Self-pay sleeve along with insurance paid hernia

[Tony Patz 4]

Okay this seems like a no-brainer, why not bill insurance for the hernia repair and charge the patient the difference in the cash price for the sleeve or other bariatric procedure. There is a place in Texas called Kim bariatric that will do this, but I am out of network. I have called several bariatric centers and they had no idea what to even think about what I was asking. Does anyone have any insight on this topic?

[Blue1213 122]

I live north of Houston and had this done. My insurance does not cover WLS so I paid the surgeon his fee and then paid a reduced price for the hospital and anesthesiologist because my insurance covered the hernia repair. I had no symptoms of a hernia but the doctor sent me for a barium swallow because he knew it would cut down on the cost. Grand total $8950

[JIA203 1]

Hi,

I'm actually in the process of getting my sleeve with Dr. Kim. I'm self pay though because my insurance has an exclusion policy for bariatric surgery. The insurance coordinator helped a lot and explained if my EGD comes back showing I have a hiatal hernia that it would bring the cost of surgery down to $4,900. Two separate payments of $2,000 and then $2,900. I would pay for one week of the Protein drinks and then pay $75 for the second. It was a program that some people were eligible for. The EGD itself would be $500. The hernia repair would be covered by insurance. The cost for the surgery center may not be covered by my insurance but I guess that's a chance I'm willing to take. I don't know if that helps.

Idk why it says Im in Kentucky. Im actually in Irving, TX.

Edited May 14, 2015 by JIA203

[TexCntryBoy 34]

I'm no attorney and I certainly understand your desire to have as small an out of pocket expense as possible but I think charging the operating room expense to one surgery while actually doing two borders on insurance fraud. I expect most surgeons are leery of this. They live or die by the insurance companies. I had to change jobs to get mine covered by insurance (not the ideal situation for everyone, I understand).

Edited May 14, 2015 by TexCntryBoy

[amsaf 16]

Im also trying to go this route but am getting nowhere im in south florida and have no clue what doctors will work with you like this. I have a referral to get my hernia repaired and figured i could use insurance for it then pay cash for the sleeve but it doesnt seem like anyone does it like that

[Blue1213 122]

If you have a hernia and your insurance covers that surgery how is it insurance fraud? Your surgeon is doing two procedures at one time, one that is covered by insurance and one that is not. You are entitled to stay in the hospital after a hernia repair so why shouldn't insurance pick up some of the cost?

[Tony Patz 4]

If you have a hernia and your insurance covers that surgery how is it insurance fraud? Your surgeon is doing two procedures at one time, one that is covered by insurance and one that is not. You are entitled to stay in the hospital after a hernia repair so why shouldn't insurance pick up some of the cost?

That's the way I see it. If you're going to the store to buy some milk might as well pick up some eggs while you're there. Now if I can just find out where to get some milk with my eggs.

[Blue1213 122]

Well I can give you my surgeon's name if you are interested. He's the one that suggested to me I buy the eggs and milk together. ???? But he's in the Houston area

[Debbie Jean 406]

I'm no attorney and I certainly understand your desire to have as small an out of pocket expense as possible but I think charging the operating room expense to one surgery while actually doing two borders on insurance fraud. I expect most surgeons are leery of this. They live or die by the insurance companies. I had to change jobs to get mine covered by insurance (not the ideal situation for everyone, I understand).

Nope. Perfectly legal and not at all uncommon. Search these boards and you will find many who have done this when WLS was specifically excluded by their insurance. It is a "self pay" option that some doctors make available as an adjunct to hernia repair.

Nothing illegal about it at all. The insurance is not billed for the WLS. The surgeon and hospital bill the patient directly at a vastly reduced rate.

Some doctors in the U.S. actually advertise this as an option. Whether a person can take advantage depends on whether their insurance will cover the hernia repair, whether the surgeon is considered in network, etc.

[Tony Patz 4]

I'm no attorney and I certainly understand your desire to have as small an out of pocket expense as possible but I think charging the operating room expense to one surgery while actually doing two borders on insurance fraud. I expect most surgeons are leery of this. They live or die by the insurance companies. I had to change jobs to get mine covered by insurance (not the ideal situation for everyone, I understand).

Nope. Perfectly legal and not at all uncommon. Search these boards and you will find many who have done this when WLS was specifically excluded by their insurance. It is a "self pay" option that some doctors make available as an adjunct to hernia repair.

Nothing illegal about it at all. The insurance is not billed for the WLS. The surgeon and hospital bill the patient directly at a vastly reduced rate.

Some doctors in the U.S. actually advertise this as an option. Whether a person can take advantage depends on whether their insurance will cover the hernia repair, whether the surgeon is considered in network, etc.

any links or key words

[Debbie Jean 406]

I'm no attorney and I certainly understand your desire to have as small an out of pocket expense as possible but I think charging the operating room expense to one surgery while actually doing two borders on insurance fraud. I expect most surgeons are leery of this. They live or die by the insurance companies. I had to change jobs to get mine covered by insurance (not the ideal situation for everyone, I understand).

Nope. Perfectly legal and not at all uncommon. Search these boards and you will find many who have done this when WLS was specifically excluded by their insurance. It is a "self pay" option that some doctors make available as an adjunct to hernia repair.

Nothing illegal about it at all. The insurance is not billed for the WLS. The surgeon and hospital bill the patient directly at a vastly reduced rate.

Some doctors in the U.S. actually advertise this as an option. Whether a person can take advantage depends on whether their insurance will cover the hernia repair, whether the surgeon is considered in network, etc.

any links or key words

"Just found out my insurance excludes WLS" was a recent thread with a happy ending. Search terms insurance hernia might work.

[Jersrose43 837]

Having worked in insurance for 20 years this is perfectly legitimate.

The doctor actually gets authorization for a hernia repair.

He bills a hernia and sleeve to the insurance. He must bill everything

Insurance pays the hernia and denies the sleeve. Remember you have authorization for that sleeve

Hospital bills both as well. They pay the hernia you pay the sleeve.

[ANewBeginning15 41]

Well I can give you my surgeon's name if you are interested. He's the one that suggested to me I buy the eggs and milk together. But he's in the Houston area

Who is your surgeon? I'm also having my surgery in Houston.

[Blue1213 122]

Well I can give you my surgeon's name if you are interested. He's the one that suggested to me I buy the eggs and milk together. But he's in the Houston area

Who is your surgeon? I'm also having my surgery in Houston.

I'm actually in The Woodlands area. I used Dr Balette. Below is his website. Since I was self pay it went very quickly. I had my surgery at the end of March. Dr Balette is awesome.

http://www.sgotw.com

[ANewBeginning15 41]

Well I can give you my surgeon's name if you are interested. He's the one that suggested to me I buy the eggs and milk together. But he's in the Houston area

Who is your surgeon? I'm also having my surgery in Houston.

I'm actually in The Woodlands area. I used Dr Balette. Below is his website. Since I was self pay it went very quickly. I had my surgery at the end of March. Dr Balette is awesome.

http://www.sgotw.com

Oh, nice! I'm scheduled to have surgery on the 19th. Closer to SW houston, though.