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Health Insurance Company BS – Out Of Network Edition

Posted Aug 12 2010 7:30am

After receiving a payment denial letter from an insurer for an operation I performed a few months ago, I figured it was time to share.

Health insurance companies play endless games with your local doctor in order to delay or avoid paying the bill.

Let’s talk by means of example:

Mr M is a 50 year old man who was admitted to a long term care hospital when I first saw him. He had a large wound on his hip that was big enough to allow both of your fists to fit inside. Wound care resulted in a clean, but very large hole. The doctors taking care of him requested the assistance of plastic surgery to shorten what would have been a 6-12 month expected healing time.

This patient has commercial medical insurance. I am the only plastic surgeon who works at this hospital. After seeing him and interfacing with his insurance company they agreed to the surgery. I even had to speak with some kind of insurance company medical director who requested that the patient be allowed to be discharged home prior to the operation, a skin graft.

Four months after the patient’s surgery and a successfully healed wound, his insurance company denied payment for the surgery due to the fact that I am not a provider for his insurance. This is BS.

As I am the only plastic surgeon who sees patients at this hospital, we will probably win on appeal, but the point is that it shouldn’t be a hat trick to get paid for work you have done months prior. This is amongst the reasons that many plastic surgeons do little if any “real medicine.”

Your health insurance company is not beyond this kind of BS either.

Best Regards,

John Di Saia MD

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