Re: Reasonable and Customary fees - Help

[Guest guest]

,

Is your suregon " in network " . If he is then he has to accept the R & C.

If your suregon is out of network, ask him if he is willing to waive

the costs beyond R & C. Since the insurance paid about $3500, I assume

that your copay is around $1000, and that R & C is $4500. This value

is pretty typical and probably at the high end if anything!

I have written many times with this dire warning to others: Beware of

going out of network with a PPO plan for this very reason.

With luck you physician will take the R & C. It is usually best to

negotiate these things upfront.

Dr. Rabkin has made him self famous for NOT accepting R & C and

demanding his whole fee UP FRONT before scheduling surgery. I have

seen more than a few get to the very end of the process only to be

stopped cold by this requirement.

Now I have more bad news: Is your hospital in network? If you

hospital is out of newtwork you could be seeing some VERY NASTY

bills. For example USC typically charges about $100,000 for 5 nights

stay while insurance will only pay $25,000 - leaving you with $75,000

out of pocket! Most hospitals are not as bad, but it is still a big

problem. Again, if you hospital is not an " prefered provider " then

you will have to negotiate/beg them to accept the R & C.

Hull

> Hi

>

> After researching surgery for a year, fighting insurance, hiring

> Walter Lindstrom and then finally having to change insurance I got

> approval and went ahead and had a DS on 6/12. I just hung up from

my

> insurance company CoreSource and they advised me they only paid

> 3,484.12 towards a bill of 12,146.00 based on reasonable and

> customary fees. They said they may pay more once they review the

> operative report. According to my bill I had a Biliopancreatic

> (4750.00), Gastrectomy (3364.00), Appendectomy471(1432.00) and a

> Enteroenterostomy (2456.00) It looks to me that the insurance

> company only paid against the Gastrectomy. Any thoughts on this,

has

> anyone else had to fight this battle? I expected to have to pay

> something due to resonable and customary charges, but I did not

think

> they would only pay 1/4 of the bill. This would leave me 8600.00

to

> pay, I think that is extreme.

>

> Thanks,

>

> DS - Dr.

> 6/12/01

> -50 lbs.

[Guest guest]

In a message dated 9/4/01 8:41:41 PM Pacific Daylight Time,

alyssaj@... writes:

> According to my bill I had a Biliopancreatic

> > (4750.00), Gastrectomy (3364.00), Appendectomy471(1432.00) and a

> > Enteroenterostomy (2456.00) It looks to me that the insurance

> > company only paid against the Gastrectomy. Any thoughts on this, has

>

>

Chances are they paid a little on everything....if you ever look at the

benefits explanations you get for anything medical...they show what was

charged and what was paid. My insurance for instance then requires them to

write off the difference. Some things they pay 100% but that is on their

scale...not the dr's scale. I'm sure when you do multiple things, they have

some table they use and it tells them what percent to pay. They have to make

it as complicated as possible and it seems the hospitals do better getting a

higher precent than the drs.

~~* AJ *~~

Age 37 5'8''

Post op 7/24/01 Open BPD/DS

self pay - Dr Baltasar -Alcoy Spain

07/24/01 BMI 64 415.1

08/06/01 BMI 59 390.2 -24.9 lbs! -10.75 inches

08/16/01 BMI 58 387.0 -28.1 lbs! -11.25 inches

08/24/01 BMI 58 386.5 -28.6 lbs! -15.5 inches

08/30/01 BMI 58 378.3 -36.8 lbs! -21.25 inches

My personal website: www.WLS4AJ.homestead.com

Check out the Bellingham Support Group at WWW.WLSBellingham.homestead.com

[Guest guest]

Re: Reasonable and Customary fees - Help

> Now I have more bad news: Is your hospital in network? If you

> hospital is out of newtwork you could be seeing some VERY NASTY

> bills. For example USC typically charges about $100,000 for 5 nights

> stay while insurance will only pay $25,000 - leaving you with $75,000

> out of pocket! Most hospitals are not as bad, but it is still a big

> problem. Again, if you hospital is not an " prefered provider " then

> you will have to negotiate/beg them to accept the R & C.

Cigna PPO told me that even though the hospital where Dr. Keshishian works

is IN network, the whole surgery will be considered OUT of network b/c Dr. K

is out of network.

(Thankfully, he's working on contracting with Cigna, so maybe I'll get

lucky.)

Also, don't hospitals accept the " reasonable and customary " almost always??

Are you telling me that if Dr. A were out of pocket, then USC hosp would

consider me out of network and expect me to pay $75k???

alyssa

[Guest guest]

Yes, I agree. Most in network hosp. and docs. have to accept whatever

amount is paid as paid in full plus any co-pays or deductibles. However,

out of network hosp. can really charge whatever they please and can refuse

to " write-off " any part of it unless you can prove some type of overcharges

or charges for services that you did not receive. Yes, hospitals do charge

for services that you don't get sometimes. My husband's aunt was charged

for hospital meals for her husband 2 DAYS AFTER HE HAD DIED! They tried to

tell her that the dates shown were not the dates the " received service " but

the date that it had been entered into the computer. WRONG. I used work

claims...only a processor....nothing to do with approval....and to have the

charges covered they have to be dated the " Date Of Service " ....the insurance

company does't give a fat flying leap about when stuff is typed into the

computer!! Just charging for a few extra pills or some service that may

have been ordered but never used can amount to hundreds in the amount of

your bill. So, have someone with you who can pay attention and go over your

itemized bill if you are paying out of network. I'm not saying these

mistakes are on purpose...just that hospitals make mistakes too....people

work there!

Hugs,

Jerry, southern gal from Louisiana still waiting on approval.

>From: lookn2bthin@...

>Reply-To: duodenalswitch

>To: duodenalswitch

>Subject: Re: Reasonable and Customary fees - Help

>Date: Wed, 5 Sep 2001 17:24:34 EDT

>

>In a message dated 9/5/2001 12:01:33 PM Pacific Daylight Time,

>terjer1976@... writes:

>

>

> > From what I understand, some hospitals refuse to " write off " the

>difference

> > and the patient is stuck paying the difference.

> >

>

>I asked and it depends on the contract...my hospital here in Bellingham has

>to write off the difference...so if I have to pay 20% of the bill...and the

>insurance only says they will pay 1000...then I only have to pay 200 even

>if

>the bill was like 2000. If I went out of network or only a participating

>hospital...I might end up paying the difference....makes alot of

>difference!!!

>

>~*~ AJ ~*~

>Age 37 5'8''

>Post op 7/24/01 Open BPD/DS

>self pay - Dr Baltasar -Alcoy Spain

>07/24/01 BMI 64 415.1

>08/06/01 BMI 59 390.2 -24.9 lbs!

>08/16/01 BMI 58 387.0 -27.9 lbs!

>08/24/01 BMI 58 386.5 -28.6 lbs!

>08/30/01 BMI 58 378.3 -36.8 lbs!

>

>

>

>

>

>

[Guest guest]

Alyssa,

If a contract is not in place then it is up to the hospital to decide

if it wants to accept R & C. And yep, you would be out $75K+ if you

went to USC with insurance that was not in the USC network. You

probably could pre-negotiate to get the R & C accepted, but your

leverage after the fact is not as good.

Fortunately USC has contracts with almost all PPO and indeminity

plans as well as medicare. However, USC doesn't have very many HMO

plans. Of cousre HMO's pay $0 if you are out of network (unless you

received special authorization).

For these reasons I am most comfortable with the PPO. I know that as

long as I stay with prefered providers, my out-of pocket is capped at

$500. I still have the freedom to go out of network but would pay

$1500 (cap for out of network) plus everything above R & C.

If for some reason I could not get surgery with Dr. Anthone, I would

probably pre-negotiate a deal with another hospital to accept R & C.

Hull

> Also, don't hospitals accept the " reasonable and customary " almost

always??

> Are you telling me that if Dr. A were out of pocket, then USC hosp

would

> consider me out of network and expect me to pay $75k???