Dont pay the bill! This is what I do for a living. First of all there should of been a rep for the SCS trial that was working with you, was there? If so go to the rep and make her do her job, which is making sure it is coded correctly and paid for. Talk to the phy. who billed the claim and tell them what your contract covers, most doctors will change their billing for patients. Who is your insurance company? There are different guidelines to appeal a claim so if you need any help please PM me and Ill be glad to help
Susan

Make sure to get a copy of your exact policy.

Is $1800 your deductible or Out of Pocket Maximum?

The policy wording shouldn't differentiate surgery.

For example, I have a $300 in network deductible and $1500 in network out of pocket max BUT $600 out of network deductible and $3000 out of network max for out of pocket.

And with my two recent hand surgeries I have met both my Out of Pocket max (in network) and Deductible (in network).

So if tomorrow I have my appendix taken out and have a complication and am in the hospital for 5 days my insurance pays it all and I owe nothing beyond office co-payments (those do not apply to out of pocket max or deductible).

But if I choose an out of network hospital and doctor then I would owe as then my annual out of pocket max and deductible begins.

If done in a surgery center and if it involves any type of incision or penetration of the body then it's surgery. I recently had carpal tunnel at an outpatient center, with just a nerve block, and 10 min surgery....but it's surgery.

What I'm confused about is making you pay a separate amount for a surgery.

As an example, with both of the carpal tunnel release surgeries I've had done plus some MRI's and knee care I've met my $1800 out of pocket max. If tomorrow I need my appendix out, have a complication and 3 days later they go back in for a second surgery, I still pay $0 in network as I've met the deductible.

So if you already met the deductible before the SCS trial, it's hard to understand why they'd charge you a surgery fee UNLESS your policy has this in it. Do you have a copy of the exact policy under which you are covered? Each policy lays out what is charged in different circumstances. So if the policy has a $500 per surgery fee even after deductible and out of pocket max are met, then it's a fee they have added which is valid. The insurance person at the office of the doc doing the SCS test/installations shoudl be able to talk directly with insurance co OR be able to explain to you what they see as your benefits. When you go in for a procedure the doctors ins staff gets your benefits from the ins co so they may know of the $500 surgical fee.

Unfortunately if your policy has a $500 per surgery fee as part of the plan, then every time you have any type of surgery it will apply. So the test implant is $500, removal could be $500, permanent placement another $500, etc. As long as it's detailed in your health insurance plan as $500 per surgery AND what you had done meets the definition of "surgery" under the plan your claim is being handled appropriately.

Do you have an actual copy of the exact health insurance plan? When you have a dispute, if not before, they should be willing to give you one. A key part of that will be under DEFINITIONS and see how they define surgery.

Years ago when outpatient surgery became common and now the norm, many ins plans had to define outpatient. For example, if your plan were to say $500 for any surgery that is outpatient but that is waived if you are admitted. If the hospital keeps you under 23 hr care it's not a hospital admission. I had my gallbladder taken out and it was 23 hour. My hubby had to work so they allowed me to stay until 5pm when he got out of work but I signed a form saying it didn't constitute admission beyond 23 hr outpatient. To be cautious they asked me to remain in bed, gave me food as if I was admitted, and did my vital signs a few times. If I had developed a problem requiring admission they would have retracted the 23 hour stay classification. So definitions in plans are key!

As much as three quarters of hospital staff are usually burdened with some sort of billing-related work in a traditional billing system. Opting for electronic medical billing solutions (ones that come with free EMR plans) that fit easily into the healthcare business' workflow are key to freeing up staff resources.

Post edited by Ron DiLauro , System Administrator 12/20/11. While your comments have value, what do they have to do with the thread and follow on posts?

It's crazy how many rules there are regarding insurance. When I was hospitalized three years ago, it was nice having a staff person that was talking to me and my husband on daily basis about the insurance. I would talk with your insurance company also to get some clarification on your policy. It does sound like you have a $500 per surgery clause in your insurance.