Unneeded second surgeon

[Some Random Guy]

What is the name of your state? MI (MI Resident w/MI coverage, hospital in Indiana)

A friend recently had a hip replacement, most of which was covered by Blue Shield health insurance. However, it turns out that the hospital had a second surgeon in on the surgery and they billed her $4700 for his services.

Her ins. co. says the second doctor was unnecessary and they aren't paying. The hospital says that she now has to pay the full $4700 with no deductions to a UCR rate.

She was never informed that a second surgeon was involved, doesn't remember ever seeing him until after the surgery, and was never informed that non-standard services were being provided. The hospital is not claiming that this was an extraordinary situation that required non-standard care. In fact, she has now found out that this is common practice for the hospital to add second doctors to many surgeries and many other patients are being stuck with these charges.

What advice should I give her on fighting this? Her insurance company doesn't want to get involved, claiming that its not covered and that's the end of their responsibility.

 

[CraigFL]

Usually BCBS prequalifies the surgery and costs-- Was this done?

 

[lealea1005]

Usually BCBS prequalifies the surgery and costs-- Was this done?

Craig is correct....usually the hospital pre-authorizes it all with the insurance company.

How did the insurance company make it's decision that the second surgeon was "unnecesary" since they were not in the operating room during the surgery?

Depending upon the length and complexity of the surgery, it is not that unusual to have a second surgeon present as an assistant to the primary surgeon. Hip surgery certainly qualifies.

 

[Some Random Guy]

BCBS was told of the surgery and informed the woman that she had coverage for the surgery before the operation. No mention of a second surgeon was made until after the surgery.

How did the insurance company make it's decision that the second surgeon was "unnecesary" since they were not in the operating room during the surgery?

The hospital has given no justification for having a second surgeon other that they planned it this way. Planned. There was no complication during surgery causing a second surgeon to be called in. He was apparently scheduled from the beginning, but BCBS may have never been informed. Not sure of that.

BCBS is not very forthcoming with information. They have just said the extra charges are denied.

But more to the point: If BCBS was properly notified of the surgery beforehand and said that it was covered, should the patient be out $4700 because the insurance company disagrees with the hospital afterward?

 

[Some Random Guy]

What a coincidence. After a month of wrangling with them over the phone and in letters, the hospital sends a letter today saying that they will accept $500 as payment in full for the $4700 bill.

I think we are going to continue to complain instead of paying for now...

 

[seniorjudge]

What a coincidence. After a month of wrangling with them over the phone and in letters, the hospital sends a letter today saying that they will accept $500 as payment in full for the $4700 bill.

I think we are going to continue to complain instead of paying for now...

Pay the dough and thank the Lord....

 

[lealea1005]

What a coincidence. After a month of wrangling with them over the phone and in letters, the hospital sends a letter today saying that they will accept $500 as payment in full for the $4700 bill.

I think we are going to continue to complain instead of paying for now...

Senior Judge is right....just pay the bill.

It would not surprise me if BCBS made the error...probably why they weren't "forthcoming with information"

 

[ecmst12]

Does the second doctor participate with BCBS? If so, were the charges denied as a contractual write-off, or as patient responsibility? Usually if a contracted doctor does not follow the proper insurance rules/guidelines, they have to eat the cost of the resulting denial, they can't pass it on to you.