Question for someone who knows about Insurance

[JJLaw08 4]

I am probably making a big deal over nothing, but I was self-pay for my surgery. The doctor charged me $3000 for the surgery, and that included free fills for the first year. Well, they have been billing my insurance, which is fine, but the insurance isn't suppose to pay anything. I have finally met my deductible this past time I went to get a fill, and I received a claim report saying the total paid to the provider was $54.40 (out of $100 he charges for a fill). I don't have to pay the balance because he writes that off so I have two questions.

1. Are they suppose to be billing my insurance whenever my insurance is not suppose to pay for those services? This may actually be helpful whenever I am no longer covered after my first year of free fills. I don't know how his office is billing it.

2. Is he getting paid twice for something I've already paid for? If so, that kinda makes me mad because he has already been paid for the first year fills. Then again, I probably shouldn't be mad because I pay enough to the insurance company so it's nice to see them actually paying for something.

I know I'm making a big deal probably over nothing, but I figured someone here would know.

[MellieW 0]

Are you sure he's not billing for an office visit? If he is indeed billing for the band adjustment I'd certainly question it. I'd remind them that they were paid for those adjustments with my $30,000 payment.

Call your insurance, or look at your EOB (explanation of benefits) and see how they are billing it. If they are billing adjustments to insurance, and they are covered benefits, then I'd say he is double dipping. In that case I'd ask for a refund for any fills you will receive in the first year. Let insurance cover it and put a few hundred bucks back in your pocket!

[JJLaw08 4]

It says surgery on the claim report. Also, it was $3,000 not $30,000. If it were $30,000 I would be even more irritated.

I did call the office this morning, and the lady got a little perturbed with me. I guess I didn't like her tone so I got a little ill with her. I asked her 3 or 4 times if he was getting paid twice. She said no he is not, but why is he getting the $54? She said the $3000 was the price of the surgery, and that he included the fills for a year as a courtesy.

[spoiltmom 44]

Technically since you paid cash up front he shouldn't be able to charge your insurance but truthfully? Unless he gave you a receipt that specifically said the money was to cover the first 12 months after care then legally yeah he can bill em.

[MellieW 0]

I'm sorry, I misunderstood. I thought it said $30,000.

So was that $3000 just the Dr's portion?

I know my surgeon charged about $3000 for just his services and the hospital and anesthesiologist billed separately. All told the surgery was around $32,000.

Either way, I have billed insurance for private practice for about 20 years and I can tell you very little is ever done as a true "courtesy". Most everything is either billed through insurance or through the patient. If you were told his fee covered adjustments for the first year, he should not be billing insurance and I would insist that they stop billing them or refund the adjustment fees included in that $3000 back to me.

[tle5000 1]

My insurance paid for everything but the Dr. billed my insurance for $2400 and the insurance paid him $1040 total.

Now get this, the Dr who assisted my Surgeon billed my insurance for $1100 and the insurance paid her a total of $188 dollars. Now the hospital has billed my insurance for $26000 and it has not been processed yet. I also got approval from the insurance for 6 fills this coming year.

[JJLaw08 4]

I'm sorry, I misunderstood. I thought it said $30,000.

So was that $3000 just the Dr's portion?

I know my surgeon charged about $3000 for just his services and the hospital and anesthesiologist billed separately. All told the surgery was around $32,000.

Either way, I have billed insurance for private practice for about 20 years and I can tell you very little is ever done as a true "courtesy". Most everything is either billed through insurance or through the patient. If you were told his fee covered adjustments for the first year, he should not be billing insurance and I would insist that they stop billing them or refund the adjustment fees included in that $3000 back to me.

Yes, the overall surgery and hospital stay total like $11,500. The hospital got about $7,000 of that, and the doctor got $3,000. I'm not sure what the rest went towards. I believe I received something stating that the fills were included in the first year, but it has been a little while so I will have to check for sure.

[MellieW 0]

Yes, the overall surgery and hospital stay total like $11,500. The hospital got about $7,000 of that, and the doctor got $3,000. I'm not sure what the rest went towards. I believe I received something stating that the fills were included in the first year, but it has been a little while so I will have to check for sure.

I know my adjustments are also covered for the first year in my surgeons initial fee. I think that's pretty standard.

But double check and if it was to be covered then, as I said, I would insist that they stop billing my insurance or reimburse me that portion of your payment.

And if she insists that he didn't get paid for the adjustments in that initial fee, and it was only extended as a courtesy, then I'd remind her of the definition of "courtesy". It isn't a professional courtesy if he is going to bill for that service! :thumbup:

[JJLaw08 4]

Also, I don't know if this is important, but I have had like 7 fills so far. I think this was only the third claim report my insurance company sent me, so are they not billing my insurance every time?

[emjay 8]

Not sure what is going on Jessica. I know someone who has insurance that doesn't pay for fills, however, her doc charges for an office visit and gets it paid that way.

If your doc says free fills for a year, there should have been some sort of documentation stating that fact given to you when you paid for your fees. The "courtesy" comment was crap. It is not a courtesy if you already paid for it in your initial fee. He may be billing as an office visit only, but it seems strange that it is coming up as a surgery.

Which kind of creates an ethical dilemma? You can contact your insurance and make them aware of what's going on, in which they will probably stop covering the costs (and then the doc will probably try to start charging you). You can remind the office that you paid for a year's worth of fills in your initial fee and shouldn't be billing your insurance. Or you can do nothing.

I'm not going to tell you what you should do. That is for you to decide.