<p>I am hoping that Jordansmom, Jym626, eadad or anyone else in the health care billing world will ring in with some ideas and solutions for our medical reimbursement problem. DS had both upper and lower jaw surgically broken and realigned in Jun by an oral surgeon. It was a complicated 5hr surgery that required a one night stay in the hospital. The final result was great, with our son’s bite nearly perfect and beautiful new profile. He had a significant underbite and difficulty with eating prior to surgery.
The problem has come with the insurance reimbursement for the surgeon’s services. Hospital, anestesia, and pathology were all reasonable bills wiith reasonalbe reimbursement. We have SC State BCBS as primary and TRICARE as secondary insurance. The oral surgeon’s bill for services was $13,800. The reimbursement by BCBS was - - - get this - - - $1995. One reason code simply said the charge was more than they allow. The other code said that when there is a second procedure, they would only pay 50% of the second procedure. Since the Dr. surgically repaired both the upper and lower jaw (2 procedures) at the same time, they will only pay 50% of the second procedure. Not sure what or why that is the case. Surely they can’t expect us to do two separate surgeries.<br>
I am so mad, I could spit nails. Insulting to me and even more insulting to the Doctor. The oral surgeon we used is Out of Network. He has been following our DS for 2years now. There is only one In-Network oral surgeon and he was booked out 7 months. His schedule did not accomodate ours. Plus he did not have the background or history with our DS. We planned this surgery right after school got out for our DS. Surgery was pre-approved by BCBS. We did get a phone call from BCBS prior to surgery advising us that their In-Network surgeon was cheaper.<br>
Of course, I plan to appeal. I am just looking for advice from all of you out there who may have gone through something similar. There is no way that $1995 can be any where close to Reasonable and Customary.</p>
<p>My husband, who is an insurance bad faith lawyer, sees this all the time. (no I am not offering his services…just a comment because this is why this specialty exists). Our insurance, which is the “best” you can purchase (read most expensive) has physicians who are preferred providers (ergo they must take what the insurance company provides for reimbursement) or if, as in the case of most general surgeons here, the doctors can’t or won’t be a preferred provider the patient has two options: be prepared to pay a lot or go elsewhere to find a doctor who is a preferred provider. My husband recently had a shoulder surgery with a pp, one of the best in the country: the doctor was paid $799 for a two hour procedure. That’s it. We had a copay…but nothing like what we would have paid had we gone out of network. (The actual charge was $15,000).</p>
<p>Sounds like a PPO, they (BCBS) will not pay reasonable and customary (out BCBS doesn’t pay reasonable and customary for anything anymore, it is all fee schedule) for Out of Network, at best they will only pay in-network rates, and $1995 with paying one-half of the second procedure sounds about right. I should think that you would get balanced billed as well, out of network for an elective procedure. </p>
<p>I wonder about the coding of the procedeure, if it was truly as complicated as you say, did the oral surgeon code for everything s/he could have?</p>
<p>Sadly, the OS probably coded properly. $6500/per is his usual fee, and BCBS pays their surgeon $1500/per, but he gets booked up for 7 months. BCBS pays us about 50 cents on the dollar, but we haven’t increased our charges in years, there seems to be little point these days when everything comes off the insurer’s fee schedule. We only update our charges every 5 years or so, just to be sure that we stay at least a little ahead of BC.</p>
<p>We do not balance bill, not worth it in our patient population, and we make accomodations for self pay patients so that they pay slightly more than Medicare.</p>
<p>Help educate me. What is balance bill? What do your recommend I do or not do in my letter of appeal?</p>