Re: My letter to: JEAN from Pennsylvania about Dr. Redan....

From: Jean (
Mon Feb 26 13:23:37 2001

At Mon, 26 Feb 2001, Mary Wade wrote: >
>Jean--Ah, Sue. Every medical procedure that they will do on you has a
>procedure code. And there will be an accompanying diagnostic code to
>explain to the insurance company why they did the procedure. I think what
>Sue was trying to convey was that until they get in there...they don't know
>exactly what they will find. In my case, they did several different
>procedures and could bill for each of them. Had there only be
>adhesiolysis...they could have only billed for that. Does this make sense?
>My guess is that she meant that she can't know now what all the procedures
>will be. In my case, there were separate codes for the adhesiolysis and
>the removal of endo. It wasn't like they up and decided to remove my
>tonsils while they were in there. It was all related and needed.
>And if they were to REALLY think up something to do for which there is no
>procedure code? Then, yes, insurance companies would cough that up, I am
>sure. Might be well to ask for clarification on this if you think Sue
>really said there are no procedure codes for what they are doing. So it's
>either 1) they don't know exactly what they will have to rearrange until
>they get in there (most likely) OR 2) they are doing procedures that are
>not recognized (very unlikely, I would think). Might not hurt to find out
>for sure. Off for the day! Your friend, Mary

Mary, You are probably right on not knowing "which" codes to use 'til they get in there. I just thought they had standard codes that they use and can check on benefits before surgery. I didn't know they don't need to provide these until after surgery. Isn't that a part of getting the pre-certification (I do need that)?

Glad to hear they didn't take your tonsils out!.....think they might have had trouble getting to them from your belly (tee hee). I don't have any womanly organs left to take. Thanks again for your help! Your Friend, JEAN (from PA) >
>-----Original Message-----
>From: Jean (from PA) []
>Sent: Sunday, February 25, 2001 10:48 PM
>To: Multiple recipients of list ADHESIONS
>Subject: Re: My letter to: JEAN from Pennsylvania about Dr. Redan....
>At Sun, 25 Feb 2001, Mary Wade wrote:
>>Jean--Something in your letter struck me as "Ut oh....think we have to
>>figure this out." It was your comment that "I am just hoping since there
>>aren't procedure codes (as I have heard
>>>from some people) for the operation that my insurance doesn't refuse to
>>>pay anything." that has me concerned and confused. This was not my
>>experience with Dr. Reich and Redan. There WERE procedure codes for the
>>procedures that they did. Could you clarify on this point? Thanks. Your
>>friend, Mary
>Hi Mary,
>I had asked my insurance company awhile back if they could tell me if
>and how much they would cover for Adhesion Lysis. They said I needed to
>get a diagnosis code and procedure code in order for them to know if and
>what they would cover.
>I told this to Sue but she didn't supply me with any codes so I could
>check on my coverage. I didn't think that would be so difficult since I
>assumed there was "a code" just for adhesions in I wrong??
>I know of others who had difficulty getting codes from Sue also.
>I don't mean to be picky or anything, just reassured.
>I hope you understand why I am worried about this.....after what my
>insurance is pulling off with the nursing home.
>I thought after all the appeals and changes in codes from the nursing
>home that the insurance would have paid them by now. Can you imagine
>the 6 week bill for intravenous antibiotics and therapy, let alone room
>and food etc.?
>It is also largely the fault of the insurance company that I am out of
>the $900 from another doctor. "They" had the wrong ID number for the
>doctor when they told me I had to pay him cause he wasn't in-network. I
>sent the doctor the small "out-of-network" amount I received PLUS I
>scraped allot of additional money together( a portion of the charge)and
>sent it to the doctor and then it was discovered he was "in-network".
>The insurance then sent the doctor "all of" the "in-network" payment
>instead of deducting what they were already paid from me
>"out-of-network" from the payment.
>The insurance then told me "I" owed the insurance company their money
>back and "I" had to get my money back from the doctor although I don't
>have it and "told them" it was all sent to the doctor! They made me pay
>them back... so now I paid the doctor, they paid the doctor AND I also
>paid the insurance company. Then I even hire and pay a lawyer cause the
>doctor won't return my money and they still won't reimburse me! What a
>mess, and I just keep losing more money!!
>I figured I was in good shape with the Scranton hospital cause they do
>participate with my insurance....but now I am not sure.
>Am I worrying for nothing?
>Does the insurance "have to pay" if the hospital is participating
>Are they "obligated to pay something" towards the doctor bill if they
>are out of network??
>Every time I start feeling really good about going there for the surgery
>something in my life backfires in my face to cause me to worry a again.
>Appeals and lawyers haven't worked for me!
>I also really thought my MD would help by writing a referral letter, but
>I was wrong.
>If this other surgeon heard of them maybe he will write one?? The
>doctors around here aren't very willing to help you. I just figured it
>"might" help in-case the insurance would say something like "you should
>(or must) go to a doctor who is in-network".
>Thanks for being a compassionate & understanding friend.
>Sorry this is so long....I get carried away.
>>At 12:52 AM 2/25/01 -0600, you wrote:
>>>At Sat, 24 Feb 2001, Helen Dynda wrote:
>>>>Jean ( ) from Pennsylvania said: "I asked my MD to
>>>>a referral paper for Dr. Redan cause even though I don't need referrals
>>>>read on here that it may help prevent insurance problems. He refused,
>>>>he never heard of them.
>>>>~ ~ ~ ~
>>>>Dear Jean, I am so sorry to hear that your doctor refused to give you a
>>>>referral to Dr. Redan.
>>>>You might ask your doctor if he has ever heard of Dr. Harry Reich. Dr.
>>>>Reich is "the most talented laparoscopic surgeon in the world!!" Dr.
>>>>performs surgery at both Community Memorial Hospital ( CMC ) in
>Scranton, PA
>>>>and at St. Vincents' Hospital in New York City. Since you are from
>>>>Pennsylvania, surely your doctor has heard of Dr. Reich.
>>>>In April 1999, Dr. Reich performed a successful adhesiolysis procedure
>>>>Deb. I saw Deb's video -- her abdominal and pelvic organs were
>>>>covered with adhesions!!. It took Dr. Reich 10 hours to complete Deb's
>>>>surgery!!! Deb is pain free today!!
>>>>For a long time Dr. Reich realized that postsurgical adhesions have been
>>>>causing so many people problems with chronic pain, infertility, bowel
>>>>obstructions, etc. Since he had been experiencing success with his
>>>>adhesiolysis procedures, Dr. Reich made a decision to specialize in
>>>>performing adhesiolysis procedures. Since Dr. Reich's specialty is
>>>>he needed to find a General Surgeon to be his surgical partner. It was
>>>>that Dr. Reich personally chose Dr. Jay Redan to be his surgical
>>>>Dr. Redan is a very skilled and experienced laparoscopic surgeon too.
>>>>On May 1, 2000 these two surgeons opened the very first Adhesions Unit
>>>>the United States at CMC. Since then Dr. Reich has been working very
>>>>closely with Dr. Redan -- at both CMC and St. Vincents Hospital --
>>>>specializing in adhesiolysis procedures.
>>>>When adhesion involvement is very severe, such as in Deb's case, it is
>>>>extremely important that the surgeon is very meticulous as well as
>>>>cautious as he lyses adhesions...for the safety of the patient and to
>>>>the patient the very best chance to become pain free. The surgeon must
>>>>sure that there is NO blood or other debris ( such as talc from the
>>>>surgeon's gloves, lint from sponges, etc.) left in the abdominal cavity.
> He
>>>>must also be very careful so that he does not traumatize internal
>>>>All of this takes time...a lot of time, if the lysis of adhesions is
>>>>to be a success!!
>>>>When a surgeon tries to complete an adhesiolysis procedure in a maximum
>>>>1-2 hours, the surgeon's decision -- to complete the adhesiolysis
>>>>within this time frame -- does NOT show consideration for the safety and
>>>>well-being of the patient. Chances are the surgeon is "rushing" the
>>>>adhesiolysis procedure simply because he knows that an adhesiolysis
>>>>procedure is the "most underpaid" surgical procedure that Medicare and
>>>>insurance companies reimburse the surgeon for.!!!!!!!
>>>Thanks for your response to my post.
>>>I think I also mentioned Dr. Reich to my MD, but not sure.
>>>I will ask the general surgeon when I go, if I am lucky maybe he will
>>>know one of them.
>>>I know exactly what you mean about the rushing etc.
>>>I do believe what you say about Dr. Reich.
>>>I definitely prefer someone who cares and is gentle!!
>>>I am just hoping since there aren't procedure codes (as I have heard
>>>from some people) for the operation that my insurance doesn't refuse to
>>>pay anything. I definitely can't afford to pay the entire doctor bill
>>>AND the hospital. I would go out of network and don't know if they
>>>would definitely be required to pay?!? When I asked for codes Sue
>>>couldn't give me any so I could check with my insurance. The insurance
>>>said I need diagnosis codes and procedure codes to see if it qualifies
>>>and for how much.
>>>I do already have a problem going on right now with the insurance
>>>refusing to pay for my nursing home care of 6 weeks (big time money).
>>>The nursing home has appealed it about 6 times now in 7 months time.
>>>The insurance company was the one who said they would only pay for my 4
>>>weeks of intravenous "if I was in a nursing home", but not as an
>>>out-patient with a visiting nurse coming in to start & stop it twice a
>>>day so I had no choice. The nursing home "is a participating facility"
>>>so it is in-network.
>>>These HMO's are something else!!! I know they definitely are not in
>>>business to do anyone any favors and will do whatever it takes to get
>>>out of paying if possible.
>>>I also never got my money back ($900) from that doctor who double-billed
>>>(me & the insurance) even after I got a lawyer.
>>>He couldn't believe it kind of luck!
>>>Hope you are still feeling good.
>>>Jean (from PA)
>Jean (from PA)

Jean (from PA)

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