Houston-area LapBanders - An insurance alert

[NewSho 20]

For those Houston-area LapBand patients who might not have heard (on the phone or on other online forums), local LapBand (and bariatric) surgeon Dr Hadar Spivak is no longer accepting United Health Care (or UHC) insurance - effective immediately.

This is a big revelation, as UHC is known as being one of the most LapBand-friendly insurance companies (for those members whose employers did not specifically choose to exclude bariatric surgery coverage). It is also an insurance company that this surgeon, and many others, often encourage their patients to switch to - so they can increase their chances of insurance approval.

He will apparently now be "Out of Network" only to patients, because (his office has said) that they can no longer accept the smaller payments that UHC is offering to their in-network bariatric surgeons now.

This means that Dr Spivak's UHC patients may be asked to defray the difference in costs between what surgery/treatment/fills/visits would cost at In-Network rates (which is usually covered at rates of 80% to 85%, and sometimes to the rare but wonderful 100% coverage) for UHC patients to now an Out of Network rate of 55% - 65% to patients.

For example, one UHC patient has said if they continued to plan to have surgery with Dr Spivak, now that Dr Spivak is Out of Network, the patient is responsible for paying a $5800 difference. (That is the difference from covering 55% of LapBand costs versus the 85% coverage they would have had when Spivak was in network.)

This is notable as Dr Spivak was one of the first LapBand surgeons in Texas, and usually leads other local surgeons in how Lap Banding issues are handled surgically and otherwise. In other words, if other local surgeons eventually follow his lead (it has happened before) then patients will have some significantly higher costs in store. (Dr Spivak and Dr Spiegel's Surgery Center is already Out of Network with United Health Care but those costs have always been detailed and explained up front.)

I realize this seems complex, but the bottom line is that the costs for patients with UHC may well be increased, effective immediately.

I am double-checking with some contacts I have from UHC (on the corporate end) to verify that the financial concerns for patients are correct.

Just an FYI.

(I will cross-post this on the insurance board, just to make sure everyone gets a chance to see this if they haven't already.)

Good Luck and Happy Band Journeys to all,

New Sho

[HeatherGurl 0]

I just talked to someone in Spivak's office and basically there is some truth in what you say.

In "MY" particular case with my coverage... My fills are still only $20 because I have out of network coverage.

BUT, like you said... IF I hadn't already had my surgery... it would have cost me a lot more.

Don't worry guys! Dr. Spivak and his office is currently trying to work with UHC to get them to meet him halfway. He is seriously interested in the needs of his patients and will do everything he can.

UHS is only wanting to give Spivak a tiny amount for performing the surgeries... SO... that is where this is all stemming from.

Thanks for the info NewSho!~!

[clmrphy 0]

My policy covers the procedure 100% My co-pay is $250. This is waived because I am a hospital employee. Dr. Spivaks office is saying that he made the decision to be paid in cash before the surgery and that I could have what the insurance company paid him. All network doctors only receive a portion of what they charge. That is a known fact before they sign a contract with an insurance company. According to UHC, it is against policy for Dr. Spivak to ask an insured to pay up front as long as he is under contract with UHC as an in network provider. He is also still listed as an in network provider.

His office states that they have been unhappy with payment from UHC since October. I was a new patient in November. I feel as if I deserved to be told of this before Monday of this week......at the same time they told me they needed $5000 and told me where I could get a loan.

I did not feel cared for as a patient. I felt caught in the middle of a fight that is between the doctor and his contract with UHC.

[NewSho 20]

My policy covers the procedure 100% My co-pay is $250. This is waived because I am a hospital employee.

Yes, as you know, you have a very generous policy indeed even by most hospital employees' policy. So I can imagine you are very disappointed.

Dr. Spivaks office is saying that he made the decision to be paid in cash before the surgery and that I could have what the insurance company paid him. All network doctors only receive a portion of what they charge. That is a known fact before they sign a contract with an insurance company.

Absolutely. As much as they may hate the sometimes ridiculous discounts that the insurance companies force them to take, most physicians don't have the option to simply remove themselves from in-network participation of such a large insurer.

According to UHC, it is against policy for Dr. Spivak to ask an insured to pay up front as long as he is under contract with UHC as an in network provider. He is also still listed as an in network provider.

Yes, until he is formally listed as 'out of network' (apparently this is being done retroactive to a certain date

His office states that they have been unhappy with payment from UHC since October.

Well, what else is new? I'm sure that's true but welcome to the wonderful world of Managed Health Care. It's really difficult when Insurance Companies have everyone - from doctors to hospitals to patients - caught in a bind. They have big lobbyists fighting to protect the interests of the insurance companies but is anyone protecting us?

I was a new patient in November. I feel as if I deserved to be told of this before Monday of this week...

I'm sure that seems unfair. I realize there was no good time to get this information, but I can understand your disappointment. There will undoubtably be others in your situation so it's important that everyone know as soon as possible so they can make plans for the potentially increased costs, if applicable.

I did not feel cared for as a patient.

This is a major headache for all involved. But honestly I don't think there is a lack of clinical care involved here. This is a well-regarded doctor with an outstanding reputation and legions of patients will attest to his quality of care. Unfortunately the reality is part of feeling 'cared for' as a patient is feeling like the financial details are being taken of also. So if we assume it's not a reflection of how a doctor cares medically for his patients, but it can still understandably make a patient feel the way you are feeling.

I felt caught in the middle of a fight that is between the doctor and his contract with UHC.

Exactly. All patients using insurance (those who are not self-pay) can easily also be caught in this same bind. On other forums people have said that the simple answer is just to self pay. I do not think this is necessarily simple or feasible for some patients.

And frankly, I have major issues with self-pay as an option even for those who have the money or financing. Why? I think it empowers the insurance companies to feel as if they are justified in not covering needed medical procedures. They literally use the rise in self-pay and self-financed patients to justify the fact that even though the insurance companies aren't paying, the patients are getting these procedures anyway. It's an unfair manipulation on the part of insurance companies, in my opinion.

Also I think self-pay works best when everything works absolutely according to plan. When things deviate even a tiny bit, there is sometimes a 'grey area' that makes things difficult to clearly know who should pay for what. Luckily the great number of procedures go smoothly. However, when someone self-pays for a procedure that should have been covered under their major medical insurance plan

it's not always easy to figure out what options the patient has.

And when something goes wrong with a surgical procedure - unlike with a major appliance like a dishwasher or a big purchase like a car, there is no implied or stated warranty.How does one handle it when their $15K surgical procedure does work as stated? We all understand that there is no guarantee in any type of surgery. But what we are seeing on this forum is that for some self-pay patients simply writing the check doesn't always mean they get what they pay for. Sometimes this can be difficult to resolve and there are no easy answers in these cases.

Hopefully we will all learn from this, and have some more concrete answers soon.

Happy Band (and UnBanded) Journeys to all.

[HeatherGurl 0]

I am really sorry that you feel so bad. I understand...

I really do hope that everything works out for you. Keep us posted!

My policy covers the procedure 100% My co-pay is $250. This is waived because I am a hospital employee. Dr. Spivaks office is saying that he made the decision to be paid in cash before the surgery and that I could have what the insurance company paid him. All network doctors only receive a portion of what they charge. That is a known fact before they sign a contract with an insurance company. According to UHC, it is against policy for Dr. Spivak to ask an insured to pay up front as long as he is under contract with UHC as an in network provider. He is also still listed as an in network provider.

His office states that they have been unhappy with payment from UHC since October. I was a new patient in November. I feel as if I deserved to be told of this before Monday of this week......at the same time they told me they needed $5000 and told me where I could get a loan.

I did not feel cared for as a patient. I felt caught in the middle of a fight that is between the doctor and his contract with UHC.

[dianam 0]

I have UHC also and was scheduled to have surgery with Dr. Spivak. I was so upset when they called and asked for $5000. The only reason I am getting to have the surgery is because my insurance pays 100%. I understand the dr changing his insurance acceptance on new patients - but it just does not seem fair when you are all ready to have your procedure. I am consulting with Dr. Spiegel on Saturday. I hope I can get my band before anything else happens.

[clmrphy 0]

do you have financial ties to dr Spivak NewSho? It sounds as if you do.

[NewSho 20]

First of all, as of today (21 March) UHC still lists Spivak as being in-network, although we know he is no longer participating as an in-network provider.

Secondly

do you have financial ties to dr Spivak NewSho? It sounds as if you do.

Ha - that's hilarious.

NO, I have no financial ties to any surgeons. If I did, what would I have to gain by posting this here? It makes no sense.

There are many existing and future patients who haven't heard yet - I simply want them to hear about it now, rather than pay the price later. This is a serious issue.

Sorry this happened to you, but don't shoot the messenger. In fact, technically the messenger should have been someone from their camp rather than everyone hearing from the "Patient Underground" , but that's how this is.

So don't let your well-documented anger (which is probably quite justified but still comes off as juvenile online) lead you to mistake me for someone on the payroll somewhere. If I were you, I'd probably spend less time insulting fellow forum (and online group) members and instead I'd focus on finding alternate ways to finance the procedure.

Good Luck and Happy Band Journeys to all.

[3loves 0]

NewSho ~ I think your level of knowledge was simply misunderstood and when I was reading your posts, that same thought (did u work for them) crossed my mind as well, but not in a negative way. I read your blog and you do have quite a bit of insurance experience which explains how you can give such a detailed description. It's it nice to have someone like yourself on this site, but I don't think, and I could be mistaken, that the previous post was meant to an angry insult. Again, I could be wrong.

You have been been down many roads that most of us won't even have to face. I appreciate your insight and IMO full of knowledge reagrding insurance and procedures. Be patient with those of us that aren't and we can learn from each other. :nervous

[NewSho 20]

NewSho ~ I think your level of knowledge was simply misunderstood and when I was reading your posts, that same thought (did u work for them) crossed my mind as well, but not in a negative way. [/quote=3loves]

Oh, calling someone an employee seems 'negative.' I did take it that way, and I do.

I read your blog and you do have quite a bit of insurance experience which explains how you can give such a detailed description. It's it nice to have someone like yourself on this site, but I don't think, and I could be mistaken, that the previous post was meant to an angry insult. Again, I could be wrong. [/quote=3loves]

No, I think that is correct. I was responding to what I saw as an attack because I came to bring some information. Considering that poster has been so unpleasant in this forum (and really warned about their behaviour on other forums) I

You have been been down many roads that most of us won't even have to face. I appreciate your insight and IMO full of knowledge reagrding insurance and procedures. Be patient with those of us that aren't and we can learn from each other. :nervous

You know, due to that experience I probably take insurance issues more to heart than most people - so that makes them seem more important to me. I can see where others think this isn't a big deal so probably I should have not bothered to share the information. What I will do is to stop posting on this thread and direct my energies elsewhere. I believe it's a case of shooting the messenger, but since I'm the one who started the thread, a better way for me handle this is to just let it go.

Happy Band Journeys To All...

[StrawartS 2]

NewSho, were you banded by Dr. Spivak? I understand that you were recently rebanded. Did the same physician do both surgeries?

[clmrphy 0]

I have never been warned of my behavior in other forums before. I found this site only last week after I had problems with my doctors office.

With your considerable knowledge on the subject, I was honestly wondering if you had inside information. My tone was short, but it was an honest mistake. Since I have asked I have assured by you that you dont work with the doctor. I have also been called names for asking and now read that I am hostile in other forums and have been warned. This is news to me, could you tell me when and where this hostility took place?

Alot of the employees I met through consults had been banded. It is not unreasonable for me to think that they may be part of a forum to get support for themselves.

[YellowRose 0]

I am in the process of changing jobs, and I was wondering if anyone out there works for Chase Bank or Sterling Bank iin Houston and if so do you know if their insurance covers the lap band surgery

[NewSho 20]

Re-post: I'll say it again

NewSho, were you banded by Dr. Spivak? I understand that you were recently rebanded. Did the same physician do both surgeries?

What I will do is to stop posting on this thread and direct my energies elsewhere. I believe it's a case of shooting the messenger, but since I'm the one who started the thread, a better way for me handle this is to just let it go.

[StrawartS 2]

I'm not sure why you bumped my comment from five days ago. I got the idea already that you don't want to answer. Seems like if you wanted to let the conversation die, it had already done so.

I hope you don't get defensive to this comment, and I understand that your long band journey has probably made you cautious, but it's just a little odd that you refuse to name names. It does look like you're promoting a different sort of agenda than just giving us information when you refuse to answer very basic questions about your story.

Unless your posts are largely cathartic, and you don't expect any replies, I would think that you would be more open to being completely honest about your story. It was pointed out in another thread a while back that you originally said you were banded recently, but then admitted that you had only been recently RE-banded and had actually had a band for five years. It's just hard to understand your posts when you don't give the whole story every time.

I debated posting this, because I know how you get when people question you. But I don't think it's fair for you to post all these comments that obviously illicit some doubt and questions from others and then get angry when we start questioning you.