ANA Discussion Forum
General Category => Insurance => Topic started by: tpaul on December 13, 2009, 06:06:04 pm
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My insurance company is saying that only 20% of the assistant surgeon is covered. They say this is "industry standard". Has anybody else run into this? Has everyone who has had a trans lab had a surgical team: neurosurgeon and a ENT surgeon?
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I had both neurosurgeon and ENT, but I am in Canada and the whole procedure is covered...
JO
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I've never heard of that - I don't think that's truly "industry standard"!
I had a neurotologist and a neurosurgeon, and both were paid for by insurance. Is it possible the the assistant is considered out of network? I know out of network providers are usually not paid for in full, but still, they should pay more than 20% if that was the case.
If you're having translab, I'm pretty sure you have to have a neurosurgeon - the ENT or neurotologist does anything outside the dura mater (covering of the brain), and the neurosurgeon has to do anything inside.
I would talk to your doctor's office about it. You have to remember that the majority of insurance company employees have no medical training, so they have no idea what's standard or not, especially for an uncommon surgery like this. I've experienced this a lot myself. I would definitely appeal their decision. 80% of brain surgery could be very expensive!
Good luck.
Lori
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Paul -
AN surgery is typically done by a team of doctors regardless of the approach. I had retrosigmoid and my team consisted of a neurotologist and a neurosurgeon. One of the reasons for the team is that AN removal is a long, tedious process done through a microscope.
Like Lori, both my docs were paid by my insurance - and neither of them had a 20% (or any other percent) limit placed on their bill.
I also had a resident in my surgery - he was responsible for my fat graft - but I was never billed for his time. Is it possible that your insurance thinks the "assistant surgeon" is a resident and therefore doesn't want to pay?
Talking to your doctor's office is a great suggestion. AN surgery is very expensive and you want to make sure you get the level of insurance coverage you are entitled to.
Please keep us posted.
Thanks,
Jan
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I don't think that can be considered standard. In my PPO plan my surgeons (2) each had their fee 'adjusted' to what the insurance company considered standard (and that is less than what they originally billed) then they were paid 80% or 85% of that (I don't remember offhand) and I was responsible for the balance. All the staff was in the plan so that obligates them to accept the insurance company's going rate. My Neurosurgeon was not in the plan but he accepted the insurance company's rates as if he was in the plan. Of course there were other factors such as a cap on my out of pocket expenses, which I did reach, so at some point I became 100% covered.
Neal
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I had translab and had an ENT and a Neurosurgeon...both were covered 100% because I had reached my deductibles long before the surgery. I also had someone who monitored the nerves and he was not covered at all, his bill was $1495.00. Worth every penny. My neurosurgeon wouldn't work without him. He had all of my facial nerves hooked up to a computer monitor and wore a wide spandex jumpsuit....I thought he looked a lot like Elvis!
Brenda
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I thought he looked a lot like Elvis!
Brenda
Brenda,
Are you sure that wasn't just the drugs? :D
Lori
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Nope, Lori, he had blue black hair and ocean blue eye and wore a while form fitting jumpsuit....his name was LeRoy...I felt instant calm because I figured his was sent by my Dad (whose name was LeRoy) and was my guardian angel! He kind of was for the facial nerves!!
Brenda
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Wow, Elvis. Don't recall him in my OR. Neat story, Brenda :)
Jan
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Hi, tpaul ~ and welcome. I'm sorry you have to contend with an acoustic neuroma and removal surgery but I'm glad you've discovered the ANA website and these discussion forums.
I would definitely pursue this payment issue with someone in your medical insurance company in a management position. I would also check this claim of 'industry standard' with your state insurance commissioner's office, because it sounds dubious to me. I smell an attempt at short-changing you on a legitimate claim and I wouldn't just accept this, even if you can afford it.
Please let us know how this is resolved - preferably in your favor.
Jim
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Thank you all for your comments. I am going to pursue with the insurance company, and wil let you know how it turns out.
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Good luck, tpaul, and Happy Holidays :)