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Medical billing

nmacnnmac Posts: 112
edited 06/11/2012 - 8:53 AM in Health Insurance Issues
I am very frustrated! I have gotten 2 bills from my SCS trials. ( I had 2 in March because the first leads didn't stim. at all on the left.) I have pretty good policy. 1800 max out of pocket. I have received bills totaling $4865. I took off from work yesterday due to illness but spent 3 hours talking to my insurance, the hospital and physician billing. The insurance says I owe $ 2800. since the procedures were coded as surgery for pain I need to pay 500. for each procedure in addition to 1800. Then the physician billing found one section that they were going to send for review to another dept. The hospital never did call back. Sooooo frustrating. Way to add stress to someone who is already struggling! Does any one know if there is a way to get help with this. It is so difficult and they are only available to talk to during my work hours. Should I pay some of the bill before i get it resolved? Do they still take payments? The bills seem to encourage you to use your credit cards, with no mention of setting up a payment plan. Thanks for letting me vent.
Severe DDD. Klippel Feil Deformity. Cervical Foraminatomy that turned into Lamy. I have tried so many treatments, therapy's and medications.


  • jlrfryejjlrfrye ohioPosts: 1,111
    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
  • SpineAZSpineAZ WiscPosts: 1,084
    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.
    2 ACDFs, 2 PCDF, 3 LIFs; Rt TKR; Rt thumb fusion ; Lt thumb arthroplasty; Ehlers Danlos 
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  • I have a 200. per person deductible and a 1800. in network out of pocket max. I currently only pay 25. for my visits in network as I have more than met the 1800.
    The "surgery for pain" 500. is what I am also concerned about. It was more of a device trial that I had to have temporarily implanted 2X and it has been removed. I feel if I was having the device implanted permanent that I would then need to pay the 500. My insurance said that I would need to have it coded differently to not have to pay the extra 1000. (500. X2)
    "Purtanous (sp?) lead implant is what they called it on my bill.
    Thanks for helping me figure this out.
    Severe DDD. Klippel Feil Deformity. Cervical Foraminatomy that turned into Lamy. I have tried so many treatments, therapy's and medications.
  • SpineAZSpineAZ WiscPosts: 1,084
    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.
    2 ACDFs, 2 PCDF, 3 LIFs; Rt TKR; Rt thumb fusion ; Lt thumb arthroplasty; Ehlers Danlos 
  • Thanks. The $ 500.00 is separate from my deductible. I have met my 1800. deductible but if I had a spine surgery for pain or hip replacement or knee replacement I would still be required to pay the $ 500. for each. The temporary "lead placement" counts as surgery. I have spoke to the PM's office, ODS and the benefit board and they aren't going to do anything to change it. I still don't think I should have to pay twice but I don't know what to do next. Do you think the state insurance commissioner would help me with this? The good news is I think I was able to get them to realize there was a mistake in my bill and I owe 1850. less. I am still liable for 2900.00 and I am suppose to have one the best policies available.
    Severe DDD. Klippel Feil Deformity. Cervical Foraminatomy that turned into Lamy. I have tried so many treatments, therapy's and medications.
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  • SpineAZSpineAZ WiscPosts: 1,084
    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!
    2 ACDFs, 2 PCDF, 3 LIFs; Rt TKR; Rt thumb fusion ; Lt thumb arthroplasty; Ehlers Danlos 
  • 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.
  • usefull content /very informative article for doctor regarding medical billing,dealing medicals bills is stress full work...i am quite satisfy with my billing service providers .carolina medical billing
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