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unbelievable billing quote for nyc surgeon..advice please

lynettellynette Posts: 217
edited 06/11/2012 - 8:40 AM in Back Surgery and Neck Surgery
Recieved a quote for just the professional billing charges for 360 fusion. Anterior part was $58,000 and the posterior part was 81,000!!!This is not any hospital anesthesia, or vascular surgeon charges!Just the spine surgeon charges!
Just want to give a quick rundown of my new insurance and how this will work for my surgeon in nyc.I am sched for 360 single level fusion on march 9th. I work for a local health care system and this is our new ins as of Jan 1.It is a BC/BS ppo product for our UHS health care system.Tier 1 is in network coverage(UHS PROVIDERS)tier 2 is out of network BC/BS providers and then there is out of network coverage.Apparently my spine surgeon does not par with any insurance and his charges will fall out of network.The billing office told me to call my insurance with the codes and fees they gave me and see what the insurance will pay of those fees and then they will let me know if they will accept that. Has anyone had experience with this? Are these charges off the chart or in the ballpark..or is it cuz he's a big time nyc surgeon he can charge what he wants. lynette


  • Those charges are a bit higher than here where I live in the Midwest...but they are not off the charts. The bill I got for a one level PLIF for my surgeon and the PA was $61,000. This was just for the surgeon -- no other charges were included, not even the hardware they implanted.

    This is, of course, not what the insurance company will pay as they have a negotiated rate...after my deductible I did not pay a penny out of pocket.
  • lol - he can charge what people will pay. I have no idea what these surgeries go for. I find it hard to believe that any surgeon gets those rates. Maybe for the whole surgery including hospital.

    Call your insurance. My husband goes to a cardiologist who doesnt participate in any plans. He accepts what our insurance will pay out of network. So I get a check and send it to them. SOunds like the same thing.

    I would suggest if they say they will accept the insurance to get that in writing from the surgeons office with dollar amounts. You don't need problems later.
  • I was prepared to pay the out of network benefit and my max out of pocket is $4000 but when the ins co told me that because he did not par with bc/bs that I could be billed over and above the $4000 if he did not accept that payment, that is a scary unknown amt of money. I hope to settle this more monday. You know you finally make up your mind to have this stupid fusion and get a plan in your head it's hard to think of possibly having to change the plan!!

    Thanks gwennie for your info! Lynette

  • My insurance co said they could not give me any estimate on what dollar amount they would cover until the claims actually came in so I asked the billing office if they can tell me in advance that they will accept what the insurance pays.I will know monday and believe me I will get it in writing.

    Kris I see you recently had surgery, I hope you are doing well. What part of NY are you from? lynette
  • SpineAZSpineAZ WiscPosts: 1,084
    I had a surgeon who was similar. I had to get him to agree in advance to stick to what my insurance company would pay for. The only reason he did is he had done surgery on me before when he was in-network (under a different insurance company due to a different employer).

    And your insurance company is right. There's no way they can estimate what something will cost as even a "simple" procedure like an appendectomy has many different variables in possible treatment, codes, etc. If you can get this surgeon's office to agree to some type of "cap" in fees make sure to do so in writing. And check if the hospital is in network as well.

    This time around, for my upcoming back surgery, I made sure to first find all the qualified Neurosurgeons and Orthopedic Spine Surgeons that accept my insurance in-network and ended up finding one that was great and in-network!
    2 ACDFs, 2 PCDF, 3 LIFs; Rt TKR; Rt thumb fusion ; Lt thumb arthroplasty; Ehlers Danlos 
  • I have checked and the neurologist, vascular surgeon and the Hospital for Special Surgery are all par with local BC/BS. Just the main player is missing!
  • jlrfryejjlrfrye ohioPosts: 1,110
    I would start by asking what your insurance would allow if they were in network. Can I ask why you are seeing a surgeon not in your plan? Unless you are very financially stable this could be financial suicide. 3 level fusion for myself with hospital, surgeon, and the works was 100,000. This did not even cover the after care of test and such. With seeing a surgeon in network my out of pocket was 1200.00. My surgeon billed my insurance co. 36,000.00 for his services but since he was in network and under contract with the ins co he was paid 16,000.00 and the rest was a write off. Have you thought of the possibility of something (god forbid) goes wrong during surgery then your agreement goes out the door.
    Good luck'
  • were about that, they came to around 120,000. but my insurance pays for all of it except for 200. The surgeon only gets a portion of what he actually asks for from the insurance companies which i think is why the require approval beforehand.

    VERY expensive internal piercings....

  • dilaurodilauro ConnecticutPosts: 9,875
    is to negotiate with the doctor/hospital. We have had several charges over the years which seem too high.
    Our Insurance company will provide us with the reasonable cost of procedure xyz (each procedure has a detailed code associated with it)

    So, once you know what the insurance company would pay for that service in your area, you have something to work with.

    Of course this is better done up front before the procedure, but it can still work after the procedure

    My son who has his own LLC business (and no medical insurance) has negotiated several times and also set up installment payment plans.

    You would be surprise at how much flexibility there is with these charges, but you have to ask and take the initiative on them

    Ron DiLauro Spine-Health System Administrator
    I am not a medical professional. I comment on personal experiences
    You can email me at: rdilauro@veritashealth.com
  • I am not familiar with fusion but for my microdiscectomy, the surgeon team I wanted was out-of-network but I chose them b/c they came highly recommended and I just felt most comfortable with them. In addition, the hospital they worked out of I was familiar with and my PCP had priveleges there so if something went wrong, he could help me.

    I told them I didn't think I could use them b/c they were out-of-network. They told me they coudl try to work with me. They did. I was able to get them to agree that I would pay my deductable and they would accept whatever my insurance company would pay them. In essense waiving the rest.

    Now, my insurance company is the same but in 2010 the coverage plan is way different making it even more challenging to go out of network. Still, they were willing to work with me. I told them that I'd like to understand how since I didn't think they would be covered by my insurance at the same rate as teh prior year but believe it or not, they said they would negotiate a rate.

    The only reason I'm switching is b/c if this surgery fails (revision microdiscectomy), I wanted a neuro surgeon involved in the fusion. Unfortunately the hospital I like...doesn't have any NS in network for my plan and actually only 1 OS in network. So I decided better for me to build a relationship with a new doctor now just in case.

    Just remember everything is negotiable if you have the option to go to another doctor. I had options and oddly, the out-of-network doctors knew that and said they really wanted to work with me if I chose them.
  • The reason I ended up with this surgeon is I went to him for a second opinion last november and my husband and I really liked him and felt I wanted the 360 approach. The local neuro does not do enough of these and plus I don't trust the vascular surgeon that would be involved. (being a nurse and sometimes knowing too much doesn't always help)My insurance changed the first of the year and I thought he would be the out of network plan that I would only have to pay the max $4000.00 which I was prepared to pay, but that is not the case.

    If something were togo wrong the hospital is in network with bc/bs and would fall in that $4000 max(which I will hit real quick.) Lynette

  • I found an older thread where there was some discussion on what each person's surgery cost -


    Just FYI - my surgery (including complications, second surgery, anesthesiologists and 9 day hospital stay) cost 163,682.05
  • Lynette, I have the same insurance you have BC/BS and Medicare, which is my primary. I wonder if you could do what the Medicare does, that is, come up with another figure you are willing to pay and then pay a part of it. And interestingly, the surgeons accept it, even if it is only a fraction of the original charge. Go figure! On the other hand, I would not be surprised if they charge paying patient the full amount so they can make up for it. Am I the only one who thinks our health care system needs some revamping?


  • Hi Lynette,

    I'm in the NY area as well, didn't use HSS tho'. My total hospital charges for MI TLIF (including 3 day hospital) stay was about $70,000 - single level fusion L5-S1. We have GHI, hospital costs are covered under Empire Blue Cross. My OSS was in-network, but about 6 weeks post I got a bill for almost $8,000 for neuromuscular monitoring during surgery - bill stated he was out of network. I called my surgeon's office very upset since I hadn't been aware that this part of the procedure would use an out of network provider. The billing manager called the neuro MD's office and spoke w/ his billing people, they said they'd accept whatever BC paid as full payment. I made sure to get the names/numbers of everyone I spoke to about this, when we received the insurance check for this service, we endorsed it and sent it certified mail return receipt requested. My cover letter recapped the earlier conversations where it was agreed the insurance payment would be accepted as payment in full and I requested I be sent a confirmation of same from the neuro MD's office. My out of pocket for surgery was $300.

    Please let us know how it works out for you.

  • for all your posts and advice. Can anyone think of any provider that I havn't checked on?? I have to see a neurologist mo pre op and he is a bc/bs provider, I have to see internist and she appears to be employed by HSS so I assume the billing is through HSS which is bc/bs/provider.(I will double ck that)I don't know about anesthesia. Also will double check vascular. Hopefully will have more info tomorrow!! lynette
  • jlrfryejjlrfrye ohioPosts: 1,110
    Here is a idea since your hospital does not have a neuro on staff you maybe able to get your ins to pay for it. I believe the rule of thumb is if there is no provider within 1 hr form your home the ins will pay. Most people do not know this. So maybe you have a bargaining tool here. I am not sure as if this would be true for you but if it is I would be contacting my ins co
  • I recieved a offer from my surgeon's office and they said I could pay $5000 over what the insurance will cover. I'm still going to negotiate this. I don't know if I can justify spending that amount of money when I could have it done plif in network for my minimal in network charge. I just have a hard time cuz my gut has told me from the start to have it done there. Hopefully they will work more with me tomorrow.
  • My bills are still coming in and are well over $400,000. Thank god for insurance. Kevin
  • Well I think I have agreements with who I need for my surgery. My surgeon's office agreed to accept $1000.00 over what the insurance will pay as a out of network provider. I also was able to contact the vascular surgeon's office and I have a written agreement that they will accept what ins pays. I also did ask the question about if surgeon had additional charges d/t complications would that change the agreement and they said no. The $1000 is the agreed amt in addition to what ins pays no matter what. The neurologist is in network, the hospital is in network and my medical dr is on hospital for special surgery staff.

    The only unknown is anesthesia. Does anyone have a bill for anesthesia. I'm sure this could be very different for everyone but just had no idea of the charge involved.

    I thought I would be relieved when I had this info and could move foward but I think it really made me think..OMG I'm really going to have this done!!!Thanks for everyones help and interest. Lynette

  • I didn't receive a bill since anesthesiologist was in-network, but EOB shows charges of $2700 (4+ hours in surgery), payment made of $2,175. If your hospital is in network, anesthesiologist should be as well, get the surgeon's office to do this legwork for you - you have enough on your plate already trying to get ready for your surgery - just MHO. Keep us posted.
  • double post - sorry
  • I just got my latest hospital bill - 11,000.00 (hardware removal, 122 min. in the OR and 4 days in the hospital).

    Don't have the dr. or anesthesiolgist's bills yet. I do get a separate bill from each unfortunately.

    Glad you got some details on your billing - I'll watch for my anesthesiologists bill and try to remember to post.
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