Guest guest Posted November 13, 2003 Report Share Posted November 13, 2003 Debbie, You said it...thankfully Cleveland took my insurance too...Actually they were made to..I had no doctors in my state that had time to see me..so i went out of state..and since none of the docs around here could see me they had to pay. My lap procedure was around 5000.00 to 7000.00 or so. I don't remember because i didn't get any of the bills. I just know it was alot. My open procedure at cleveland was just 20,000.00 for the surgeon..thats not counting the 8 day stay and every one else (anesteshia, and so on.). So it is pricey. In Indiana Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 13, 2003 Report Share Posted November 13, 2003 , I haven't had the surgery, so I can't offer any info there. Does your insurance company have "participating" and "non-participating" doctors? If I go to a doctor who participates with my insurance, then I'm only responsible for my 20% of the "reasonable and customary" charge and they pay 80% of the R & C fee and then the doctor has to "eat" (no pun intended) the difference. However, if I go to a doctor who does NOT have a signed contract to participate with my insurance, then *I* am on the hook for the difference between what was charged and what the insurance agreed to pay. Also, my insurance has a maximum of $2000.00 out-of-pocket per year -- once I've paid $2000.00 in copays, they pay 100% beyond that (of the R & C fees.) I always make sure to ONLY go to "participating" doctors.... when I had my tonsils out in 1998, the doctor and the hospital had to write off almost $3,000.00 in excess fees. If I hadn't been at a participating facility and using a participating doctor, I would have had to pay that on top of my 20%. So I guess my suggestion would be to contact the surgeon's office and see if he will write off the difference between the two fees. Considering that he only had to "work" for about three hours, I think $12,000.00 is pretty darn steep!!!! (how do I get a job paying $3,000/hour is what I want to know!) They may be willing to cut you some slack (again, no pun intended) and erase part or all of the balance due, esp. if they didn't tell you BEFORE the procedure that you'd be on the hook for seven grand! Good luck, and please keep us posted as to what comes of all of this. This is something that many of us end up dealing with at one time or another. Debbi in Michigan, thankful that The Cleveland Clinic participates with my insurance! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 13, 2003 Report Share Posted November 13, 2003 Hi , I haven't had the surgery, but I am in NYC. My doctor recommended surgery and referred me to a surgeon, so I'm just wondering how you liked your surgeon. Would you recommend him? Where in NYC was he? Which hospital? Thanks. in NYC > Hi -- I had my Heller myotomy and partial fundoplication July 1st, > and, as I had reported earlier, my eating has returned to basically > normal. Went through a period of mild to moderate spasms, but that > subsided within a month or so. I have had one emotionally induced > relapse to a two hour spitting up event. I am very happy with the > result. > > The question I need help with is related to a problem I am having > with insurance reimbursement. The fee for the surgeon alone was > $12,000. My insurance is paying around $4,500. I am going to appeal > their reduction for " usual, customary and reasonable, " but I need > some comparable fees. If you had basically the same surgery, please > respond with your surgeon's charge, his or her name and location, > especially if it was outside of a managed care, participating > physician network. My surgeon's name is Barry Salky and he is in New > York City. Thank you so much. > (davidjohnson@w...) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 13, 2003 Report Share Posted November 13, 2003 I am dealing with the same thing. My doctor, Dr Vanderpool in Dallas, TX, charged 5500 for four hours of surgery. That is not counting the hospital, anestetics, or any one else. I asked his office staff and his fee is 5500. 12,000 for just the surgeon sounds way high. I have a PPO with Blue Cross Blue Shield and I am responsible for 10% of what they deem resonable. I would call your insurance and ask if you owe what is left of the whole bill or what is left of the reasonable charge. If it is of the resonable charge, then you and the insurance both win. Paige > > Hi -- I had my Heller myotomy and partial fundoplication July 1st, > > and, as I had reported earlier, my eating has returned to basically > > normal. Went through a period of mild to moderate spasms, but that > > subsided within a month or so. I have had one emotionally induced > > relapse to a two hour spitting up event. I am very happy with the > > result. > > > > The question I need help with is related to a problem I am having > > with insurance reimbursement. The fee for the surgeon alone was > > $12,000. My insurance is paying around $4,500. I am going to > appeal > > their reduction for " usual, customary and reasonable, " but I need > > some comparable fees. If you had basically the same surgery, > please > > respond with your surgeon's charge, his or her name and location, > > especially if it was outside of a managed care, participating > > physician network. My surgeon's name is Barry Salky and he is in > New > > York City. Thank you so much. > > (davidjohnson@w...) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 13, 2003 Report Share Posted November 13, 2003 , I had a lap hellers w/ dor fundoplication 1 1/2 years ago. My surgeon charged $8,000 for the procedure and my insurance paid $2500 to my surgeon. This was through Aetna EPO in No CA. Good luck with your insurance problem. Sandi in No CA -----Original Message-----From: spyglider [mailto:davidjohnson@...] Sent: Thursday, November 13, 2003 10:31 AMachalasia Subject: Surgical FeeHi -- I had my Heller myotomy and partial fundoplication July 1st, and, as I had reported earlier, my eating has returned to basically normal. Went through a period of mild to moderate spasms, but that subsided within a month or so. I have had one emotionally induced relapse to a two hour spitting up event. I am very happy with the result.The question I need help with is related to a problem I am having with insurance reimbursement. The fee for the surgeon alone was $12,000. My insurance is paying around $4,500. I am going to appeal their reduction for "usual, customary and reasonable," but I need some comparable fees. If you had basically the same surgery, please respond with your surgeon's charge, his or her name and location, especially if it was outside of a managed care, participating physician network. My surgeon's name is Barry Salky and he is in New York City. Thank you so much. (davidjohnson@...) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 13, 2003 Report Share Posted November 13, 2003 Hi , I absolutely would recommend him, but recall the fee. He started the laparoscopic program at Mt. Sinai Hosptial, upper East Side, and had done over 125 Heller's. I felt, by his knowledge, questions, and presentation, that he could do the procedure blindfolded, but he wasn't particularly open to my ambivalence and meddling in " surgical " affairs -- my request to back out if he found a hernia (and after having repaired it). So, I went to the table with ambivalence despite his eminence. He did find a hernia, repaired it and proceeded to incapacitate my defective sphincter. Alas, I am happy on this side of the nightmare. Please help me out, though, by telling me at least the name of the surgeon you are considering and where he practices, as well as perhaps how many Heller's he has performed, and, for sure, his standard, unadjusted fee, relative to insurance programs with which he does not participate and any other such surgeon information you may come across. Good luck with this excruciating process of turning yourself over to the surgeon. > > Hi -- I had my Heller myotomy and partial fundoplication July 1st, > > and, as I had reported earlier, my eating has returned to basically > > normal. Went through a period of mild to moderate spasms, but that > > subsided within a month or so. I have had one emotionally induced > > relapse to a two hour spitting up event. I am very happy with the > > result. > > > > The question I need help with is related to a problem I am having > > with insurance reimbursement. The fee for the surgeon alone was > > $12,000. My insurance is paying around $4,500. I am going to > appeal > > their reduction for " usual, customary and reasonable, " but I need > > some comparable fees. If you had basically the same surgery, > please > > respond with your surgeon's charge, his or her name and location, > > especially if it was outside of a managed care, participating > > physician network. My surgeon's name is Barry Salky and he is in > New > > York City. Thank you so much. > > (davidjohnson@w...) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 13, 2003 Report Share Posted November 13, 2003 Thanks, , If you got any insurance EOB's, explanation of benefits, they would state how much your doctor was paid. But, if they are not readily available, the name of your surgeon would still be helpful. Thanks. > Debbie, > You said it...thankfully Cleveland took my insurance too...Actually > they were made to..I had no doctors in my state that had time to see me..so i > went out of state..and since none of the docs around here could see me they had > to pay. My lap procedure was around 5000.00 to 7000.00 or so. I don't > remember because i didn't get any of the bills. I just know it was alot. My open > procedure at cleveland was just 20,000.00 for the surgeon..thats not counting the > 8 day stay and every one else (anesteshia, and so on.). So it is pricey. > In Indiana Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 13, 2003 Report Share Posted November 13, 2003 Thanks, Debbi, I did not consider cost at the time I made my decision as to the surgeon. Clearly, I agree that it is greatly, financially advantageous to go to a participating physician when possible. So, now I pick up the pieces, and am doing an appeal based on the usual, customary and reasonable being too low, regardless of my surgeon being high end and non-participating. Again, thanks for your interest and all of your thoughts on this. > , I haven't had the surgery, so I can't offer any info there. > > Does your insurance company have " participating " and " non- participating " doctors? > > If I go to a doctor who participates with my insurance, then I'm only responsible for my 20% of the " reasonable and customary " charge and they pay 80% of the R & C fee and then the doctor has to " eat " (no pun intended) the difference. However, if I go to a doctor who does NOT have a signed contract to participate with my insurance, then *I* am on the hook for the difference between what was charged and what the insurance agreed to pay. > > Also, my insurance has a maximum of $2000.00 out-of-pocket per year -- once I've paid $2000.00 in copays, they pay 100% beyond that (of the R & C fees.) I always make sure to ONLY go to " participating " doctors.... when I had my tonsils out in 1998, the doctor and the hospital had to write off almost $3,000.00 in excess fees. If I hadn't been at a participating facility and using a participating doctor, I would have had to pay that on top of my 20%. > > So I guess my suggestion would be to contact the surgeon's office and see if he will write off the difference between the two fees. Considering that he only had to " work " for about three hours, I think $12,000.00 is pretty darn steep!!!! (how do I get a job paying $3,000/hour is what I want to know!) They may be willing to cut you some slack (again, no pun intended) and erase part or all of the balance due, esp. if they didn't tell you BEFORE the procedure that you'd be on the hook for seven grand! > > Good luck, and please keep us posted as to what comes of all of this. This is something that many of us end up dealing with at one time or another. > > Debbi in Michigan, thankful that The Cleveland Clinic participates with my insurance! Quote Link to comment Share on other sites More sharing options...
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