"...a hernia repair that I DID NOT HAVE..."
(I'm going through this right now, with a surgeon that billed my insurance for a hernia repair that I DID NOT HAVE, and that my insurance correctly refused to pay for, which now the doctor'soffice is chasing ME into collections for, over $3000)
Hello, Julia
Without knowing anything about your situation, here is one possible scenario. The surgeon recognized the hernia caused by the incision was a complicated closure. (An incision into the abdominal cavity causes a hernia, so you probably did have one, created when the surgeon entered your abdominal cavity.) He took extra care and used mesh in the surgical closure, and documented this in his report. Mesh is expensive, and not a routine part of an abdominal surgery, so in order to compensate for this supply, and the surgeon's extra work, the billing staff reported it on the claim. The insurance company's automated claims editor recognized a hernia procedure as "incidental" or part of the primary abdominal procedure and denied that portion of the claim.
I occassionally see insurance claims that describe a person having had an open abdominal procedure, or even sometimes a closed one (laparoscopic) in conjunction with a hernia repair. In most cases, surgical correction of a hernia is a routine part of any abdominal area operation, even if the hernia existed before the operation, and is not related to the primary procedure (i.e. gall bladder removal). As such, it is not eligible for separate insurance reimbursement aside from the primary operation.
There are a couple of correct reasons why the hernia repair will still be reported and put on the insurance claim. One is when the hernia is in a different place entirely than where the operation was performed, and the surgeon had to all but prepare a separate surgical site in order to do the surgical correction. Another reason could be that the surgeon had to take extra means and attention in order to close (correct) the hernia. Even if the hernia was caused by the operation procedure itself (called incisional hernia), a complicated hernia may require the surgeon to use a mesh substance and extra means for suture. In this case the surgeon will report this extra work for the hernia, and his billing staff will likely put it on a claim form.
Many insurers allow some extra reimbursement for using mesh, or for surgery with such complications. These can even be in an agreement between insurers and "participating" surgeons. In all such cases, the claim has to be submitted correctly. And some insurance companies do not allow extra in these circumstances. In such cases, the denial usually does not become the patient's responsibility.
It is unfortunate you have been put in the middle.It is this kind of red-tape money game that is part of the problem with the U.S. health system, maybe moreso than most the blames tossed around on this list. Sliver lining: here is your chance to learn and do something about it first-hand.
Good luck.
Hello, Julia
Without knowing anything about your situation, here is one possible scenario. The surgeon recognized the hernia caused by the incision was a complicated closure. (An incision into the abdominal cavity causes a hernia, so you probably did have one, created when the surgeon entered your abdominal cavity.) He took extra care and used mesh in the surgical closure, and documented this in his report. Mesh is expensive, and not a routine part of an abdominal surgery, so in order to compensate for this supply, and the surgeon's extra work, the billing staff reported it on the claim. The insurance company's automated claims editor recognized a hernia procedure as "incidental" or part of the primary abdominal procedure and denied that portion of the claim.
I occassionally see insurance claims that describe a person having had an open abdominal procedure, or even sometimes a closed one (laparoscopic) in conjunction with a hernia repair. In most cases, surgical correction of a hernia is a routine part of any abdominal area operation, even if the hernia existed before the operation, and is not related to the primary procedure (i.e. gall bladder removal). As such, it is not eligible for separate insurance reimbursement aside from the primary operation.
There are a couple of correct reasons why the hernia repair will still be reported and put on the insurance claim. One is when the hernia is in a different place entirely than where the operation was performed, and the surgeon had to all but prepare a separate surgical site in order to do the surgical correction. Another reason could be that the surgeon had to take extra means and attention in order to close (correct) the hernia. Even if the hernia was caused by the operation procedure itself (called incisional hernia), a complicated hernia may require the surgeon to use a mesh substance and extra means for suture. In this case the surgeon will report this extra work for the hernia, and his billing staff will likely put it on a claim form.
Many insurers allow some extra reimbursement for using mesh, or for surgery with such complications. These can even be in an agreement between insurers and "participating" surgeons. In all such cases, the claim has to be submitted correctly. And some insurance companies do not allow extra in these circumstances. In such cases, the denial usually does not become the patient's responsibility.
It is unfortunate you have been put in the middle.It is this kind of red-tape money game that is part of the problem with the U.S. health system, maybe moreso than most the blames tossed around on this list. Sliver lining: here is your chance to learn and do something about it first-hand.
Good luck.
posted by nawledge at
7:51 PM
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