Help what should I do ?

[bellabeans 74]

PA CHARGES I was sleeved 9/7 approved by Aetna ins and also have a secondary insurance that I am covered by 100% . Today I received a bill for $2500. My surgeons PA billed the insurance co 40,000 and it was denied, keep in mind the surgeon also billed the insurance company and was paid what Aetna pays with no responsibility from me . I never saw this dr the day of my surgery before , after or any time during my hospital stay . The bill says that the PA appealed the bill and it was denied , and they have dropped the charges to $2500 that I owe . I don't know how they decided to adjust the bill by $37500. I called the insurance co and they told me I could appeal it and that it was not paid because she is out of network. My surgery was prior approved by my insurance company so why would it be approved if the Pa was out of network . My surgeon is in network though. Sounds to me like the office is double dipping . I'm not sure how to handle this because my son is being sleeved within the month and has worked so hard to get all of his requirements in . I don't want to cause a scene in the office at least not until my sons procedure is done .

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[blizair09 3,250]

I had a second doctor (labeled surgery assistant) that billed my insurance. I never met the man in my life and I still have no idea what he had to do with anything. And he was out of network. But luckily, my insurance paid him completely, so I didn't have to worry about it. But it still unnerves me that this person was part of my surgery when I neither met him nor signed consent forms regarding him.

[bellabeans 74]

I'm not sure what to do , the insurance company told me to appeal it but it makes me mad why does she get paid she never saw me

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[fatontheinside 92]

I work for an insurance company. I'm not totally following your situation here but it sounds like what took place was legit. When it comes to a surgery you have the facility fee, the surgeons fees, the anesthesiologist, and then any other ancillary charges that go along with it.

Just because your insurance company approved the surgery, doesn't mean that your claims will be paid at the in-network benefit level.

If they are telling you to appeal, I would appeal. If this is indeed a second person or assistant that was in there and they are out-of-network, you had no control over that. I would maybe call and ask to talk to a supervisor so they can explain it a bit better. But if they tell you its still out-of-network, write in and appeal. Whats the worse that could happen?

Good luck!!!

[bellabeans 74]

Would they even consider ? I feel like my surgeons office is being sneaky . They knew my insurance . If I would have known their was involvement from someone other than my surgeon I would have made sure they took my insurance . I didn't even see her that day or any other day I was in the hospital. I'm not even sure what she is billing for because she wasn't thee the day of my surgery.

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[savyourdvine1 110]

It my seem as though something is fishy however, it could be legit. I had two situations similar to yours. I located a dr. in my insurance portal. After contacting the office I asked(as usual) if they took bcbs... they said yes. After my visit, they billed my insurance almost three thousands and my insurance denied the claim, stating out of network. The dr. office then reduced that amount to a mere $400 and something dollars for me to pay. I appealed it and the insurance paid all of it. The second event was 5000 dollars worth of rental equipment sent to my home without prior authorization. The insurance refused to pay. However, at the end of that matter.... the two of them worked it out. I paid nothing. I would appeal it. The insurance will probable pick it up.

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[bellabeans 74]

I have the papers to appeal and will be sending them in. I can't see why they would not . They no longer have to pay for any diabetic medications or high blood pressure meds no more bi pap and I'm not getting a monthly MRI to see why my back hurts all the time . ( it was my weight lol ) fingers crossed !!

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[hmills653 365]

Can you make some small monthly payments until after your son's surgery? Or maybe try to appeal the process may take a little while then surgery will be done.

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[Diana_in_Philly 1,426]

APPEAL. And talk to your surgeon's office. If he's approved, they should have his PA approved. I'd let them know that you aren't paying a dime because they didn't get all the personnel in their office onto the roster with your carrier. They clearly knew your carrier when they accepted you as a patient and agreed to accept your insurance. Write a strong letter to them. They may withdraw the bill. (I had a similar issue with my primary doc a few years ago when one member of the practice group was not in network and treated me for a sick visit - lo and behold, I didn't have to pay beyond my co-pay.)