Hello all,

I just received a bill from my hospital where I had my lap band done. When I look at the pre-certification letter that came before my surgery from my insurance company, I now notice that it says I'm approved for Ambulatory surgery - not inpatient surgery. So, someone at the surgeons office didn't request approval for the right thing.

This is not making me very happy with my surgeon's office right now. That is because my surgery was originally scheduled for April 7th (Monday) and I was called by my surgeon's secretary on Friday the 4th at 5pm in the evening saying she had to cancel my surgery for Monday because my insurance company never received her fax for pre-certification. She called me the morning of April 7th and said she had verbal confirmation that I was approved and scheduled my surgery for that Thursday, the 10th.

I cannot call my insurance company (Empire Blue Cross/Blue Shield) because they only answer their phones 8:30am to 5pm Monday thru Friday. Right now, I feel like I'm going to throw up. Do you think they will be able to straighten this out, or am I stuck with the $5,000 bill?? BTW - I called twice before my surgery and I know my surgeon and hospital were covered by my insurance along with the procedure. So, there's no reason I should have this bill. Any advice to calm my mind would be greatly appreciated.

I wouldn't worry too much. Did you get an explanation of benefits from your insurance company that shows where they paid the hospital? If you havn't received one yet don't worry about the hospital. If you have look at it and see if it says what you are responsible for. Sometimes clinics etc. will try to bill you for the whole amount not covered by insurance eventhough they are contracted to accept a certain amount. You should only have to pay a portion of the hospital bill your "co-pay". If someone made a mistake about the precertification and did not follow the guidelines then I am pretty sure you cannot be held liable for any charges due to their goof up. Don't stress too much..... What are they gonna do repo your band?:incazzato:

I did receive an explanation of benefits - which did have a total of $5100 as my responsibility. There was a footnote that went with that total that said "This service is not covered because we were not notified in accordance with your policy's medical management guidelines." I had received that letter from the Medical Management team stating I was approved, so I didn't worry about that EOB until I just got this bill. This is all on the hospital/surgeon's secretary. My insurance was notified, but in the approval letter I just noticed that it was for ambulatory surgery not inpatient. All the lap bands from this hospital are done inpatient, so I don't know where my insurance company got the idea this was outpatient.

It's just frustrating, I don't understand why this whole insurance thing has to be so complicated.

If you had the right thing and were pre-approved for it, then you just have to get the hospital to rebill your insurance company with the correct code. They have incentive to do this because they want their money.

Before I decided to have lap band surgery, insurance was no biggie. Almost everything I did was covered except for a co-pay and once in a while I'd get a bill for $50 or $100 saying not everything was covered, but that was rare. But with lap band I have had to jump through so many hoops, it's not funny. I haven't even gotten my pre-approval yet either. I am sort of dreading the rest of the process at this point.

Good luck!

The day befor my surgery was scheduled I received a letter from my insurance company stating they would not approve an overnight stay. I called my surgeon's office and told them about this and they

changed me from over night to same day surgery. After my surgery I O2 saturation was staying low and I required oxygen, so they kept me overnight. My insurance did cover the over night stay and I only ended up paying $68.00 of the $34,000.00 hospital bill.

I get bills all the time. They're from the hosptial saying the insurance was paid X amount and there's balance of X. Scary every time even though I know that it means the hosptial and my insurance are still negotiating the cost.

You'll know more tomorrow. Also know that most charges at hospitals are negotiable.

There are ways to get around that pre-cert, if you didn't stay over 24 hours for example you just stayed overnight, but was discharged before you hit 24 hours the hospital should bill it as a 24 hour observation stay, which is considered outpatient. Something I would definitely do, is contact the financial department at the hospital and see what they can do to get it fixed. I still would not lose sleep over it, it just may take a little work to get it taken care of. Perhaps if you fight it enough the hospital will just write it off or a portion of it anyhow.

when checking in at the hospital, the register had to check several times if my husband and I were approved for same day or overnight. she explained that some insurances will only pay for same day, but the surgeons in our town do the surgery as overnight. now we would be free to go same day if there were no complications but they want that extra time just in case. the hospital is working with them to get it so that those that are approved for same day has the right codes. very complicated, but if you were there overnight and only approved for same day, and there were no complications sounds like there was a miscommunication between surgeon and hospital.

Call your dr's office tomorrow and advise them that the precert they obtained was for outpatient surgery and not inpatient. Also advise them that you are being balanced billed. They can call your insurance co and have them change the precert from outpatient to inpatient. The only negiotating the facility will do will be a payment plan. And you shouldn't be paying anything extra if you can get it covered. If all else fails...appeal! Good luck!

define:Ambulatory Surgery - Google Search

Surgery done in the doctor’s office or at a surgical center, and not requiring an overnight stay.

Insurance and Medical Billing Glossary

Surgery that can be performed in an outpatient setting and does not require an overnight stay in a hospital. Ambulatory surgery is general planned ahead of time. Maybe referred to as one-day, in-and-out, or outpatient surgery.

mhcc.maryland.gov/consumerinfo/amsurg/glossary.htm

I work for BCBS. They can approve it as outpatient surgery. It is a pre-set day allowance based on what type of surgery it is and the national average of how many days are needed for post-op recovery. They do not go by the surgeon's "usual" stay. Good news is, you can appeal it. Bad news is, they still may require your surgeon to submit proof of a medical necessity for you having to stay overnight. Contact your BCBS, find out what exactly you need to do. Could be the hospital can handle it, leaving you out of it for the worries.

I called Empire today and after being shuffled between the medical management department and regular customer service I was informed that the $5,000 was a penalization for not receiving pre-authorization. However, according to one of the reps she said she saw not one, but two pre-authorization approvals. One for the surgeon and one for the hospital. She said there was no reason for the $5,000 bill - and that she was sending the claim for resubmission. Very disappointing - two departments at my insurance company cannot even talk to one another.

So, this was not even the doctor office's fault. Empire told me that even though I spent the night, because I was out by the next morning after surgery, that is still considered Ambulatory surgery and that my pre-authorization was correct for this surgery. I was just very disappointed with how the first 4 people I spoke with didn't want to help me - both reps from the medical management department did absolutely nothing and had no advice as to why I was receiving this bill. Although I finally got someone the 5th time I called who seemed to know what she was doing, I will be following up next week to verify that the claim is in processing/or has been resubmitted. I also notified the hospital that the claim was being resubmitted and didn't seem too concerned about helping me either.

Sometimes I think the self-pay people have the right idea - these insurance companies are just a pain.

I also have Empire BC/BS. I haven't received anything out of the ordinary for my surgery, but they didn't pay for two of the pre-surgical tests I had done. The hospital has you come in and do all the testing on one day and they submit to insurance on multiple bills. One test wasn't covered and I knew that, but the other should have been. I called Empire and found out that the provider billed under a diagnostic code that wasn't covered, but there was a covered code on the same date of service. The customer service rep resubmitted to the claims adjuster to see if they could pay under the covered diagnostic code. About two weeks later, I got a new EOB showing they had paid that part.