Complaint 16 of 16 in “Claim Denied / Delayed in Whole or Part”

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  • Insurance Carrier: United Healthcare
  • State: NJ

Consumer Complaint:

My son had emergency surgery on 3-25-2008. United Healthcare has determined an emergency appendectomy with esophagogastroduodenoscopy with biopsy has no call for an assistant surgeon. They refused to pay the bill in full. They have made payment against all 3 procedures listed on the EOB but they have, in my opinion , pulled a number out of a hat and paid only that sum. My plan pays for emerg. surgery at 100%. Now either it is covered or it is not. By the fact that they paid anything toward the procedure tells they are covered. I am now in collection from the Dr.s office for $2005.00.

Insurance Expert Answer:

Let's face it, the insurance company wants to hold down health care costs and the provider wants to maximize the income for the practice. Having two surgeons in there and billing makes the practice more money and having three would make the practice even more money.

I am not a physician and have no idea if the insurance company is being reasonable or not. Very often this depends on the facts and circumstances in the particular case. Perhaps one is normally enough but here there were a series of special circumstances and two were required. Or, as the insurance company's position suggests, perhaps the insurance company is just plain wrong and two are always used, but then again perhaps it is right and the first doctor was lazy or knew his or her colleague needed more practice or wanted to help pay for a new swimming pool.

You should explain this to the health care provider and ask the providers -- starting with the doctor who called in the assistant surgeon -- to justify the bill and help you straighten this out with the carrier.

In addition, the provider has probably billed you for the \"rack rate\" for the assistant surgeon and not the dramatically lower rate the insurance company would have paid him/her had it covered the bill. For example my guess (and I am only guessing) is the surgeon billed $3,000 for his/her time BUT under the contract with United Health Care the carrier only paid about $700 -- its negotiated discounted rate.

By the same token, the assistant surgeon's bill would have been reduced to about $500, not the rack rate it is seeking to charge you. If in fact you can't resolve this between the assistant surgeon and the insurance company, the assistant surgeon should be willing to take the same percentage reduction as the prime surgeon did as that's what seems to be the \"reasonable and customary.\"

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