Explanation of benefits

[jssybravo 4]

Hi everybody,

I received a letter from my insurance company (explanation of benefits) stating that the Surgeons used to do my surgery were out of network and in the letter they told me that i'm responsible for $ 21,000.00. I called then billing Department at my Dr. Office and they told me no to worry about it because they will appeal. they repeated no to worry about it. they told me to wait, that they will submit paper work and at the end i will be only responsible for my deductible and my co- payment, i'm nervous because i can't be responsible for $ 21,000.00. Has someone heard something like this ...???.

[Purplrose323 32]

I went out of network with my lap band surgery. Most likely what you surgeon is doing is appealing to get the out of network fee that your insurance company pays and then they will write off what the insurance doesn't pay aside from your deductible. I would ask how they work it. I only had to pay my surgeon $330 which was my deductible and then they accepted the payment the insurance paid, which was not anywhere near what the cost of the surgery was.

[jssybravo 4]

Thank you very much for your response, it makes me feel better. I got really worried when i saw the explanation of benefits, however it is their responsibility for not letting me know they were using out of network surgeons, i'm willing to pay but i can't afford all that money.

[Purplrose323 32]

No problem. I knew going in the Dr. didn't take my insurance, but at the time lap band was very new so I wasn't gonna go to just anyone. They should have notified you from the very first call you made to them. I worked in a surgeons office and that was one of our first questions, was what insurance the patient had and if we participated. Do you have out of network benefits with your health insurance???

[jssybravo 4]

Hi again, let me tell you that the first question i asked before this surgery was if they were in my network and of course they said yes, it was kind of weird because they made me go thorugh the same steps everybody goes, phsyc, nut, Primary Dr six monts visits, i had sleep apnea and was treated with the cpap machine, my bmi was 39, the insurance sent me the approval the day before the surgery and now that i read the approval letter it talks about the gastro sleeve surgery and is approving the inpatient staying at the hospital. The hospital is in network so they approved it. I get now that The approval was only for the hospital.

Now, i do have outpatient coverage, my plan states that i will not pay more than 5,000.00 in one calendar year using in network Providers and no more than $10,000.00 if i use out of network. However $10,0000 is still too high for me. My deductible is 2,0000 for me and 4,000,00 for my family.

[Purplrose323 32]

Most likely that's why your provider is out of network, the get paid more by the insurance as an out of network provider than if they were to accept the insurance. Sad but true. Hope it all works out! Good Luck! The should have been honest with you from the beginning.

[Cindeez 22]

I would get that in writing from your doctors office.