Assistant surgen fee

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bemis
Regular Member


Date Joined Feb 2010
Total Posts : 38
   Posted 5/6/2010 7:01 PM (GMT -6)   
I just got a statement from my insurance company.It was for the Assistant Surgen the bill was $6,296.The ins code was EE Assistant surgen's fee limited to reasonable and customary.Covered $53.58 x 60% coverage = plan benafit of $32.15 leaveing me with the ballance.I can see the surgen haveing a big fee but the assistant!!I guess its time for a call to Johns Hopkins although they have my credit card and just charge it for any ballance after Ins pays.I have been trying to not worry about the money as I have enough to worry about but I find this troubleing.Thanks for the chance to vent   DICK  20 days RT to go
age 55 /psa 10-09 5.4/biopsy 11-09 Gleson 3+3=6 3+4=7/ Radical prostateectomy 1/22/10/pathology positive margins and extraprostatic extension pt3a,decided to do adjunct radiation therapy,PSA 4-1-10 <0.1,started RT 4-13-10


goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2691
   Posted 5/6/2010 7:06 PM (GMT -6)   
Wow ! Surprise. Those are those things they don't tell you. Hopefully he will accept assignment.

Good luck and thanks for venting. Hopefully someone else will be saved by your experience/
Goodlife
 
Age 58, PSA 4.47 Biopsy - 2/12 cores , Gleason 4 + 5 = 9
Da Vinci, Cleveland Clinic  4/14/09   Nerves spared, but carved up a little.
0/23 lymph nodes involved  pT3a NO MX
Catheter and 2 stints in ureters for 2 weeks .
Neg Margins, bladder neck negative
Living the Good Life, cancer free  6 week PSA  <.03
3 month PSA <.01 (different lab)
5 month PSA <.03 (undetectable)
6 Month PSA <.01
1 pad a day, no progress on ED.  Trimix injection
No pads, 1/1/10,  9 month PSA < .01
1 year psa (364 days) .01


142
Forum Moderator


Date Joined Jan 2010
Total Posts : 6949
   Posted 5/6/2010 9:25 PM (GMT -6)   
If they are "in-network", I would expect that they have to write off the difference as a part of the insurance company agreement. I have seen tens of thousands written off so far in this PCa challenge.
Out of network is another story. That is why I have been almost vicious about requiring they pre-certify literally everything. If anyone or anything has been shown out of network, I have overridden the choice for one that is in.
That could mean less quality care, if you have limited choices, but I can't afford the out of network "out of pocket" on my policy.

60Michael
Veteran Member


Date Joined Jan 2009
Total Posts : 2222
   Posted 5/7/2010 6:42 AM (GMT -6)   
While I might be wrong, I do think they have a responsility to tell you that fee might not be covered. Asst. Surgeon? Now my surgeon had an assistant who charged $500.00 that was out of pocket and we were told ahead of time. So I can live with that. I would certainly ask for explanantions when you are up to it.
Michael
Dx with PCA 12/08 2 out of 12 cores positive 4.5 psa
59 yo when diagnosed, 61 yo 2010
Robotic surgery 5/09 Atlanta, Ga
Catheter out after 10 days
Gleason upgraded to 3+5, volume less than 10%
2 pads per day, 1 depends but getting better,
 started ED tx 7/17, slow go
Post op dx of neuropathy
T2C left lateral and left posterior margins involved
3 months psa.01, 6 month psa.4, 6 1/2 month psa.5 on 11/28/10
Starting IMRT on 1/18/10, Completed 39 tx at 70 gys on 3/12/10
6 week Post IMRT PSA .44 a drop from .5 but maybe more
Great family and friends
Michael


Steve n Dallas
Veteran Member


Date Joined Mar 2008
Total Posts : 4829
   Posted 5/7/2010 6:49 AM (GMT -6)   

Ditto on the Doc's office writting off the balance.

Did you do robotic where the surgeon sits across the room and MUST have another person standing over you?


Age 55   - 5'11"   215lbs
Overall Heath Condition - Good
PSA - July 2007 & Jan 2008 -> 1.3
Biopsy - 03/04/08 -> Gleason 6 
06/25/08 - Da Vinci robotic laparoscopy
05/14/09  - 4th Quarter PSA -> less then .01
11/20/09 - 18 Month PSA -> less then .01
Surgeon - Keith A. Waguespack, M.D.


don826
Veteran Member


Date Joined May 2008
Total Posts : 1010
   Posted 5/7/2010 7:13 AM (GMT -6)   
Hi Bemis,

Look closely at who the assistant is. I had some surgery for a hernia years ago and there was a charge for "surgical assistant" and the name was the GP who refferred me to the surgeon. Turns out that this was a referral fee and the GP was not even in the room. I was P*&@# to say the least. Insurance would not cover the referral but would cover the "assit". (I was insured at the time) I got the amount reduced. It was almost 50% of the surgeon's fee as I recall.

Keep looking at those bills. Medical charges are some of the sloppiest I have seen and charges for doing nothing are rampant.

Best to you,
Don
Diagnosed 04/10/08 Age 58 at the time
Gleason 4 + 3
DRE palpable tumor on left side
100% of 12 cores positive for PCa range 35% to 85%
Bone scan clear and chest x ray clear
CT scan shows potential lymph node involvement in pelvic region
Started Casodex on May 2 and stopped on June 1, 2008
Lupron injection on May 15 and every four months for next two years
Started IMRT/IGRT on July 10, 2008. 45 treatments scheduled
First 25 to be full pelvic for a total dose of 45 Gray to lymph nodes.
Last 20 to prostate only. Total dose to prostate 81 Gray.
Completed IMRT/IGRT 09/11/08.
PSA 02/08 21.5 at diagnosis
PSA 07/08 .82 after 8 wks of hormones
PSA 10/08 .642 one month after completion of IMRT, 6 months hormone
PSA 03/09 .38 six months post radiation and nine months into hormones
PSA 06/09 .36 or .30 depending on who did the test
PSA 09/09 .33 one year after IMRT and 16 months into hormone
PSA 03/10 .32 18 months after IMRT Still on hormones


bemis
Regular Member


Date Joined Feb 2010
Total Posts : 38
   Posted 5/7/2010 8:07 AM (GMT -6)   
All Hopkins is out of network for me.When I was diagnosed by my local Uralogist, he would not give me a referal to hopkins as a medical necessity.As a result I decided to spend the extra money.In network its a 20 % co-pay out 40 %.I am goiing to pursue relief. Dick Today I'll be half way done with RT!
age 55 /psa 10-09 5.4/biopsy 11-09 Gleson 3+3=6 3+4=7/ Radical prostateectomy 1/22/10/pathology positive margins and extraprostatic extension pt3a,decided to do adjunct radiation therapy,PSA 4-1-10 <0.1,started RT 4-13-10


medved
Veteran Member


Date Joined Nov 2009
Total Posts : 1096
   Posted 5/7/2010 1:15 PM (GMT -6)   
The problem with "out of network" is not so much the 20% less coverage (or whatever), but that the hospital/docs are not bound to accept the negotated rates. Still, the difference between $6,000 + charge and $50 reasonable and customary is pretty extraordinary.

The insurance situation at JHU is interesting in that not all the docs there participate in the same insurance plans, even though they are all JHU employees. For example, there are some plans that Walsh, Partin and Carter do not participate in, but the other docs do. I guess those docs probably have all the business they need, and JHU does not need to sell their services for the lower negotiated rates.

bemis - if you dont mind me asking, who did your surgery there and what was the surgeon's fee?

(At JHU, I would be VERY surprised if the "assistant" charge is a referral fee. The practice of paying referral fees, and particularly the practice of dressing up referral fees as something else, such as an assistant fee, seems unethical to me, and I assume probably illegal too).
Age 46.  Father died of p ca. 
My psa starting age 40: 1.4, 1.3, 1.43, 1.74, 1.7, 1.5, 1.5
 


Zen9
Regular Member


Date Joined Oct 2009
Total Posts : 310
   Posted 5/7/2010 3:18 PM (GMT -6)   

Slightly off point, but just to illustrate the games the medical profession plays:

My wife's internist announced last week that there will now be an annual fee of $1,500 (not covered by insurance) just to be "accepted" as a patient, above and beyond the charges for actual services rendered.

Zen9


mspt98
Regular Member


Date Joined Dec 2008
Total Posts : 375
   Posted 5/7/2010 4:28 PM (GMT -6)   
Yes, I have heard where some doctors are charging these "patient fees" just to become part of someone's practice. What a bunch of a bull. I realize internists are p----off that they are only making $180,000 instead of $400,000 that the specialists are making. But if I get such a fee I will definately change doctors....................
my age=52 when all this happened,
DRE=negative
PSA went from 1.9 to 2.85 in one year, urologist ordered biopsy,
First biopsy on 03/08, "suspicious for cancer but not diagnostic"
Second biopsy on 08/14/08, 2/12 cores positive on R side, 1 core=5% Ca, other core = 25% Ca, Gleason Score= 6 both cores,
Clinical Stage T1C
Bilateral nerve sparing Robotic Surgery on 09/11/08, pathological stage T2A at surgery
No signs of spread, organ contained,
4 0's in a row now, 14 months out
Incontinence gone in early December '08,
ED remains, have given up on penile rehab, trimix injections used for sex now, that's the way it's going to be ...


deer hunter
Regular Member


Date Joined Jan 2010
Total Posts : 246
   Posted 5/7/2010 7:03 PM (GMT -6)   
They arelike most car salesman they try to charge for everybody and the paperwork along with it
DEERHUNTER
dx age 57 01/06 open RP 4/06 psa in 01/06 8.1  surgery path report Gleason 3+4=7 poorly differentiated  tumor was 90%involved in both lobes surgical margins postive. in the right apex and right radial margins tumor grade G3  perineural invasion present high grade of PIN found  T2c NX MX PSA 0706  .01 10/06 .02 01/07 .03 04/07 .04  06/07 .05  07/07 .08 07/07 bone scans pelvic ct neg. 08/07 proscintic scan neg.9/07 psa.10 net with rad onc. wanted to do SRT but i did not do it 10/07  saw a new dr at Emory University [my old dr urg. suggested second opinion ]  bone scans negs ct scans pelvics neg. biopies of the bladder and adrinal glands neg.another proscintic scan neg.12/07 Psa .11 clinial trial Emory injected with protons to try and find the cancer cells no luck 3/08 psa .17 06/08 psa .23 psa 09/08 psa .32 12/08 psa .39 3/09 psa .39 6/09 psa .43  meet with medical onc. he said  i might have waited to long to start SRT 7/09 psa .50  another bone scan ct scan all neg.MRI neg. meet rad. psa the last of 7/09was .55 onc. 7/09 started casdex 50mg 1 day for 30 days 2 shots of lupron started rad treament 10/09 40 treatments 75 gm 12 shots each time all aroud pelvic finished 12/09  psa .07 and psa 01/10.05 next dr visit 03/10 wait and see 3/10 psa.05


bemis
Regular Member


Date Joined Feb 2010
Total Posts : 38
   Posted 5/8/2010 6:48 AM (GMT -6)   
Well I'm sitting at my desk getting all my bills statements etc. out to look at the whole situation. I'll report back. DICK
age 55 /psa 10-09 5.4/biopsy 11-09 Gleson 3+3=6 3+4=7/ Radical prostateectomy 1/22/10/pathology positive margins and extraprostatic extension pt3a,decided to do adjunct radiation therapy,PSA 4-1-10 <0.1,started RT 4-13-10


medved
Veteran Member


Date Joined Nov 2009
Total Posts : 1096
   Posted 5/17/2010 8:42 AM (GMT -6)   
Dick - were you able to work out what the "assistant surgeon" fee was for, and how Johns Hopkins would deal with it?
Age 46.  Father died of p ca. 
My psa starting age 40: 1.4, 1.3, 1.43, 1.74, 1.7, 1.5, 1.5
 


MrGimpy
Veteran Member


Date Joined Jul 2009
Total Posts : 504
   Posted 5/17/2010 10:02 AM (GMT -6)   
I had at least 2 surgeons.

In this day and age it is highly unlikely ( nor would you want) only one Dr in the OR
Stats:
Age: 52, PSA (2008)=1.9
Biopsy on 01/09/09, Gleason Score = 3+3
One (1) out of twelve (12) cores was positive, plus external nodule found
Surgery (Da Vinci, robotic prostatectomy): 4/7/09
Post Op Path 3+3
Removed Catheter: 04/19/09
100% bladder control - Pad free 7/09
PSA 7/09 undetectable, <0.01 - 3 months post-op
PSA 1/10 undetectable, <0.01 - 9 months post-op
Trimix provides 100% erectile function


offpsa
New Member


Date Joined Jun 2009
Total Posts : 15
   Posted 5/17/2010 10:35 AM (GMT -6)   
Can anyone tell me what is the final cost for prostate cancer surgery?
 
I supose their are variables, but a ball park would be good.
 
Thanks

Casey59
Veteran Member


Date Joined Sep 2009
Total Posts : 3172
   Posted 5/17/2010 10:45 AM (GMT -6)   
offpsa said...
Can anyone tell me what is the final cost for prostate cancer surgery?
 
I supose their are variables, but a ball park would be good.
 
Thanks
Insurance was billed approximately $50K for everything, starting with biopsy, ending with DaVinci surgery.

James C.
Veteran Member


Date Joined Aug 2007
Total Posts : 4462
   Posted 5/17/2010 11:05 AM (GMT -6)   
My open RRP, one night stay, was $36,134 inclusive, from biopsy to first post surgical psa test. That's what BCBS said they paid.
James C. Age 63
Gonna Make Myself A Better Man www.youtube.com/watch?v=a6cX61oNsRQ&feature=channel
4/07: PSA 7.6, Recheck after 4 weeks Cipro-6.7
7/07 Biopsy: 3 of 16 PCa, 5% invloved, left lobe, GS3+3=6
9/07: Nerve Sparing open RRP, 110gms, Path Report- Stg. pT2c, 110 gms., margins clear
3 Years: PSA's .04 each test since surgery, ED continues: Bimix- .3ml PRN, Trimix- .15ml PRN


MrGimpy
Veteran Member


Date Joined Jul 2009
Total Posts : 504
   Posted 5/17/2010 11:48 AM (GMT -6)   
There are many factors that make it diff for each patient

How many nights stay ? Even something as simple as needing extra Pain meds or BP/statin meds
Stats:
Age: 52, PSA (2008)=1.9
Biopsy on 01/09/09, Gleason Score = 3+3
One (1) out of twelve (12) cores was positive, plus external nodule found
Surgery (Da Vinci, robotic prostatectomy): 4/7/09
Post Op Path 3+3
Removed Catheter: 04/19/09
100% bladder control - Pad free 7/09
PSA 7/09 undetectable, <0.01 - 3 months post-op
PSA 1/10 undetectable, <0.01 - 9 months post-op
Trimix provides 100% erectile function


bemis
Regular Member


Date Joined Feb 2010
Total Posts : 38
   Posted 5/18/2010 7:08 AM (GMT -6)   
Well I didn't make much progress trying to figure my bill out from Johns Hopkins I have never recieved a bill from them for the Assistant Surgen.I just got my Ins. statement on the bill.I did see that my bill for my surgen was the same amt. as for the assistant $ 6,296. It seems the assistant would be less?I'm getting a little burned out with my adjunct RT as I go to work at 6:30 leave for the hospital at 10:30 and get home at 3:30.By then I'm beat and can't think about getting on the phone with the Hospital.RT is going well, by friday I'm pretty tired but the weekend helps rejuvinate me.I switch from whole pelvis to IMRT today, they said I would get some X-rays for alignment before the treatment.13 days to go. DICK
age 55 /psa 10-09 5.4/biopsy 11-09 Gleson 3+3=6 3+4=7/ Radical prostateectomy 1/22/10/pathology positive margins and extraprostatic extension pt3a,decided to do adjunct radiation therapy,PSA 4-1-10 <0.1,started RT 4-13-10


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 5/18/2010 7:22 AM (GMT -6)   
offpsa:

the "list price" of my open surgery, including 4 days in the hospital and everything else related to it was around 89K. I am not sure what it was settled for, as I still haven't been asked to pay for any of it in nearly 18 months.
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Incontinence:  1 Month     ED:  Non issue at any point post surgery, no problem post SRT
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, next one:  July
Latest: 7/9 met 2 rad. oncl, 7/9 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 out 38 days, 9/9 - met 3rd rad. oncl., mapped  9/9, 10/1 - 3rd corr. surgery - SP cath/hard dialation, 10/5 - 11/27 IMRT SRT 39 sess/72 gys ,cath #8 33 days, Cath #9 35 days, 12/7 - Cath #10 43 days, 1/19 - Corr Surgery #4,  Caths #11 and #12  same time, 2/8-Cath #11 out - 21 days, 3/2- Cath #12 out - 41 days, 3/2- Corr Surgery #5, 3/6 Cath #13 out - 4 days, Cath #14- 27 days, Cath #15 - 26 days, Cath #16 - 4/23 put in


bemis
Regular Member


Date Joined Feb 2010
Total Posts : 38
   Posted 5/22/2010 6:52 AM (GMT -6)   
Well GOOD NEWS I got my Hopkins bill for the assistant surgen and low and behold they accepted the ins companys adjustment!!!Bill $6,296. Ins pmt recieved $32.15,Adjustment - $6,242.42 Amt due now $ 21.43 I just finished getting the check written.I find the whole thing confuseing and wish the industry would bill everyone the same amt.I feel for the people with no ins who get no adjustments and are expected to pay the full amt..I ve got 9 more days of RT to go and am feeling pretty good other than the fatigue which slows me down in the afternoons. DICK
age 55 /psa 10-09 5.4/biopsy 11-09 Gleson 3+3=6 3+4=7/ Radical prostateectomy 1/22/10/pathology positive margins and extraprostatic extension pt3a,decided to do adjunct radiation therapy,PSA 4-1-10 <0.1,started RT 4-13-10


compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7205
   Posted 5/22/2010 8:26 AM (GMT -6)   

Dick:

 

WHAT A RELIEF, RIGHT??!@!

I bet you paid that bill in record time!

Mel


63 years old . PSA-- 3/08--2.90; 8/09--4.01; 11/09--4.19 (Free PSA 24%),  after 45 days on cipro! DREs have always been normal. PCA-3 was about 75 (way above the 35 threshold). That led to:

Biopsy on 11/30/09. 5 out of 12 cores positive. Gleason 4+3. 2 cores were 3+3 (one 5% and the other 30%) on one side. On  other side:2 cores are 4+3 (5%)--1 core 3+4 (30%) no peri-neural invasion. prostate is 45 grams. Stage: T1C.  

Surgery with Dr. Menon at Ford Hospital, 1/26/10. He says all looked good. Spared nerves. Unfortunately: Pathology Report: G 4+3 (65%-35%). Cancer in 15% of gland. Lymph Nodes: Clear.  Perineural Invasion: yes. Seminal Vessical Involvement: No.  Extraprostatic Extension: yes.  Positive Margin: Yes-- focal-- 1 spot .5mm. Final Weight is 52.7 gms.  (Second opinion from Jon Epstein at Hopkins confirmed these results)

 Incontinence: joined that club-- definite leaks—1 pad/day. Night is dry, was  using 1 pad at night for security, but pretty much dispensed with that most nights. Update: no pads at night. No pads while at home, but still very uncomfortable. Use 1 pad for out-of-house activities. Suddenly got MUCH better on 3/10/10, almost overnight. Still some urgency but no pads about 90% of the time.  As of 3/12/10--completely continent! Uh...OH. As of about 3/16/10 problems with constant urgency although no pads needed--feels like an infection but none showing in urine.

Update: since late March all is well in that area. I would say 99.9% continent (a spurt here and there, maybe 5 spurts per week).

First post-op PSA on 3/10/10--DRUM ROLL: 0.01 Next PSA in mid-June.


medved
Veteran Member


Date Joined Nov 2009
Total Posts : 1096
   Posted 5/22/2010 9:53 AM (GMT -6)   
That is a happy result, particularly since you mentioned in earlier post that all Hopkins is out-of-network for you - which presumably means you could have been balanced billed by the doctor.  (By the way, Maryland -- where Hopkins is located -- recently enacted legislation that impacts the ability of hospital-based physicians who are out of network to balance bill patients, resolving a long dispute between insurers and docs.  I won't describe the legislation here - unless someone asks - because it is probably not of sufficient general interest, and in any event does not become effective  until next year -- but if it effects you, you might want to have a look).
Age 46.  Father died of p ca. 
My psa starting age 40: 1.4, 1.3, 1.43, 1.74, 1.7, 1.5, 1.5
 


compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7205
   Posted 5/22/2010 10:57 AM (GMT -6)   
Medved:

Can you elaborate a bit.
I got a second opinion on my pathology from Jon Epstein at Hopkins.

They are not in network. They sent the bill to my insurance company. It was $250. My insurance is only paying them a very small amount but the EOB says I should only pay $60. I wonder if Hopkins will honor that, since they have no ties with my insurance company.

Mel

63 years old . PSA-- 3/08--2.90; 8/09--4.01; 11/09--4.19 (Free PSA 24%),  after 45 days on cipro! DREs have always been normal. PCA-3 was about 75 (way above the 35 threshold). That led to:

Biopsy on 11/30/09. 5 out of 12 cores positive. Gleason 4+3. 2 cores were 3+3 (one 5% and the other 30%) on one side. On  other side:2 cores are 4+3 (5%)--1 core 3+4 (30%) no peri-neural invasion. prostate is 45 grams. Stage: T1C.  

Surgery with Dr. Menon at Ford Hospital, 1/26/10. He says all looked good. Spared nerves. Unfortunately: Pathology Report: G 4+3 (65%-35%). Cancer in 15% of gland. Lymph Nodes: Clear.  Perineural Invasion: yes. Seminal Vessical Involvement: No.  Extraprostatic Extension: yes.  Positive Margin: Yes-- focal-- 1 spot .5mm. Final Weight is 52.7 gms.  (Second opinion from Jon Epstein at Hopkins confirmed these results)

 Incontinence: joined that club-- definite leaks—1 pad/day. Night is dry, was  using 1 pad at night for security, but pretty much dispensed with that most nights. Update: no pads at night. No pads while at home, but still very uncomfortable. Use 1 pad for out-of-house activities. Suddenly got MUCH better on 3/10/10, almost overnight. Still some urgency but no pads about 90% of the time.  As of 3/12/10--completely continent! Uh...OH. As of about 3/16/10 problems with constant urgency although no pads needed--feels like an infection but none showing in urine.

Update: since late March all is well in that area. I would say 99.9% continent (a spurt here and there, maybe 5 spurts per week).

First post-op PSA on 3/10/10--DRUM ROLL: 0.01 Next PSA in mid-June.


medved
Veteran Member


Date Joined Nov 2009
Total Posts : 1096
   Posted 5/22/2010 1:36 PM (GMT -6)   
In a typical health insurance plan, the insurer determines the "allowed" charge for a particular service and then agrees to pay some specified percentage of that (say, 80%) if the doctor (of facility, if it is a facility charge) who provides the service is "in network" and a lower percentage (say, 60%) if the doc (or facility) is "out of network".  In-network docs agree to accept the "allowed" charge as full payment for the service rendered.  That is why you see, on your bill, a "contractual adjustment."  So the provider may bill $1000 "retail" for some service, but the "allowed" charge by the insurer may be, say, $300.  The in-network doc then writes off the $700 difference.  (He can still charge you for the portion of the allowed charge that the insurer does not pay -- the 20% or whatever).  However, an out of network doc can typically bill you for the full difference between his "retail" charge and what the insurer pays.  That is referred to as "balance billing."  This is something patients often don't focus on,  until it is too late.  They may think the difference between  using an in network doc and an out of network doc (or facility) is simply the difference between, say, 80% coverage and 60% coverage.  The bigger difference, however, can be the balance billing.  Balance billing is controversial, and some states have tried to limit it.  But the docs say "if I choose not  to join a network, I should be able to bill whatever I want." 
 
Balance billing is particularly controversial with respect to doctors who a patient does not choose -- for example, typically a patient does not choose his anesthesiologist or (except for some particularly sophisticated people who populate this board, and who are not at all typical of medical patients) their pathologists.  And of course they don't choose their ER docs or emergency surgeons, etc.   But if one  of these people turns out to be out of network, and decides to balance bill the patient, it can be VERY expensive.  There are people who have had to file personal bankruptcy because of this sort of unanticipated balance billing.
 
In Maryland, the largest health insurance company in the state refuses to pay out of network doctors directly.  Instead, it pays the patients.  The insurer does this in order to induce docs to join  the network.  A doc who joins the  network must waive the right to balance bill, but he gets the benefit of direct payment from the insurer, rather than having to chase patients who often don't pay or pay very late, etc.  This is a substantial benefit for docs.  The MD legislature had a proposed bill that would have required all insurers in the state to make direct payment to out of network docs.  (Most already did, but as I said the largest one did not).  The docs union (so to speak) liked that but the largest insurance company hated it.  The insurer would lose  its leverage to keep docs in the network.  If a doc could get direct payment from the insurer even if he was out of network -- and at the same time preserve the right to balance bill -- why not do that?  Then someone said "lets add an amendment to this bill to make balance billing illegal."  That insurers liked that but the docs did not.  In the end, a compromise was worked out where (1) insurers have to pay out of network docs directly (whatever their reimbursement is to out of network providers under the particular policy); (2) out of network doctors who are "hospital affiliated" cannot balance bill; but (3) these out of network docs will get reimbursed by the insurance company at a higher rate than in network docs who provide the same service -- to compensate for the prohibition on balance billing.   I have oversimplified this a little bit and left out some detail, but that is the basic idea.  It is (in  my view) a novel compromise.  It has not taken effect yet.  It is also not the law in other states, so, as they say, your mileage may vary.
 
Some of you seem to  have an experience where an out of network doctor did not balance bill.  That happens.  No doctor or hospital is required to balance bill.  But it is a risk when you use an out of network doctor or facility and do not address the issue up front.  I am told by some doctor friends that it is often possible to negotiate with out of network doctors, to eliminate or very substantially reduce any balance billing.  But, of course, the time to do that is before the service is rendered -- and many patients are not focused on that sort of thing  when they are facing a serious illness or surgery.
 
 


Age 46.  Father died of p ca. 
My psa starting age 40: 1.4, 1.3, 1.43, 1.74, 1.7, 1.5, 1.5
 

Post Edited (medved) : 5/22/2010 2:31:34 PM (GMT-6)

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