Mary, Really don't know the answer to that one.....never contacted officials before. Have no idea who or how. You would think the nursing home would.
I think (and am praying) the nursing home will absorb the loss if the insurance doesn't ever pay. The woman who talked to me at the nursing home said it wouldn't be right if they make me pay the bill cause the nursing home did tell me I was covered, and they would try to get them to absorb the bills. Well...at least I am lucky that everyone up there liked me and after spending 6 weeks there they know me very well. My husband's mom had also been in there for 4 years.
The other doctor is another story....and he has no right to that money at all. That is double-billing and is "suppose to be" illegal I thought. Since he is in-network he "must" accept what they paid which is never the full amount. He managed to get full coverage this way!
My husband said maybe I should call the Senator??? If a lawyer meant nothing would the Senator?
JEAN (from PA)
>
>-----Original Message-----
>From: Jean (from PA) [SMTP:creative@enter.net]
>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 general....am 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
>(in-network)???
>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.
>JEAN
>
>>At 12:52 AM 2/25/01 -0600, you wrote:
>>>At Sat, 24 Feb 2001, Helen Dynda wrote:
>>>>
>>>>Jean ( creative@enter.net ) from Pennsylvania said: "I asked my MD to
>write
>>>>a referral paper for Dr. Redan cause even though I don't need referrals
>I
>>>>read on here that it may help prevent insurance problems. He refused,
>since
>>>>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.
>Reich
>>>>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
>for
>>>>Deb. I saw Deb's video -- her abdominal and pelvic organs were
>completely
>>>>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
>Ob/Gyn,
>>>>he needed to find a General Surgeon to be his surgical partner. It was
>then
>>>>that Dr. Reich personally chose Dr. Jay Redan to be his surgical
>partner.
>>>>Dr. Redan is a very skilled and experienced laparoscopic surgeon too.
>>>>
>>>>On May 1, 2000 these two surgeons opened the very first Adhesions Unit
>in
>>>>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
>extremely
>>>>cautious as he lyses adhesions...for the safety of the patient and to
>give
>>>>the patient the very best chance to become pain free. The surgeon must
>be
>>>>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
>organs.
>>>>All of this takes time...a lot of time, if the lysis of adhesions is
>going
>>>>to be a success!!
>>>>
>>>>When a surgeon tries to complete an adhesiolysis procedure in a maximum
>of
>>>>1-2 hours, the surgeon's decision -- to complete the adhesiolysis
>procedure
>>>>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
>other
>>>>insurance companies reimburse the surgeon for.!!!!!!!
>>>
>>>Helen,
>>>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 either....my kind of luck!
>>>
>>>Hope you are still feeling good.
>>>JEAN
>>>
>>>--
>>>Jean (from PA)
>>>
>--
>Jean (from PA)
>
-- Jean (from PA)