Posts Tagged denial
After receiving a payment denial letter from an insurer for an operation I performed a few months ago, I figured it was time to share.
Health insurance companies play endless games with your local doctor in order to delay or avoid paying the bill.
Let’s talk by means of example:
Mr M is a 50 year old man who was admitted to a long term care hospital when I first saw him. He had a large wound on his hip that was big enough to allow both of your fists to fit inside. Wound care resulted in a clean, but very large hole. The doctors taking care of him requested the assistance of plastic surgery to shorten what would have been a 6-12 month expected healing time.
This patient has commercial medical insurance. I am the only plastic surgeon who works at this hospital. After seeing him and interfacing with his insurance company they agreed to the surgery. I even had to speak with some kind of insurance company medical director who requested that the patient be allowed to be discharged home prior to the operation, a skin graft.
Four months after the patient’s surgery and a successfully healed wound, his insurance company denied payment for the surgery due to the fact that I am not a provider for his insurance. This is BS.
As I am the only plastic surgeon who sees patients at this hospital, we will probably win on appeal, but the point is that it shouldn’t be a hat trick to get paid for work you have done months prior. This is amongst the reasons that many plastic surgeons do little if any “real medicine.”
Your health insurance company is not beyond this kind of BS either.
John Di Saia MD
Originally posted 2010-08-12 07:30:10.
Patients are frequently frustrated (as we your surgeons are) with emergency room work. Even when patients have insurance coverage, there are almost invariably delays and underpayment that thwart patient care.
Plastic surgeons already have an issue with emergency work. Many emergency room patients are without insurance and simply disappear when it comes time to pay the bill. It is bad enough that emergency work takes us away from our families at frequently ungodly hours.
I have had a few recent emergencies with Anthem Blue Cross patients in which the billing was a roller coaster. I am not a Blue Cross Provider and don’t want to be a Provider. The reason is simple. I don’t want to be bound to their rates for everything I do. Not being a Provider leaves me the option of billing the patient. I do not take emergency call because I like it. One of the hospitals that I use mandates that plastic surgeons take call. They don’t care that I live 50 miles away. At some point I may drop this hospital. I figure I should have the choice.
Nevertheless, one of my recent emergencies was in the evening on a Saturday. It involved a surfer who had burst open his scalp falling from his board. The surgery was somewhat involved and the bill to Anthem Blue Cross was around $2400. Two months later we received a letter from a negotiating company indicating that Blue Cross would pay $850 if I signed a statement that I would not bill the patient for any of the remainder. This was their “Take it or leave it” out of network negotiation.
My office called the patient telling him about the letter and that 35% of my bill was not acceptable. We gave him the opportunity to call his insurer to obtain a better reimbursement or we would simply bill him for the $2400.
The patient himself brokered a deal with Anthem Blue Cross and the bill was paid in the amount of $2100. We wrote off the $300. His point to the insurer was that in this emergency he was lucky to get a plastic surgeon and he could not control the fact that I was not a Provider.
The reason behind presenting this is to let you the client know that to Anthem or any insurance company you are the client. Your doctor’s office is just a vendor. Sometimes you have to pick up the phone and fight with your insurer to get the bill paid or be prepared to pay it yourself.
John Di Saia MD
Originally posted 2010-10-25 07:30:18.
Healthcare insurance companies are on my short list for contempt.
They underpay, take forever to pay, deny after approval and rescind for fun. Why should I not pitch them the BS they deserve in return?
Today I received a particularly funny (and O-So-Typical) letter concerning a woman for whom I performed breast reduction a few weeks ago. This case was the largest I have done this year with over 4 pounds of breast tissue in the removed specimen. Her back pain is gone. She can stand up straight. And her husband looks like an worked-up fiancé (amongst the best compliments in my book).
Bottom Line: This case was medically-indicated and I did a great job. Sorry Blue Cross.
Nevertheless, Blue Cross via letter issued a denial/delay of payment after the surgery had been performed (and after their own pre-operative approval). They are trying to make payment the responsibility of the HMO arm of her insurance plan. I am not an HMO provider. They know it won’t work, but it will delay payment.
This is Health care Insurance Company B.S. Maneuver #1 from the “We’re Cornered But We Can Still Delay The Payment” chapter.
They know this abuse is amongst the reasons doctors drop insurers. I can certainly see why many of my friends have done so.
More of that wonderful treatment from your insurance industry.
John Di Saia MD
Originally posted 2005-06-30 20:09:00.
Breast reduction is misunderstood online. The operation is defined as the reduction and lifting of breasts. This is not the same as removing or reducing the size of breast implants in a woman’s breasts. That is called an implant exchange.
Implants are not usually involved especially when an insurance company is scheduled to pay for it with the possible exception of surgery to reconstruct a woman’s breasts after breast cancer surgery.
It is difficult enough to get most insurers to pay for “clear cut” medically-necessary plastic surgery. Breast reduction surgery is the reduction of naturally enlarged breasts and that is all.
Breast reduction used to be one of the more common insurance-covered procedures in my Orange County plastic surgery practice. With the economy as of late, insurers are not always so quick to approve them, but for the right patient they are still do-able.
Usually we see our patients for a consultation and then apply to their insurers for pre-approval if the cases seems reasonable by insurance company standards. We don’t make the rules on approval, but we do know the game. Appeals are not uncommon.
These days insurers are looking for a certain amount of breast gland to be removed in a certain sized woman in order to allow coverage. In addition they like to see documentation of things like bra strap furrows, the “dents” some larger breasted women get in their shoulders from breasts weighing against them over the day. Insurance pre-approval usually covers surgery for a 90 day period. The exact nature of that coverage varies by the plan.
Insurers don’t tend to like claims is which liposuction has been involved. This can trigger denials on cosmetic grounds at the time of billing. In cases of breast implants in larger breasts, we have staged the surgery to avoid insurance denial. That means taking the implants out in one operation and waiting several months to a year before re-operating for breast reduction. It might sound silly, but again we don’t make the insurer’s rules regarding payment.
John Di Saia MD
Some Cigna PPO insurance plans do not cover breast reduction specifically. We saw a patient in the office and tried to obtain pre-approval for a breast reduction. Medical necessity was clearly in play in this slender 5 foot tall woman with size EE breasts. The insurer’s representatives did state however a month into the process that her insurance plan specifically excluded the benefit of breast reduction.
Watch your plan specifics when you sign up for that health insurance. When you’d like to use it it might not be there for you.
John Di Saia MD