Calling All Experts On Insurance And Billing...did Insurance Overpay And Lapband Doctor Overcharge?

[Cyndie B 17]

Hello - so I got my EOB in the mail yesterday and I have been stewing ever since! First of all, I had a hernia repair and lapband together. The lapband was not covered by my insurance...according to the doctor's office...so I paid $5,500 of my own money and my insurance was going to cover the difference of $4,500 which was the hernia repair and anesthesia.

I first had to have the procedure done to check for the hernia. The doctor's office billed $17,500 and my insurance paid $7,175. Next was the actual operation. The doctor's office billed $29,500 and my insurance paid $16,025.

Now, according to the doctor, it only takes an additional 5 minutes to fix the hernia while he is doing the band...WTF...so even if I subtract the $4,500 for the anesthesia, he got paid $11,525 to do a procedure that took 5 minutes?

In my ever-so-humble opinion, I think that the doctor's office should not have charged me for the $5,500. If they said that the insurance would cover the "other $4,500", then didn't the doctor get paid $11,525 just for the hernia repair...that took 5 minutes? That is what it looks like to me!

I just wanted to get other opinions on this before I start my rant to the doctor's office tomorrow....if anything they should give me a discount or something!

[kmt1973 92]

I don't think I would complain, bc yes all dr's overcharge. But, if you only paid around $5000 for a very expensive surgery that your insurance does not cover, I would be so so thankful. I am currently waiting on approval and if I am denied I will have to pay about $15,000 to have it done. And thats just to the dr. It sounds like your dr's office just switched around the numbers so your insurance would absorb most of the cost.

[running_scared 125]

I think it sounds like the doctor was trying to get your insurance to cover most of the costs, but I think the lap band only costs about $17,000 altogether, so it seems like they might have over billed your insurance by a lot.

[Grider 92]

DEPENDS- I had hernia repair as well- it all was about $26,000. I only have a copay from Hosp, about $1100. as insurance covered both,, but if you did both with a copay of $5k you are doing great!

[DELETE THIS ACCOUNT! 12,703]

I agree with the others, it sounds like your doctor billed in such a way to absorb a big chunk of what would've been your costs.

I've seen people pay triple what you paid for their surgery out of pocket.

[bluetigereyes 95]

OK...I have worked with medical Insurance for over 20 years.....Let me try to explain how this works. The doctor can bill for each procedure done, separately. Especially if he did one procedure and then had to go back in and do another, as long as you were out of your post op period. (there is a time, set by a global standard that all follow up within a specified time period is included with the surgical charge). Its unfair to say that *ALL* doctors overcharge. Typically Insurances have a set price that will be paid on a specific CPT code (Billing code). That means it doesnt matter if they charge $10,000, if the insurance only allows $1,000, they have to write off that other $9,000 if they are contracted with the insurance. The doctor cannot bill you for that amount. Now, on the other hand, if you see a non-contracted doctor, they CAN charge you the difference, so make sure you see a doctor that is contracted with your inusrance.

Now, on to your specific situation.....I agree that the doctor says it only takes an extra 5 mins to repair the hernia, however, he is billing the insurance for a "hiatal Hernia repair" which, if performed alone, would cost that much. I do not believe the doctor did anything wrong...that is just how Insurance billing works.

I hope this helps

[Ladybandito 516]

It's kind of funny that my dr seems to have done the opposite, in that I was private pay and after the procedure he said I did have a hernia, and that he repaired it .... But my cost remained exactly the same!

[RobinGirl 34]

It is very common for Doctors to bill the insurance higher than cash pay. I think they do it for two reasons. 1. They are trying to establish a higher negotiated rate even though they are only paid a small portion of it. 2. They get to write off the difference as a loss come tax time. Bigger losses than profit equal less taxes. I also think the insurance companies like it when they are billed such a high rate because they can then show the policy holder a larger savings, even though it is just an inflated price.

[Ladybandito 516]

Well, an update on my earlier post. Turns out that even though I was cash pay, doc DID bill my insurance for the hiatal hernia portion. I just got the notice from my carrier.