You wanted a fight? We may have one. BC/BS wants to pay $2300 for DS

OldBroad

OldBroad

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I just this morning was able to view the EOB for my surgeon's services. It was the only part of my care that was out-of-network. Dr. Elariny won't accept the negotiated rate for the DS.

Here is what Elariny's office billed, and what the insurance company paid:
  1. $24,071 vs. $2,287, for the DS itself
  2. $10,290 vs. $768 for"laproscopic" services
  3. $5,421 vs. $520 for umbilical hernia repair
  4. $1,368 vs. $121 for liver biopsy.
I am still in data-gathering mode. For example, I only got one of the CPT codes (43845 for the first item). I will be getting a complete set of documentation from Elariny's office in a couple of days, at which point I will be able to make a more coherent argument for why BC/BS is full of shit to try to pay so little for such a complex procedure. Mostly, I need to vent now so I don't blow a gasket before I've even started to fight.
 
First of all, you need to make a number of determinations, to (1) see how far off their numbers are from UCR; and (2) whether you are being charged properly:
  • What is your out-of-network coverage rate? 50% after a huge deductible? Or only 20%? What is your out-of-network deductible?
  • What is your yearly out-of-pocket max, including out-of-network charges?
  • What is the coverage rate for IN-NETWORK for some of the procedures?
    • And shouldn't those procedures which were NOT 43845 be covered at in-network rates? Elariny is IN-Network for procedures other than the DS.
  • What is your route of appeal?
Don't blow a gasket until and unless you need abdominoplasty ...

Elariny's numbers DO seem awfully high. Back in 2003, Aetna paid about $8500 of Rabkin's $12K fee - that included (1) DS itself; (2) cholecystectomy; (3) complex appendectomy of retrocecal appendix (required two additional lap ports); (4) umbilical hernia repair; (5) lysis of adhesions from previous surgeries; and (6) two years of follow up care. Over $40K seems hugely excessive.
 
  • The coverage rate is 65% of UCR.
  • I've already met my deductible, so that's not an issue.
  • The charges in excess of UCR don't count towards the catastrophic limit (this was news to me today, but it looks pretty clear in the plan brochure, much to my unhappiness)
  • I have no idea if Elariny can be in and out of network for different procedures during the same surgery.
  • First appeal is internal, but goes to a different team than the original decision-makers. I have six months to file, but I won't wait to start the process once I've got the data I need.
 
You need to find out (from reading the EoC? it's probably not there) whether he can be both in and out of network for the different procedures. In fact, he may be in violation of his contract with BCBS if he DIDN'T parse the procedures out.

When people get plastic/reconstructive surgery, sometimes they have part of the procedure covered, and part not (the removal of the pannus may be covered, but not the abdominoplasty to tighten the abdominal muscles; they may get a simultaneous boob lift) - it is customary for both surgeon and anesthesiologist to track and charge time for the non-covered surgery separately.
 
To help put this in perspective. I had surgery in Jan 2011. BCBSTN Medicare covered mine. So the amount my surgeon was actually paid was the Medicare negotiated rate and I owed NOTHING more to him.

He BILLED $15,000 for the DS. He was paid $1,845.90. And that was for a straight simple virgin DS. No gall bladder removal, no appendix removal, no hernia repair, no adhesions. JUST the DS itself. My surgeon was in network. But the percentage is about the same.
 
so question. If a surgeon bills $15,000 and is paid $5,000 by insurance does his practice get to write the difference off as a loss (expense) and reap that tax benefit?

and yes those charges look incredibly high. $41K for one surgery?
 
Income that is not earned is not taxed, so it's not a tax write off exactly. That's reaching back several decades to Federal Income Tax I, second year of law school.
 
Shhh .... I haven't heard anything from BC/BS or Elariny. Last I heard, Elariny was appealing the fee and my appeal was put on hold until his was determined. I'm afraid to ask anyone what is going on since I'm not being dunned by Elariny for the difference between what he billed (>$25,000) and what I paid him upfront ($11,000) plus what what BC/BS paid (<$4,000)
 
I am very lucky in that we have a BCBS PPO through my wife and her policy is incredible. We pay $250 for an admission at in network facility with an in network physician and whatever BCBS pays the surgeon and hospital is between them because we are only on the hook for $250. No deductible, no out of pocket, nada. Now our copay is going up to $350 this years and the monthly premium went from $175 to $200, but that is still miles ahead of anybody else I know. In fact it blew Caterpillar's insurance, any of the multiple choices, the hell out of water.

I know different plans vary all over the map so we are very lucky to have the coverage we do.
 
DianaCox said:
You need to find out (from reading the EoC? it's probably not there) whether he can be both in and out of network for the different procedures. In fact, he may be in violation of his contract with BCBS if he DIDN'T parse the procedures out.

When people get plastic/reconstructive surgery, sometimes they have part of the procedure covered, and part not (the removal of the pannus may be covered, but not the abdominoplasty to tighten the abdominal muscles; they may get a simultaneous boob lift) - it is customary for both surgeon and anesthesiologist to track and charge time for the non-covered surgery separately.
Click to expand...

Diane, I am in the same boat as Old Broad....same surgeon. Only Aetna. He is out of network for me, so they will pay 80% of UCR, which they have said is about $4K. So they are paying their % of that. He is billing me for the rest. I think his fee is high, but more importantly right now, the UCR is ridiculously low. I am not even sure how to go about finding out the information I need before I appeal it. Any ideas?
 
I don't know how one can find out what the UCR is - it is a closely held trade secret as far as I know. I think someone should file a class action suit to get this data disclosed and authenticated.
 

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