Self-Pay Complications

[revision in TX 38]

Has anyone had issues with being a self-pay, then having your doctor bill insurance also?

This happened to me and my insurance company doesn't seem interested in recovering the payment.

Basically, they took my money as payment in full; but they billed a bunch of hyped up add-on charges to insurance.

I say it's double-dipping.

Anyone have a similar experience?

Noone seems to mind as long as it's out of the insurance carrier's pocket, not their own!

[SoccerMomma73 1,867]

If it's charges that were supposed to be covered by your payment then it is absolutely double dipping and wrong wrong wrong. If they're additional and legit charges I suppose it's a different story. Without more info I'm leaning towards it being a it skeevy.

[*Misty*Raine* 192]

Has anyone had issues with being a self-pay, then having your doctor bill insurance also? This happened to me and my insurance company doesn't seem interested in recovering the payment. Basically, they took my money as payment in full; but they billed a bunch of hyped up add-on charges to insurance. I say it's double-dipping. Anyone have a similar experience? Noone seems to mind as long as it's out of the insurance carrier's pocket, not their own!

I guess what I don't understand is if the insurance could be billed, why wasn't instead of u self paying? And if it wasn't covered, how are they billing now? That's my confusion!

[revision in TX 38]

Basically what happened is.....I have UHC, but this particular plan does not cover bariatric care at all. So, I paid for the surgery myself. Well, in order to get insurance to pay on the surgery, they billed "unlisted liver procedure" instead of wedge liver biopsy...."unlisted procedure, stomach" rather than gastric bypass...."adhesion repair" rather than lap-band removal...and also charged for a (hiatal) hernia repair. Mind you, all of those things were to be INCLUDED in my revision surgery (that's why it's more expensive than a "virgin" bypass), but they had my insurance information from my (original) consultation and submitted it. Since the coding "appeared" medical, UHC covered a pretty significant portion of it. Thinking I should get a refund for anything that insurance DID pay, I phoned the office to find out when I'd get a refund check and, to my surprise, they said they would be keeping BOTH payments!

Adhesions were expected, due to the band; I've had a hiatal hernia for OVER 10 years, but the op report reads as if it was "discovered" during surgery!!! Adding what they billed insurance PLUS what I paid up front, my surgery was nearly $58,000!!! That is ridiculous. The average for bypass is $22,000, which is what I "self" paid prior to surgery.

Just a side note....I had NO complications, NO unexpected/unplanned procedure and the hospital and anesthesiologist both wrote off ALL charges except what I paid up front...only the surgeon billed/was paid by my insurance company.

I tried to "appeal", but UHC wouldn't since it was not a denial. The insurance commission only regulates insurance, not MD's. The Medical Board only cares if you have "injuries" (for malpractice), they don't care about how the MD codes the surgery. Most patients don't mind because, had UHC NOT paid, they would not have billed me anything....they would have just "

settled" for what I paid them up front. Because the patient usually doesn't get a bill, most don't mind and/or don't complain when the doctor submits "medical" codes and gets payment. It is a common practice by bariatric surgeons (even the "good" ones!), but it's wrong, wrong, wrong.

I am continuing to pursue it because I work in the healthcare industry and I am just so infuriated by all the fraud, abuse and waste in "the system" that I am not going to let them get away with this, even though almost all of them do it!!

Sorry to go on and on, but I am just SOOOOO frustrated and angry that I go on a rant when I discuss it. I asked all the right questions, reviewed the contract, etc., etc., and I STILL got "used". I am still trying to work with UHC to either ask the doctor for a refund or else tell him he needs to refund it to me...even if I don't get it, I don't want the doctor paid twice.

If your insurance doesn't cover your surgery and you end up paying yourself....BE SURE that you have an "iron-clad" contract and understanding with your physician about what will be billed and HOW it will be billed.

As a side note, even my PCP said it's "illegal as hell" (quote, sorry for the language) the way they billed it; it's not just me being upset because I didn't get a refund.

[SoccerMomma73 1,867]

I was self pay with my band and ended up getting some money back post op from the hospital because insurance covered my barium swallow and chest X-ray and some various things....but the hospital paid me back....there's got to be so done in that hospital or hospital system that can see this is total fraud.

[revision in TX 38]

SoccerMomma73:

I actually got a call from UHC on Friday last week, saying that they were referring my "case" to another dept to follow-up on my surgery. The rep told me that, regardless of anything else, the MD agreed to accept whatever was paid as "payment in full" (by out-of-network provider), so I am entitled to either what I paid OR what insurance paid them.

She said the dept they are sendig it to will have more time to pursue it than the Customer Service Reps do, so they should have some kind of answer for me within 60 days MAXIMUM.

So, I'm in a holding pattern for now. But at least it appears they are in agreement with my viewpoint and will try to get the office to refund some of my money!! YEAH!

(The hospital and anesthesia never billed me a penny beyond what I paid up front...only the surgeon!)

[SoccerMomma73 1,867]

SoccerMomma73: I actually got a call from UHC on Friday last week, saying that they were referring my "case" to another dept to follow-up on my surgery. The rep told me that, regardless of anything else, the MD agreed to accept whatever was paid as "payment in full" (by out-of-network provider), so I am entitled to either what I paid OR what insurance paid them. She said the dept they are sendig it to will have more time to pursue it than the Customer Service Reps do, so they should have some kind of answer for me within 60 days MAXIMUM. So, I'm in a holding pattern for now. But at least it appears they are in agreement with my viewpoint and will try to get the office to refund some of my money!! YEAH! (The hospital and anesthesia never billed me a penny beyond what I paid up front...only the surgeon!)

awesome!!! Actually sounds like you're where you need to be now. Evil me wants to see a bunch paid back to you for his misbehavior