Medical Insurance Problem with surgery fees and billing.. Please help!?

Question

I had nose surgery approximately three months ago.

I had a deviated septum and tip work done. The doctor

quoted me at 5,400. Insurance covered the bridge work

b/c of my breathing problem. The doctored requoted me

at 4,000. I paid 4,000 in full that day. Now three months later,

I received a bill for 4,200. How could the doctor do this? He was only suppose to bill insurance for 1,400... NOT 4,200!

One of my fees was general anesthesology(sp?) which was already included in the 4,000 that I paid. Insurance only paid 755.00. Now I am left with a 3,500 bill. The surgery agreement was for 5,400 NOT 8,225. Is this illegal for the doctor to do? I did not approve for him to bill my insurance that much nor did I sign that I would pay the remaining balance b/c insurance already said they would pay the deviated septum part. I can't believe the doctor did this just in order to cushion his wallet. What do I do? Negotiate w/ the doctor or insurance company?

Answer 1

Write the doctor's office a letter and state the date and what was agreed upon.  This error may be made by one of his assistants and they might not know what they are doing or the doctor may not know what his assistant is doing.  The office should have given you a written account of what was to be paid for and what was covered in this amount.

I would copy the insurance company and include a copy of your cancelled check.  Tell him that as agreed your account has been paid in full.

Answer 2

Hopefully, you got a written agreement on the amounts you would owe. If so, take a look at it and if the doctor has not followed those guidelines, call him on it.

Also, verify that the insurance was billed-even for the services that would not be covered.

If the insurance paid your anesthesiologist as a preferred doctor, there should have been an adjustment done in accordance with that agreement he has with your insurance.

You should have explantions of benefits from your insurance showing the amount he needs to write off as a preferred provider.

Make sure you understand all that you are being billed for and that it is according to your agreement.

Answer 3

If this was done in the hospital you're going to have fees from the faciliy (hospital), surgeon, and the anesthesiologist..seperately. I have members call all the time upset because they were told that their hospital bill would only be a certain amount, but they failed to tell them the surgeon bills for his part, the anesthesiologist bills for his part etc..etc..

did the bill come from the doctor..or the hospital? who?

edited to add: I would discuss with the doctor not the insurance company.. check your EOB and see what your liability is..sometimes a provider will bill you for the contractual write-off..subset procedures etc.. that the provider shouldn't have billed seperately for.

Answer 4

You said that you negotiated a deal with your doctor, correct?  Did you also negotiate the hospital/surgical facility charges in advance?  Generally, for a surgical procedure, you'd get separate bills from the doctor, hospital/surgery facility, and anesthesiologist.

Do you have written documentation about the quote you got from your doctor?  If the quote didn't specifically say that it included everything (doctor, hospital/surgical facility, and anesthesiologist), then you might be out of luck.  The hospital/surgery center is still entitled to be paid for the use of their facility.  And generally doctors aren't able to negotiate and accept payment in advance on behalf of the facility...unless they happen to own the surgery center.

Also, your doctor is legally obligated to put all of the services you received that day on the bill.  (Even the ones you were planning to self-pay for.)  So, its not at all unethical  for the doctor to send a copy of the entire bill to the insurer.  The insurance company needs all the information on what was being done that day to accurately process the bill, and believe me...they will deny the cosmetic stuff you already paid for!

The reason the insurer needs the documentation on what else was done that day is due to how outpatient surgeries are reimbursed.  When multiple procedures are done in one day, the doctor doesn't get the full amount for each procedure.  (There's a reimbursement mechanism called ASC Grouping, which is a pretty standardized way of determining all that stuff...I won't bore you with all the technical jargon right now.  lol)  At any rate, every surgical procedure done that day is required to be on the claim submitted to the insurer, in order to adequately assess what proportion of the time/expense in the operating room went to each surgery...that's how the insurer calculates how much they will pay the doctor.

I would confirm with the doctor whether you actually owe any additional money, or whether you're just looking at the Explanation of Benefits from your insurance company.  When the insurer processes your claim, they will deny the cosmetic portions of your surgery.  And they will have to reflect that denial on your EOB.  The EOB isn't a bill - its just a statement showing how your insurer processed the claim.  If you had already settled that portion with the doctor in advance, then you should be okay.

But if you're being billed for hospital charges that weren't included in your doctor's negotiation...well, there isn't much you can do about that.  Unless the doctor provided you with paperwork in advance stating that your quote was supposed to include *everything.)