Insurance Approved 100% - Now Doctor wants MORE $$$$?

[UltraGeek 0]

I have really good insurance. I was approved for the lapband procedure and my insurance will cover 100%. I received a letter in the mail from my insurance detailing everything.

I received a call from the doctor office late last week telling me that I was NOT approved and that I would need to finance my procedure. I quickly told them that I was in fact covered 100% and that I already new that the Doctor was also 'in network'. Thinking the office assistant was missinformed I asked her to read the letter my insurance sent her and to call me back.

The doctors office called me back on Friday afternoon. This time they tell me that the doctors in office surgery clinic is not certified by my insurance and that the doctor is requiring that I pay an additional $8k which I could again finance. I then told the doctor assistant that my insurance would cover 80/20 for an out of network facility and that I find it very hard to understand why the costs were getting so skewed. I told her I would call my insurance and verify everything.

I now feel that I do not trust this particular doctor. The costs seem really skewed to me. He wantred $17k for the surgery and $450 for each fill/adjustment thereafter.

So I am looking for a new doctor in the Los Angeles area. I have SAG insurance FWIW.

-UG

[aubrie 6]

OH MY GOD!!! this is like reading my own post. I had the EXACT same thing happen to me yesterday. I was stunned. I FINALLY got approval after months of doing backflips, and then an appeal. I got approved and called my doctor on cloud 9 to schedule the procedure. They then tell me that I will have to pay the doctor $3,000 up front before I even set foot in the hospital. They say that Aetna doesn't pay enough, and that I have to make up part of the difference. They "claimed" that Aetna would only pay him $1085. I had to pay $3,000 and they would write off $1915. I called Aetna and was on the phone with them for 2 and a half hours!!! I provided the procedure code given me by the doctor, and they told me over and over again, department after department, same story, that the reasonable and customary amount they pay a doctor from that area was $6000. What the hell? What was he complaining about? did he think I wouldn't ask? Now Aetna is suspicious. this has really turned into a nightmare. What do I do????

[aubrie 6]

I forgot to add to my post above that the doctor also said he only includes one year of follow up for self pay. Insurance patients only get 90 days of follow up. that doesn't even include your first fill really.... I was so upset. Do I trust this guy? Someone please explain what UltraGreek and my doctor is up to. It sounds really fishy.

[cdyoliver 0]

I have really good insurance. I was approved for the lapband procedure and my insurance will cover 100%. I received a letter in the mail from my insurance detailing everything.

I received a call from the doctor office late last week telling me that I was NOT approved and that I would need to finance my procedure. I quickly told them that I was in fact covered 100% and that I already new that the Doctor was also 'in network'. Thinking the office assistant was missinformed I asked her to read the letter my insurance sent her and to call me back.

The doctors office called me back on Friday afternoon. This time they tell me that the doctors in office surgery clinic is not certified by my insurance and that the doctor is requiring that I pay an additional $8k which I could again finance. I then told the doctor assistant that my insurance would cover 80/20 for an out of network facility and that I find it very hard to understand why the costs were getting so skewed. I told her I would call my insurance and verify everything.

I now feel that I do not trust this particular doctor. The costs seem really skewed to me. He wantred $17k for the surgery and $450 for each fill/adjustment thereafter.

So I am looking for a new doctor in the Los Angeles area. I have SAG insurance FWIW.

-UG

Hi,

I am in the Los Angeles Area and have Blue Cross of CA insurance. It is Cobra so I pay 500.00 a month. Since I was an employee we went to Lumenos which is another story... I am so upset that I paid the 15,ooo dollars and I it is not even working. I suspect partially due to the stress. Not working, taking 15K out of my 401 and being told that my insurance co will not pay... I was told this by the DR. I am SO upset that I cannot see straight. I had one fill and cannot hardly eat solids only liquids. I am single no family and am so frustrated. Reading your stories helps me think that I can still get the money from the ins co. I am 5'4 and weigh 210. One Dr said I have a bad heart valve that would get better with surgery. I have a bad back. I don't have diabetes yet as I wanted to do everything I can to avoid getting sicker as I got older. I am 50 alone and depressed not to mention frustrated with this place that really hasn't been there for me what so ever.. Does anyone have any suggestions on what I can do on my own to get this surgical center to get off their buts and do something.. You know, they never even took a thyroid test. Mine happens to be very low!!!

[Chris61 0]

I have UHC insurance and we had no problems with the doctors. Here is the statement down under claims Notes and I think most insurance has something like this "We have applied the contract fee. The patient is not responsible for the differance between the amount charged by the physican or health care professional and the amount allowed by the contract, expect in situations where there is an annual benefit maximum for this service. The patient is also responsible for any copay,deductible and coinsurance amounts."

I hope that this will help you out.

Chris

[aubrie 6]

I finally took out a medical/surgical loan through Capital One. For me it was only 1.99% interest on the $3000 extra I needed. I set it up on payments for 18 months. It took about 10 minutes to get approved. It was a snap and solved the problem. So I'm having my surgery on the 19th! WOO HOO!!! :)