Surgeons, Medicare, other insurance...and what you need to do!!

From: Helen Dynda (olddad66@runestone.net)
Sat Sep 30 08:51:22 2000


Adhesions surgeries are very difficult and can be very lengthy procedures for surgeons!! I know that Dr. Harry Reich performed an adhesiolysis for Bev...which took 5 hours. He also did an adhesiolysis for Deb...which took 10 hours. An adhesiolysis procedure is a risky surgery...unless the surgeon proceeds very carefully and cautiously. When a surgeon does NOT proceed in this way, there is a real possibility that the surgeon may unintentionally cause injury to the patient. The surgeon may accidentally nick or cut into the patient's bowels, ureter, bladder or other vital organs. Unless the surgeon takes his/her time to proceed slowly, the aforementioned injuries can be a real possibility. This is exactly why you do not want to have just any surgeon perform an adhesiolysis for you!! You want a surgeon, who is highly skilled and very experienced with procedures involving adhesions.

I recently learned that I could NOT have surgery at the new Adhesions Unit at Community Medical Center at Scranton, PA!! Why, you may ask? When a Medicare patient is admitted to any hospital in the state of Pennsylvania, the Medicare patient's surgeon must agree to abide by Medicare's schedule of reimbursement before he/she is permitted to perform surgical procedures at that hospital. If the Medicare patient's surgeons do NOT agree with Medicare's method of payment, then these surgeons are not allowed to perform surgery for the Medicare patient!!! What does that mean in my case? It meant that I could not have Dr. Harry Reich and Dr. Jay Redan as my surgeons!! ( I will explain why in my next paragraph.) It also meant that I COULD NOT even self-pay to have Drs. Reich and Redan as my surgeons. In other words it meant that I absolutely could not have surgery at the new Adhesions Unit...unless my surgeons agreed to Medicare's method of payment for surgeries!!! Using a term Bev has used...I was miffed!!!

In my case, Medicare does not consider the length of time that it takes for a surgeon to complete an adhesiolysis procedure. After all, to Medicare, an adhesiolysis procedure is just a matter of a surgeon "slicing through the adhesions to set the adhesions free." What I am trying to say is that Medicare has NO knowledge as to what a surgeon needs to do - nor does Medicare have any concept of how much time is involved - in order to complete and give their patient the BEST chance for a successful adhesiolysis.

Medicare's schedule of payments to surgeons specifies so many $'s for each specific surgery. It does not matter to Medicare how many hours an adhesiolysis takes! Medicare looks at their schedule; and then pays 80% of what Medicare has listed on their schedule of reimbursement. Then the Medicare patient's supplementary insurance steps in and pays the remaining 20%. Anything ABOVE Medicare's schedule has to be written off - meaning that the surgeon, the hospital, and the anesthetist CAN NOT bill the Medicare patient for the unpaid balance. Considering the length of time some adhesiolysis procedures can take, this could amount to a loss of thousands of dollars for the surgeon, the hospital, and the anesthetist. Thus surgeons are not fairly compensated for their skill and for the length of time it takes to complete difficult adhesion surgeries.

Surgeons, who do not have the international recognition that Dr. Reich has, are aware that surgeries for adhesions can take many hours to complete. Their first lengthy adhesiolysis experience teaches them to NEVER do another adhesiolysis...UNLESS they combine it with another surgical procedure, such as a hysterectomy. They are paid much better for the hysterectomy...and perhaps that is one way to explain why so many hysterectomies are done...for the wrong reasons...where perfectly healthy reproductive organs are hysterectomized.

This explains why so many men and women have had surgery after surgery for adhesions...and, as a result, they keep developing more and more adhesions and increased chronic pain. Unless men and women have a thorough understanding of every aspect of adhesions, they will keep making the same mistakes. If they blindly agree to have a adhesiolysis procedure done over and over by JUST ANY surgeon, this becomes a futile attempt at trying to release adhesions...which only exacerbates ( makes worse ) the adhesions and chronic pain problem!!

What can men and women, who suffer from chronic pain as a result of adhesions, do? They can start by making an effort to learn as much as they can about ARD ( Adhesion-Related Disease ). As a result of educating themselves about ARD, men and women will eventually develop a better understanding about adhesions...an understanding which will be there to help them make the "right decisions" regarding what to do about their adhesion pain.

I read a book, which was written by a male Ob/Gyn, in which he advised women to seek female gynecologists rather than male gynecologists for their medical and surgical care. His reasoning is that female gynecologists understand the female reproductive system far better than their male counterparts. He also said that some male gynecologists tend to look at hysterectomies as an easy way for them to increase their earnings. How many women, diagnosed as having endometriosis, have lost their reproductive organs because they were told by their male gynecologist that a hysterectomy would end their endometriosis? A hysterectomy DOES NOT cure endometriosis!! Unless a woman - who suffers from endometriosis - has done research on endometriosis, she does not know that!! As a result she needlessly loses her ability to have children.

Knowledge is power!! Put that power back in your hands by learning everything you possibly can about your particular medical problem(s)!!


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