain the situation and ask them to write of any expenses that were over the normal in-network charges.
I don’t think you are going to get the insurance company to pay anything over than what is stated in your policy. Hell they try to get out of paying for things that are covered.
I had a similar problem not too long ago when a DEPARTMENT within an in-network hospital was determined by the insurance company not to be in-network. I asked the same question as you - do I have to check with everyone that may be involved to see if they specifically are in-network? Essentially, the insurance company said “yes”.
It’s worth a try as it was totally out of control. I have had out of network things paid if I have a reasonable excuse for needing or getting the service in that way. When you get turned down just keep talking to the next guy up the ladder.
Most insurance also has a way to file a written grievance and you might not owe that amount until that is decided. It could at least buy you some time if finances are tight.
Is the bill from the hospital, or from the asst. surgeon directly (or his practice). Lots of times doctors who work in hospitals don’t work for the hospital - they’re actually independent contractors who bill separately. I’d complain to the insurance company - I got a bill reduced in a similar ER case once, since Blue Cross agreed that an in-network hospital is sort of obligated to make sure that the doctors you see in the ER won’t bill past the in-network rates.
The hospital billing dept. has nothing to do with this situation, other than to collect whatever amount they think is due from the patient, whether or not insurance pays the bill.
The OP should contact the insurance company to find out how a not-in-network assistant surgeon managed to get on the surgical team, and how the insurance company typically handles this situation. If the assistant surgeon was operating under the umbrella of the (in-network) hospital, the his or her charge should be covered at the in-network rate. The insurance company is the only one that can sort this out. The hospital billing department doesn’t give a rat’s ass about any of this stuff. All they want is the bill paid immediately, and if not they turn the patient over to collections.
Thanks for the advice, although I’m still royally confused. I don’t have a bill yet, but I have a feeling it will be on behalf of the surgeon. So far I’ve got the insurance company telling me there’s nothing they can do, and I’ve left a voice mail at the hospital with no return call. This is going to be difficult, I think.
I think what’s going to happen is, the insurance co, the hospital, and the assistant surgeon are all going to say “not my problem,” and I’m going to write a big check.
If you don’t have a bill yet, you have nothing to fight. As was said upthread, insurance companies will try to avoid paying the in-network stuff, where there should be no doubt, let alone the out-of-network. Wait until you get a bill, then go to whoever is sending the bill and talk to them.
When/if you get a bill, ask the insurance company for a “single case agreement,” which means that the surgeon will be considered in-network for you. As a provider, I have gotten these. If that doesn’t work, raise holy hell with the billing department. It is ridiculous for one employee of the hospital to be out of network for you. You can’t possibily be expected to check. This happened to me once, and the hospital wrote off the charges.
The billing department will give a “rats ass” if they do the billing for the doctor which the OP does not know the answer to yet.
You are tad touchy.
It is not like some out of network surgery assistant snuck in through the cracks and was trying to pull a fast one. It was an emergency surgery. They are going to grab whoever it available on short notice, in-network or not.
Since the OP stated he has no bill yet then he should just wait until he gets the paperwork and then go from there.
