The good news, got sleeved on December 16th, including 2 hernia repairs. Doing good after I got off of protein shakes at two weeks. Had diarrhea for 9 days, developed a lactose intolerance.
Now the kicker. Got approval thru Aetna for the hernias and sleeve. The sleeve I felt was needed due to constant back pain and knee pain. And yes, lost 25 pounds already and only needing hydrocodone, once in last ten days, yea!
My sleeve was postponed from 7:30 a.m. to 5 p.m. Since the day previous and the day of surgery, had nothing to eat but a little water the previous day, I dropped below the bmi of 35. Hospital WOULD NOT allow sleeve to be done charged to insurance. I am in my gown in pre-op in tears because I felt I really needing this done. 1.2 pounds light, really. Dr. said no more openings the rest of year and would of cost me more if I reset after the first of year, due to deductions starting over. I was able to pay the out of pocket additional amount of $9,000 after two weeks earlier paying $3700 which should have covered my insurance deductible. I contacted Aetna after getting home and lady I talked to said that doesn't sound right. I am trying to get hospital to submit claim to insurance, but I know Dr. will be p.i.a. because he has gotten his cash money. ANY SUGGESTIONS or thoughts, please share! I had read before that once insurance approves that they don't care and hope you lose weight, to make the surgery easier. I know this is all the doing of the hospital and really is upsetting me.

That's weird. My Aetna plan only cared about my starting weight, not my surgical weight. I would make some noise about that for sure. BCBS is the same.

On my surgery day, I didn't get weighed until I asked to be weighed. I wanted to know for my own information, what I was starting with. So me in my hospital gown, little footies, and hat they gave me walked across the preop area to officially weigh in.

I used to work with a BCBS to help providers resolve claim denials when they filed incorrectly. An in - network provider (hospital, surgeon, lab, anesthesiologist, physical therapist, etc) must file the claim with the insurance. MUST. No options. And no way the hospital can decide that they won't submit because they think it won't be covered.

As an example, a plastic surgeon is in-network with the insurance. Doesn't mean all procedures he or she does is covered. But they still have to file the claim. Say I was in a car accident and needed plastic surgery to fix skin around my eye. Covered. Same procedure but due to me wanting an "eye lift" is not covered. The first medically necessary and the 2nd cosmetic.

Here's the thing... the HOSPITAL cannot decide that you suddenly don't meet their criteria, and then let you go cash pay. If you don't meet their criteria, method of payment won't change that. The whole thing is shady.

You can't submit the claim yourself, because it's more than just submitting receipts.

Don't back down. I would go ahead and file a complaint with your insurance company.

The reason I would attempt to file the claim myself and be reimbursed is that the MD already has your money. If they submit to insurance he gets paid AGAIN. Then you must wait for the MD to reimburse you.

Most insurance companies will reimburse you for any out of pocket costs they actually cover

This is really bugging me....who actually told you they would not bill ins ?

Because honestly Doctors/ nurses in the hospital do not control billing in a way. Someone does it for them. The hospital would bill for their portion..room/OR time/ medications etc and Dr's office would bill for their portion for services separately.

I would at least file the receipts you have to the insurance as this will stop any timely filing limits. The insurance will most likely need the bill on special forms (UB04 for hospital and a CMS-1500 for the surgeon. These are not the forms that are sent/given to patients. Some insurance requires it to be filed electronically.

However they will then pend the claim and ask for the correct forms from the providers. Many time the providers are more likely to respond better to the insurance company.

The insurance company should pay you directly if you have submitted the proof of payment. The problem will be if the hospital charged $9,000 but the PPO allowed amount is only $7,000 then the hospital should be writing that amount off and refunding you. Getting that $2,000 may be difficult.

The reason I would attempt to file the claim myself and be reimbursed is that the MD already has your money. If they submit to insurance he gets paid AGAIN. Then you must wait for the MD to reimburse you.

Most insurance companies will reimburse you for any out of pocket costs they actually cover

Actually this isn't quite true. You can check a box on the claim form that says the payment has already been made to the doctor and then a check gets mailed to you directly. I used to do medical billing, contact your insurance company and talk with a rep they will help you find the forms and the names of the documents you need to submit your claim. The hospital under HIPPA has to provide you with the records you need to process you claim.

Here's the thing... the HOSPITAL cannot decide that you suddenly don't meet their criteria, and then let you go cash pay. If you don't meet their criteria, method of payment won't change that. The whole thing is shady.

You can't submit the claim yourself, because it's more than just submitting receipts.

Don't back down. I would go ahead and file a complaint with your insurance company.

That is exactly the point. Hospital claimed at bmi of 34.8 it didn't meet their requirement to file and told the Dr. it wouldonly be done with cash pay.

The reason I would attempt to file the claim myself and be reimbursed is that the MD already has your money. If they submit to insurance he gets paid AGAIN. Then you must wait for the MD to reimburse you.

Most insurance companies will reimburse you for any out of pocket costs they actually cover

Actually this isn't quite true. You can check a box on the claim form that says the payment has already been made to the doctor and then a check gets mailed to you directly. I used to do medical billing, contact your insurance company and talk with a rep they will help you find the forms and the names of the documents you need to submit your claim. The hospital under HIPPA has to provide you with the records you need to process you claim.

I go back next week, with my newest approval letter I got today APPROVING my 2nd day in hospital and the SLEEVE. Please explain my submit options you are bringing up. I know it will be a p.i.a. to get money back from hospital and especially the Dr. office.

On my surgery day, I didn't get weighed until I asked to be weighed. I wanted to know for my own information, what I was starting with. So me in my hospital gown, little footies, and hat they gave me walked across the preop area to officially weigh in.

I used to work with a BCBS to help providers resolve claim denials when they filed incorrectly. An in - network provider (hospital, surgeon, lab, anesthesiologist, physical therapist, etc) must file the claim with the insurance. MUST. No options. And no way the hospital can decide that they won't submit because they think it won't be covered.

As an example, a plastic surgeon is in-network with the insurance. Doesn't mean all procedures he or she does is covered. But they still have to file the claim. Say I was in a car accident and needed plastic surgery to fix skin around my eye. Covered. Same procedure but due to me wanting an "eye lift" is not covered. The first medically necessary and the 2nd cosmetic.

But that is EXACTLY what the hospital did and the Dr. followed suit.

This is really bugging me....who actually told you they would not bill ins ?

Because honestly Doctors/ nurses in the hospital do not control billing in a way. Someone does it for them. The hospital would bill for their portion..room/OR time/ medications etc and Dr's office would bill for their portion for services separately.

The Bariatric Manager at Detar Hospital, Victoria, Texas. Told Dr. this too and his office required immediate payment also.

Where do you live? The more I think about it the more bizarre this story sounds.

South Texas, hospital in Victoria, Texas.

I would at least file the receipts you have to the insurance as this will stop any timely filing limits. The insurance will most likely need the bill on special forms (UB04 for hospital and a CMS-1500 for the surgeon. These are not the forms that are sent/given to patients. Some insurance requires it to be filed electronically.

However they will then pend the claim and ask for the correct forms from the providers. Many time the providers are more likely to respond better to the insurance company.

The insurance company should pay you directly if you have submitted the proof of payment. The problem will be if the hospital charged $9,000 but the PPO allowed amount is only $7,000 then the hospital should be writing that amount off and refunding you. Getting that $2,000 may be difficult.

Yeah, it gets worse. Had paid hospital $3000 two weeks before surgery to cover out of pocket including Dr. share. Dr. office threw pissy fit and had to pay them an additional $700, THEN on surgery day had to pay $5500 to hospital and $3500 to Dr. the CASH price and where the hell is the $3700 at? I'm just not very smart at this.

This is really bugging me....who actually told you they would not bill ins ?

Because honestly Doctors/ nurses in the hospital do not control billing in a way. Someone does it for them. The hospital would bill for their portion..room/OR time/ medications etc and Dr's office would bill for their portion for services separately.

The Bariatric Manager

Once the surgeon files the claim, the insurance company will pay him the agreed upon fee. This is done monthly. They will also recoup the fee you paid to the surgeon (subtracting it out of the total payment) and will reimburse you.

If you file the claim, it can start the investigation into why the surgeon did not do the correct and legal thing per his contract.