CPT code 61796 (Stereostatic Radiosurgery) - Fair & Customary Charges

[michelekrentz]

Hello everyone!

If you've had the stereostatic radiosurgery performed upon you, what did your insurance company pay on this particular piece?

I have a HUGE discrepancy of what my insurance company paid and what the doctor wants for just this procedure (code 61796).

I've tried to call United Healthcare (an insurance company he does participate with) and they will not give any information out on what they pay for this code.

I need to get figures to show what is a reasonable and customary charge for this procedure code so I can better negotiate with this doctor. There is no way I can pay the balance, which is over 21k for just this code. It seems quite excessive for out of pocket cost, but I need more facts to work with.

ANY help is appreciated. Thank you!

[ppearl214]

Hi Michele and welcome.

Do you have your insurance through an employer (ie: you, spouse/partner, etc)? They should have the benefits package outlining what is covered and not.  You can also phone UHC and inquire to them what they deem as Reasonable/Customary (R&C) for the "Stereotactic Radiation" procedure.  They must disclose to you what they paid as you should also receive in the mail an EOB (Explanation of Benefits) which will tell you anyway....so, for their Cust Svc not to tell is crazy!  UHC is famous for not being one of the best health plans for coverage (I was briefly on it via my husband's employer and they barely covered anything for me) but they should disclose to you. Ask for an EoB of the procedure.  The dr's office should disclose to you as well.

Phyl

[leapyrtwins]

Lots of docs will let you "off the hook" for what your insurance doesn't cover.

Have you asked about that possibility?

Just a thought,

Jan

[nteeman]

If he does participate that means he agrees to the amount for the procedure that UHC pays. Usually the EOB from UHC should state the billed amount, the amount allowed, the amount UHC paid, and the amount that the patient pays.  It usually states that the patient is not responsible for any other differences.

Neal

[Jim Scott]

Michele ~

See Jan's post (#2). 

When I asked my doctor about the cost of the AN debulking surgery he was going to perform, he assured me that he would accept "whatever your insurance pays" and urged me not to worry about money, just about getting well.  He kept his word.  My medical insurer (Blue Cross, then) paid approximately $28,000. to my neurosurgeon and his assistant (also a neurosurgeon) and $60,000 to the hospital.  I never received a bill from the doctor.  Its worth asking.

Jim

[AnnR]

My charges for the cpt code of 61796 were $5,754.00. I have Medicare....Medicare allowed $908.79 as ucr and my neurosurgeon rec'd only $789.64 for his part.  as you may know, that Medicare has very different guidelines than private ins.  The totals for all the services, received day of GK at Jackson, Ms at the hospital, was just over $124,000.00.  of which Medicare allowed $8,924.50.......

Maybe this will help you.

I know that if you are on Medicare as I am, that  if the doctor accepts assignment then he must accept what Medicare allows for Medicare patients.

Just as someone else wrote.....talk to the physician's patient accounts people or even him....you never know till you ask.

AnnR