Author Topic: Is This Ethical (Insurance Related)?  (Read 30291 times)

fenimore

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Is This Ethical (Insurance Related)?
« on: December 30, 2006, 03:23:56 pm »
The neurosurgeon I'm considering here in NJ (removal of a 2.8cm NA) does not accept any insurance.  He operates with an otolaryngologist.  He tells me that the  bill will be submitted to my insurance company by the otolaryngologist as the lead doctor, with him as an assistant.  It sounded good until the neurosurgeon's secretary told me not to talk to my insurance company or employer about this arrangement because they (the doctors) would get in trouble.  I'm worried enough about the surgery and recovery without wondering about getting in trouble with my insurance company.  Has anyone else heard of this type of thing?

ppearl214

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Re: Is This Ethical (Insurance Related)?
« Reply #1 on: December 30, 2006, 03:26:50 pm »
Hi Fenimore and welcome.....

Based on what you just wrote, I'd run like heck!  You can go to your State Board of Registration of Physicians to find a qualified neurosurgeon who will accept your insurance.  Also, you can check here under "Physicians" to find AN treating physicians in your area that come recommended by other AN patients.

Welcome to the forums.....

Phyl
"Gentlemen, I wash my hands of this weirdness", Capt Jack Sparrow - Davy Jones Locker, "Pirates of the Carribbean - At World's End"

Obita

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Re: Is This Ethical (Insurance Related)?
« Reply #2 on: December 30, 2006, 03:46:00 pm »
Hi fenimore:

Yikes.  I have never, ever heard of anything like this!!  Like you said, as if this isn't stressful enough...........

You will find a ton of posts on here regarding your gut feeling........you need to listen to it.

I did recieve two bills for the surgeons.  One for the Otologist/Neurotologist and one for the Neurosurgeon.

Welcome to the forum and good luck, Kathy
Kathy - Age 54
2.5 cm translab May '04
University of Minnesota - Minneapolis
Dr. Sam Levine - Dr. Stephen Haines

Jim Scott

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Re: Is This Ethical (Insurance Related)?
« Reply #3 on: December 30, 2006, 04:48:17 pm »
fenimore:

Welcome to the board. 

To answer the question stated in your post: no, this 'arraignment' is not ethical.  It is a form of fraud.  You should not get involved in this scheme.  Besides, what surgeon doesn't take any medical insurance plan?  That sounds very suspicious to me.  Is this man even licensed?  I'm serious.  Not accepting any medical insurance sets off many alarms t for me. 

In any case, even if you foolishly went along with the scheme, should your insurance company ultimately refuse to pay your neurosurgeon's fee as an 'assistant' (they are not all that stupid) you would be liable for that fee and I can tell you, it will be high.  Probably in the neighborhood of $30,000. or much more.  Who needs that kind of worry?  Not you.

I would suggest you pass on this ethically-challenged neurosurgeon and find someone who is not only competent but plays by the rules - and takes your insurance.


Jim[/color]
4.5 cm AN diagnosed 5/06.  Retrosigmoid surgery 6/06.  Follow-up FSR completed 10/06.  Tumor shrinkage & necrosis noted on last MRI.  Life is good. 

Life is not the way it's supposed to be. It's the way it is.  The way we cope with it is what makes the difference.

Palace

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Re: Is This Ethical (Insurance Related)?
« Reply #4 on: December 30, 2006, 05:02:15 pm »
 :-X

If they are doing that with insurance.........what are they going to do to your head; run like HECK.  Yes, I'm serious!



Frightening,



Pal
22 mm Acoustic Neuroma (right side)
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Joef

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Re: Is This Ethical (Insurance Related)?
« Reply #5 on: December 30, 2006, 05:31:07 pm »
I have trouble with this for 3 reasons... (and I'm not even counting the moral ones!)

1. If a doctor is willing to do this, I would bet he has NOT done many AN's before .. and that would worry me

2. If the insurance questions him, he will say "Oh thats just a mistake by the nurse" and YOU will be stuck with the bill !
    He wont risk his livelyhood on you....

3. and you can't say a thing if something goes wrong! .. what if you have a problem and end up suing the doctor ...
     the doctor of record will be the wrong one ... YOU will end up in touble... 
« Last Edit: December 30, 2006, 05:33:22 pm by Joef »
4 cm AN/w BAHA Surgery @House Ear Clinic 08/09/05
Dr. Brackmann, Dr. Hitselberger, Dr. Stefan and Dr. Joni Doherty
1.7 Gram Gold Eye weight surgery on 6/8/07 Milford,CT Hospital

fenimore

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Re: Is This Ethical (Insurance Related)?
« Reply #6 on: December 30, 2006, 05:40:52 pm »
Actually, I find that more and more surgeons and physicians here in New Jersey are dropping out of many of the major plans, if not all of them. Basically, you pay them whatever you're paid by your carrier, then you have to negotiate the balance with the doctor.  In fact, the older and more experienced they are, the more likely it seems that they will be very selective, because they already have solid reputations.  That's what the neurosurgeon said.  The younger guys have to accept insurance, but he doesn't have to anymore.  I had abdominal surgery a year ago, and the colorectal surgeon did not accept any insurance.  My BC/BS Horizon PPSplan paid me only $1500 of $7000.  I negotiated with him and he settled for a lump sum of $3000 which was out of my own pocket, plus the $1500 from the insurance company.  Then I found that the anesthesiology department no longer accepted my Horizon PPS, and I paid them $1000 out of my pocket.  This was at Englewood Hospital in Bergen County.  I can feel for the doctors-they do better by negotiating with the patient rather than accepting a pittance from the insurance company.  That's why the plan I asked about at the start of this thread sounded too good to be true-sort of like the neurosurgeon sneaking in behind the otolaryngologist!

ppearl214

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Re: Is This Ethical (Insurance Related)?
« Reply #7 on: December 30, 2006, 05:49:53 pm »
fenimore, that may be the case in NJ and I feel that having to fork over that many thousands of dollars since you have to "negotiate" directly with the dr's is .... well, to me.... not kewl.  I have BC/BS... not one penny came out of pocket for my treatment.  Only my Rx's.  Even to do an 80/20 based on PPO in network (or even 70/30 out of network) is more reasonable. Have you researched hopsitals in NYC or even Philly that can do your treatment? 

This is really sending a red flag and can understand and respect what you are saying...... but, hard to swallow.

Phyl
"Gentlemen, I wash my hands of this weirdness", Capt Jack Sparrow - Davy Jones Locker, "Pirates of the Carribbean - At World's End"

fenimore

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Re: Is This Ethical (Insurance Related)?
« Reply #8 on: December 30, 2006, 06:12:01 pm »
The problem is that when Horizon says they will pay 80% of a non-participating physician's fee, they mean 80% of what they deem reasonable, not what the doc actually charges. If it was 80% of the actual charge, that would be great, although for neurosurgery, that's still leaves a major burden.  Maybe other plans and insurers do pay more than mine to non-participating docs, I just don't know.

Anyway, I hate to feel that I have to select the surgeon on the basis of his participation in my plan, rather than his competence.  I wonder if the big guys in NYC like Dr Post (Mt Sinai) or Dr Stieg (Weill-Cornell) take most insurance plans.  I bet they don't!




Joef

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Re: Is This Ethical (Insurance Related)?
« Reply #9 on: December 30, 2006, 06:58:33 pm »

I would look into NYC somewhere ..  heck ... Boston is only 3 or 4 hour Drive!
4 cm AN/w BAHA Surgery @House Ear Clinic 08/09/05
Dr. Brackmann, Dr. Hitselberger, Dr. Stefan and Dr. Joni Doherty
1.7 Gram Gold Eye weight surgery on 6/8/07 Milford,CT Hospital

jerseygirl

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Re: Is This Ethical (Insurance Related)?
« Reply #10 on: December 30, 2006, 07:30:17 pm »
This is actually becoming very common in both NY and NJ for the top doctors not to participate in the major insurance plans. Patients with HMO's are out of luck but those with open plans where they can go out of network negotiate the surgery fees with the doctor. Starting January 1st, I will have an open plan so I can choose the doctor based on the competence not participation. Dr. Post, for instance, does not participate in any insurance plan but his secretary said " He'll work with you". Some flatly state that they will accept whatever insurance will give them, so you have to ask what your responsibility will be.

 There is a team in NY I spoke to that has a neurosurgeon participating in my plan but not otolaryngologist. They operate together. When I asked about how it is going to work, I was told that   I would be admitted by a neurosurgeon but the otolaryngologist will be "the assisting doctor". It is happening everywhere, so I do not think this NJ doctor is necessarily unethical. What I have to question is how many AN he has done and what is his record. That would be my decision criteria. There are quite a few experienced surgeons in NY and, like somebody said, Boston is just a few hours away and so, I might add, is Pittsburgh.  Local is not necessarily best. Having said that, I must admit that I am still undecided!

                  Eve
Right side AN (6x3x3 cm) removed in 1988 by Drs. Benjamin & Cohen at NYU (16 hrs); nerves involved III - XII.
Regrowth at the brainstem 2.5 cm removed by Dr.Shahinian in 4 hrs at SBI (hopefully, this time forever); nerves involved IV - X with VIII missing. No facial or swallowing issues.

Battyp

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Re: Is This Ethical (Insurance Related)?
« Reply #11 on: December 31, 2006, 01:39:35 pm »
Oh boy..I know when I had my ankle reconstruction I had an ortho guy doing it and a foot guy helped.  I did not get a bill from the foot guy nor did my insurance that I know of. 

I'd hate to think I have insurance and it wouldn't cover with my surgery it was around 100K to which I paid 1000 out of pocket.  Not an amount I'd want to have to neogiate  :-\  I'd make sure I'd have everything in writing signed by the doctor first so I didn't have to worry after and....like jersey girl said..I'd be more concerned with their surgical ability and how many an's they've seen and look elsewhere if it's minimal.  There's too many options out there if you can travel.


jerseygirl

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Re: Is This Ethical (Insurance Related)?
« Reply #12 on: December 31, 2006, 02:09:53 pm »
I 100% agree with BattiePrincess about traveling. If you think you have to pay, then make sure you pay for the best!

             Eve
Right side AN (6x3x3 cm) removed in 1988 by Drs. Benjamin & Cohen at NYU (16 hrs); nerves involved III - XII.
Regrowth at the brainstem 2.5 cm removed by Dr.Shahinian in 4 hrs at SBI (hopefully, this time forever); nerves involved IV - X with VIII missing. No facial or swallowing issues.

Sam Rush

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Re: Is This Ethical (Insurance Related)?
« Reply #13 on: December 31, 2006, 03:02:18 pm »
It's the doctors right to accept ins or not. All I know is that the best in the world. Dr. Brackmann and team at house clinic accepted my ins. as 100% of payment for Dr, B and NS DR, Swartz who billed seperately.  This was Cigna ins.
1 cm AN translab, Dr. Brackmann, Dr. Schwartz, Dr Doherety HEI   11/04   Baha 7/05

roub1

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Re: Is This Ethical (Insurance Related)?
« Reply #14 on: December 31, 2006, 03:15:02 pm »
 Not only is it not ethical but it is illegal. That Dr. is committing insurance fraud and by knowingly participating you are likewise guilty. The insurance company can and will sue to recover anything that is paid and you will become a party to that too. I would take the advise already given, run. I would also file a compalaint with the State Medical Board and Attorney Generals Office