Medical service provider asks for consent to pursue insurance company

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southerndoc
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Re: Medical service provider asks for consent to pursue insurance company

Post by southerndoc »

spammagnet wrote: Sat Jun 12, 2021 7:02 pm How much assistance does a competent general surgeon need for a laparoscopic appendectomy?
Somebody to hold the camera. $11k is a lot. I don't think surgeons charge that much. Charge seems ridiculously high.
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Candor
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Re: Medical service provider asks for consent to pursue insurance company

Post by Candor »

With several professionals/Doc's who seem to confirm this is an exorbitant charge it would make me wonder if there was an undisclosed complication during the surgery. Or maybe it is just a blatant money grab.
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cockersx3
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Re: Medical service provider asks for consent to pursue insurance company

Post by cockersx3 »

Have had this happen to my wife and I several times. It is a very common ploy to have an out of network doc find a way to get involved in the surgery and submit an outrageous bill.

First step is to call your insurance company and explain what happened. We have done this before, and they have dealt directly with the out of network provider. Never had to pay the bill any time this happened...was told by insurance company to not pay, and I didn't, and never heard from the provider again.

DO NOT call the provider directly, you will be directed to a collection agent that is trained to do one thing and one thing only....get you to pay their fee. This is exactly what they want you to do. Don't fall for it!
Mr. Rumples
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Re: Medical service provider asks for consent to pursue insurance company

Post by Mr. Rumples »

Perhaps a call to the NJ Dept. of Banking and Insurance which handles medical insurance issues under ACA might provide some insight: 1-888-393-1062 or (609) 777-9470
https://www.state.nj.us/dobi/division_c ... tguide.pdf

A regional TV news network did an article about a high medical bill, in that case it was an ambulance. It helped.
https://www.wric.com/news/taking-action ... ance-bill/

Just today, there was an article in the Richmond Times Dispatch about something similar. . If nothing else, a reporter might do a story:

https://richmond.com

These situations are different of course, yet similar.
"History is the memory of time, the life of the dead and the happiness of the living." Captain John Smith 1580-1631
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larrydmsn
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Re: Medical service provider asks for consent to pursue insurance company

Post by larrydmsn »

Candor wrote: Sun Jun 13, 2021 7:43 pm With several professionals/Doc's who seem to confirm this is an exorbitant charge it would make me wonder if there was an undisclosed complication during the surgery. Or maybe it is just a blatant money grab.
We were told my son's appendix hadn't ruptured at the time of surgery and the operation went smoothly. And my son recovered at the expected pace. So I highly doubt there was any complication during the surgery. However it was possible that there was some undisclosed mistake by or problem with the surgeon that fortunately didn't cause any real trouble. I will call the primary surgeon to get more info. Thanks.
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larrydmsn
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Re: Medical service provider asks for consent to pursue insurance company

Post by larrydmsn »

cockersx3 wrote: Sun Jun 13, 2021 7:49 pm ...
First step is to call your insurance company and explain what happened. We have done this before, and they have dealt directly with the out of network provider. Never had to pay the bill any time this happened...was told by insurance company to not pay, and I didn't, and never heard from the provider again.

DO NOT call the provider directly, you will be directed to a collection agent that is trained to do one thing and one thing only....get you to pay their fee. This is exactly what they want you to do. Don't fall for it!
Thanks cockersx3. Yes I will check with my insurance company and the primary surgeon but won't call the assistant service provider. BTW, did you live in a state with no surprise billing law at that time? If so, was your health insurance plan covered by that state law?
lj3md
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Re: Medical service provider asks for consent to pursue insurance company

Post by lj3md »

You can request a copy of the operative report. We put in the not exactly what the PA does during the procedure. Also, you can look at the procedure codes that were billed. That should be on the bill you received from the MD and the insurance company. That would let you know if anything else was done. There are up charges for a more complex procedure than a standard procedure, but this is rare and does not typically result in much more than a 20-30% increase. The reason for this has to be documented in the op note. Talk with the surgeons office in the morning and I would hope it would be easily worked out.
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larrydmsn
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Re: Medical service provider asks for consent to pursue insurance company

Post by larrydmsn »

Mr. Rumples wrote: Sun Jun 13, 2021 8:01 pm Perhaps a call to the NJ Dept. of Banking and Insurance which handles medical insurance issues under ACA might provide some insight: 1-888-393-1062 or (609) 777-9470
https://www.state.nj.us/dobi/division_c ... tguide.pdf

...
Thank you Mr. Rumples. I certainly hope I won't get a bill from that assistant service provider and will have no need to call the numbers you provided. But if there is such a need, I will try them. Thanks.
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JonnyDVM
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Re: Medical service provider asks for consent to pursue insurance company

Post by JonnyDVM »

TropikThunder wrote: Sun Jun 13, 2021 5:16 am “I’m sorry Mr or Ms Surgery Assistant, but I never requested your services. If the primary surgeon decided they needed help, they can pay you out of their fee. Good day. I said good day!”
My favorite reply in the thread.

Not much to add other than it’s clear this is a ploy to run up the bill and your insurance isn’t having it. I would not sign and ignore it, but I don’t think it matters if you sign or not. The insurer isn’t paying them for that.
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larrydmsn
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Re: Medical service provider asks for consent to pursue insurance company

Post by larrydmsn »

lj3md wrote: Sun Jun 13, 2021 8:59 pm You can request a copy of the operative report. We put in the not exactly what the PA does during the procedure. Also, you can look at the procedure codes that were billed. That should be on the bill you received from the MD and the insurance company. That would let you know if anything else was done. There are up charges for a more complex procedure than a standard procedure, but this is rare and does not typically result in much more than a 20-30% increase. The reason for this has to be documented in the op note. Talk with the surgeons office in the morning and I would hope it would be easily worked out.
Thanks a lot lj3md. I've checked my Explanation of Benefits and don't see any procedure code. I will call the primary surgeon's office and get the operative report if possible. Thanks.
Duzz78
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Re: Medical service provider asks for consent to pursue insurance company

Post by Duzz78 »

Lee_WSP wrote: Sun Jun 13, 2021 10:57 am You are not under any obligation, legal or otherwise, to sign it. It is not a bill. It is a request for you to assign your rights to compensation by the insurer over to the surgical center.

File it away somewhere for a year and see if they even send you a bill (they shouldn't since they were compensated by the insurer).
Do not do anything until your received all the Explanation of Benefits from your insurance company for all 3 or 4 providers for this emergency. Do not worry about any bill you receive from a provider yet. Do not sign any form from a provider yet. Wait until you receive the all Explanations of Benefits related to this emergency surgery from your insurance company. You should receive an EOB for the facility/ER, the surgeon who performed the surgery, and the anesthesiologist who was needed as well. Possible a 4th EOB-lab work. You will receive bills and other from each of the providers. Then I would call my insurance company and have them explain the codes and the letters (UG, E5, etc.) and go through these EOBs. The insurance company knows more than you do. Insurance billing is complicated and complicated some more. Trust your insurance company. Also ask them what RAPL means. This automatically comes into play in emergency situations.

I do not live in NJ, but for my surgery in my state, I was billed over $160,000 from the doctor alone. He was charging for 3 procedures each for him and his assistant. In the end, I only had to pay the remainder of my deductible plus my out-of-pocket maximum at the in-network rate. That was $6000. Period. Total for all providers. All other costs were paid by my insurance company (UHC) or written off by each provider. I paid per my EOBs and it has been several years now. I never received a request for additional funds once my insurance EOBs were generated.

What you will pay will be decided by the terms of your insurance policy. What ever your deductible is and what ever your back end cost is (out-of-pocket) is most likely all you have to pay under the terms of the contracted rate agreed by each provider. In case of emergencies, that agreed contracted rate has already been negotiated by all parties on your behalf way before you entered those doors of that facility. That is why I knew I was only responsible for $6000. My maximum OOP was $6000. Per my plan, once that was paid, as long as I continue to follow my plans requirements, I never paid any additional funds toward any doctor, lab, facility or other provider for the rest of that calendar year. I have a High Deductible Health Plan.

It is possible NJ has some state law saying otherwise.
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larrydmsn
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Re: Medical service provider asks for consent to pursue insurance company

Post by larrydmsn »

Duzz78 wrote: Mon Jun 14, 2021 12:28 am Do not do anything until your received all the Explanation of Benefits from your insurance company for all 3 or 4 providers for this emergency. Do not worry about any bill you receive from a provider yet. Do not sign any form from a provider yet. Wait until you receive the all Explanations of Benefits related to this emergency surgery from your insurance company.
Thanks for the advice
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celia
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Re: Medical service provider asks for consent to pursue insurance company

Post by celia »

First, I would make all my phone calls to the insurance company and not call any doctor offices until they say to call the doctor office.

Secondly, you need to know that most doctor services and even some services in the emergency room are not billed by the hospital. These private contractors do their own billing and can include surgeons, anesthesiologists, x-ray/lab analyzers, and ambulances and are usually not in any "network". Some of them may not even be in the operating room or may bill for a service received after your son left the hospital. A common example is for doctors who read scans or x-rays offsite. And I had a "floor doctor" bill for services received a week after I left the hospital to authorize a wheelchair to be delivered to my house. (That doctor was later working remotely but reviewing my records after I was home.)

One of the harder things is to understand how YOUR insurance works. The first thing they do is to "adjust" the billed amounts, then pay a percent (or all) of that amount. In your case, if you were trying to use "in network" services and the insurance claims something was not "in network", you can remind them that this was an emergency and there was no time to look for options. The Explanation Of Benefits will tell you how much you have to pay (unless there is a secondary insurance, then you'll have to wait for their explanation, too.) Luckily, the claims department can answer most questions.
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cockersx3
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Re: Medical service provider asks for consent to pursue insurance company

Post by cockersx3 »

larrydmsn wrote: Sun Jun 13, 2021 8:52 pm
cockersx3 wrote: Sun Jun 13, 2021 7:49 pm ...
First step is to call your insurance company and explain what happened. We have done this before, and they have dealt directly with the out of network provider. Never had to pay the bill any time this happened...was told by insurance company to not pay, and I didn't, and never heard from the provider again.

DO NOT call the provider directly, you will be directed to a collection agent that is trained to do one thing and one thing only....get you to pay their fee. This is exactly what they want you to do. Don't fall for it!
Thanks cockersx3. Yes I will check with my insurance company and the primary surgeon but won't call the assistant service provider. BTW, did you live in a state with no surprise billing law at that time? If so, was your health insurance plan covered by that state law?
Not sure if my state has the "no surprise billing law." But like others have indicated, large multi-state employers like mine are covered by ERISA federal statutes which supersede applicable state law. So even if my state has a "no surprise billing law," it would not apply since it is covered by federal vs state law.
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larrydmsn
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Re: Medical service provider asks for consent to pursue insurance company

Post by larrydmsn »

Thanks celia and cockersx3.

Update: I called the insurance company BCBS today. The representative confirmed our company health plan was fully funded, not self-funded. I brought up the request from the assistant service provider and he confirmed this provider was out-of-network and BCBS paid the small portion since that service had been provided at an in-network hospital but the billed amount was more than what was allowed. He recommended I do nothing about that request and don't get involved. If that assistant service provider sends me a bill, I should forward it to BCBS and they will deal with that service provider. He further provided the name of the assistant. Some googling showed she was listed as an Anesthesiologists on most websites and as a general surgeon on a couple others (a bit strange), but she was not the primary surgeon for sure.

My research seems to indicate fully funded plans are regulated by state laws, not federal ERISA regulations. If I am not mistaken, I think our health plan is protected by NJ no surprise billing law. I plan to just do nothing and let that assistant service provider to deal with BCBS, if it still wants to.
TropikThunder
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Re: Medical service provider asks for consent to pursue insurance company

Post by TropikThunder »

larrydmsn wrote: Mon Jun 14, 2021 7:06 pm He recommended I do nothing about that request and don't get involved. If that assistant service provider sends me a bill, I should forward it to BCBS and they will deal with that service provider.
Good to hear. I think it’s a good example of “I pay for insurance so I don’t have to deal with this” although it often doesn’t work out that way.
larrydmsn wrote: Mon Jun 14, 2021 7:06 pm He further provided the name of the assistant. Some googling showed she was listed as an Anesthesiologists on most websites and as a general surgeon on a couple others (a bit strange), but she was not the primary surgeon for sure.
I’m struggling to find a way to comment that doesn’t make accusations of waste/fraud/abuse since all we know is what you’ve told us. But there’s no way in Hades that someone is both a surgeon and an anesthesiologist given the training requirements. Maybe it’s a bookkeeping error, somebody fat fingered a code somewhere, etc, who knows. But I’d love to hear a physician try to explain how a provider is billing for both those specialities.
JustGotScammed
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Re: Medical service provider asks for consent to pursue insurance company

Post by JustGotScammed »

Sure, sign it. You can always trust insurance companies and everyone associated with hospital billing to do the right thing.
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scorcher31
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Re: Medical service provider asks for consent to pursue insurance company

Post by scorcher31 »

Just to second, I would not call the surgeons office nor the assistant who may or may not work for the surgeon. As the insurance company says stay out of it. Maybe it was supposed to be a code for the anesthesiologist and somehow got miscoded, but that's not your problem. Just like car insurance, forward everything to your insurance company and let them work it out.
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larrydmsn
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Re: Medical service provider asks for consent to pursue insurance company

Post by larrydmsn »

TropikThunder wrote: Tue Jun 15, 2021 12:14 am I’m struggling to find a way to comment that doesn’t make accusations of waste/fraud/abuse since all we know is what you’ve told us. But there’s no way in Hades that someone is both a surgeon and an anesthesiologist given the training requirements. Maybe it’s a bookkeeping error, somebody fat fingered a code somewhere, etc, who knows. But I’d love to hear a physician try to explain how a provider is billing for both those specialities.
To clarify, she didn't bill for both specialties. She billed over $11K for "Surgical Assistant". But I found through googling that she was listed as an anesthesiologist on most websites but as a general surgeon on a couple others. But we know our primary surgeon was a gentleman. So her bill was exorbitant no matter what. I can give you her name through private chat if you are interested in finding out more. Thanks.
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larrydmsn
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Re: Medical service provider asks for consent to pursue insurance company

Post by larrydmsn »

scorcher31 wrote: Tue Jun 15, 2021 6:33 am Just to second, I would not call the surgeons office nor the assistant who may or may not work for the surgeon. As the insurance company says stay out of it. Maybe it was supposed to be a code for the anesthesiologist and somehow got miscoded, but that's not your problem. Just like car insurance, forward everything to your insurance company and let them work it out.
Yes exactly, especially given that our health plan is probably covered by NJ's no surprise billing law.
Katie
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Re: Medical service provider asks for consent to pursue insurance company

Post by Katie »

Is the assignment form clear that if you sign, they agree to only go after the insurance company and not you?
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larrydmsn
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Re: Medical service provider asks for consent to pursue insurance company

Post by larrydmsn »

Katie wrote: Tue Jun 15, 2021 10:39 am Is the assignment form clear that if you sign, they agree to only go after the insurance company and not you?
No. It only says they require my consent to pursue the payment from the insurance company. I think they got paid a reasonable amount already (over $400 for anesthesia in a simple surgery) and I don't plan to help them get anything more than that.
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