Medical service provider asks for consent to pursue insurance company

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Topic Author
larrydmsn
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Medical service provider asks for consent to pursue insurance company

Post by larrydmsn »

My wife and I took our teenage son to the ER at night in April and he had Laparoscopic appendectomy on the same day to have his appendix removed.

In May we received an Explanation of Benefits from our health insurance company. It showed a service charge "Surgical Assistant" that the provider had billed for $11391. The insurance company only covered $406 (including a coinsurance of $45 from us), leaving about $10985 not covered. This explanation said "You may have to pay our provider $11030" (coinsurance of $45 + not covered amount of $10985). Since this was not a bill we haven't taken any action.

A few days ago we received a letter from that surgical service provider. It asks us to fill out a consent form so that this provider can pursue the payment from our insurance company. The consent form says in bold and all caps that "THIS CONSENT WILL BE A DIRECT ASSIGNMENT OF MY RIGHT AND BENEFITS UNDER THIS POLICY". Further, it says, if we give the consent, we will authorize the release of our protected health info from insurance company to them. It will also authorize them to initiate a complaint, reopening, appeal or fair hearing on my behalf to the insurance company for adjudication as necessary to acquire full payment.

At the time of our son's surgery, we saw two people in addition to the primary surgeon in the operating room. We haven't received the bill from the primary surgeon yet (not even the Explanation of Benefits related to the primary surgeon's service). We have no idea what the surgical assistant or assistants had done during the surgical procedure but the amount they billed seems excessive to us.

We live in New Jersey which has a No Surprise Billing Act that prevents out-of-network service providers from balance billing patients for emergency medical service. I've heard that many surgical assistant service providers are out-of-network. I guess this may be why that provider is trying to get money from our insurance company directly instead of from us.

My questions are:
1. Should we give that service provider the consent? The broad authorization is concerning. The bold and all caps line sounds ominous. If we don't give them the consent, can they take any action against us?
2. Are we at any real risk of having to pay the $11030 as mentioned in the Explanation of Benefits? Are we completely protected by NJ's No Surprise Billing Act? Can the provider pursue the payment from us at all if they can't get it from the insurance company in the end?

Thanks in advance.
Larry
DebiT
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Re: Medical service provider asks for consent to pursue insurance company

Post by DebiT »

First, let me say I don’t know.

However, they likely need your consent to bill, and seem to be asking just to deal with your insurance company to get payment from them. I don’t know the specifics of your NJ law, but I wouldn’t be surprised if you need to give a provider the ability to bill your insurance in order to be protected by the law.

You might try calling that provider’s billing office to understand more clearly how it works. I suspect you’ll be ok.

Good law. Not sure if my state of California has it. Out of network providers in hospital settings is a big problem.
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runninginvestor
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Re: Medical service provider asks for consent to pursue insurance company

Post by runninginvestor »

IANAL but it appears to be part of the appeals and arbitration process that NJ has, and they likely need your consent to go into appeals/arbitration with the carrier:
https://www.state.nj.us/dobi/division_c ... twork.html

Three are several possibilities depending on whether the plan is self-funded. Just providing this link in case more knowledgeable people come across this thread and would be able to provide more specific action based on what NJ outlines.
adamthesmythe
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Re: Medical service provider asks for consent to pursue insurance company

Post by adamthesmythe »

That form sounds like the one I fill out before seeing a provider. Perhaps it fell through the cracks before an emergency procedure.
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ResearchMed
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Re: Medical service provider asks for consent to pursue insurance company

Post by ResearchMed »

I thought our assorted signed forms at any hospital (or physician office as well) already included permission to bill insurer, etc.
Does that not include pursuing them if they deny a claim? That doesn't quite make sense.

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Big Dog
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Re: Medical service provider asks for consent to pursue insurance company

Post by Big Dog »

I'm confused. In your post, you say the insurance company already paid $406. If that's the case, what else is there for teh insurance company to pay as they've already processed what they consider reasonable, which I assume complies with NJ law? ($11k for an 'assistant' seems mighty high as when I and my D went thru an appendectomy, there was no assistant needed as any general surgeon can perform this procedure solo. Heck, my D's primary surgeon didn't even get bill $11k a couple of years ago.
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larrydmsn
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Re: Medical service provider asks for consent to pursue insurance company

Post by larrydmsn »

DebiT wrote: Sat Jun 12, 2021 11:48 am You might try calling that provider’s billing office to understand more clearly how it works. I suspect you’ll be ok.
Thank you. Yeah I will give them a call to get more info.
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larrydmsn
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Re: Medical service provider asks for consent to pursue insurance company

Post by larrydmsn »

runninginvestor wrote: Sat Jun 12, 2021 12:13 pm Three are several possibilities depending on whether the plan is self-funded. Just providing this link in case more knowledgeable people come across this thread and would be able to provide more specific action based on what NJ outlines.
Our insurer is BCBS which isn't a self-funded. So my understanding is that we are covered by the NJ no surprise billing law. Thanks.
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larrydmsn
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Re: Medical service provider asks for consent to pursue insurance company

Post by larrydmsn »

ResearchMed wrote: Sat Jun 12, 2021 12:33 pm I thought our assorted signed forms at any hospital (or physician office as well) already included permission to bill insurer, etc.
Does that not include pursuing them if they deny a claim? That doesn't quite make sense.

RM
Thanks. Seems they billed the insurer but need my consent to maybe go to an arbitration?
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larrydmsn
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Re: Medical service provider asks for consent to pursue insurance company

Post by larrydmsn »

Big Dog wrote: Sat Jun 12, 2021 1:02 pm I'm confused. In your post, you say the insurance company already paid $406. If that's the case, what else is there for teh insurance company to pay as they've already processed what they consider reasonable, which I assume complies with NJ law? ($11k for an 'assistant' seems mighty high as when I and my D went thru an appendectomy, there was no assistant needed as any general surgeon can perform this procedure solo. Heck, my D's primary surgeon didn't even get bill $11k a couple of years ago.
Thanks. We've found this surgical assistant charge unusually high too. I think this was why the insurer only paid a small portion. I am not sure whether we should get involved more to give this provider our consent to fight the insurer.
RunningRad
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Re: Medical service provider asks for consent to pursue insurance company

Post by RunningRad »

This is the classic "surprise billing" scenario, and believe it or not, $11,000 is not an unusual fee for the mystery "assistant surgeon". I work in appeals for an insurance company, and we do not authorize exorbitant payment for this legal scam.
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anonenigma
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Re: Medical service provider asks for consent to pursue insurance company

Post by anonenigma »

Call the insurance company and file a grievance. This should get them into conversation with the provider. The surprise billing of patients who enter via the ER at “in-network” hospitals is grotesque.
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ResearchMed
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Re: Medical service provider asks for consent to pursue insurance company

Post by ResearchMed »

RunningRad wrote: Sat Jun 12, 2021 2:26 pm This is the classic "surprise billing" scenario, and believe it or not, $11,000 is not an unusual fee for the mystery "assistant surgeon". I work in appeals for an insurance company, and we do not authorize exorbitant payment for this legal scam.
What happens to the claimed "fee" in that case?
Does that "assistant" just fold wrt any fee beyond the portion already paid? Do they do after the patient?
:annoyed

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quantAndHold
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Re: Medical service provider asks for consent to pursue insurance company

Post by quantAndHold »

It sounds like you live in a state that doesn’t allow balance billing, and you have a 10% copay, and the insurance company allowed a $450 charge by the surgical assistant, but not the other $11k. Because of your state’s anti-balance billing law, the only way the surgical assistant is going to get more than $450 is by going after the insurance company. If they succeed, you will also be on the hook for a larger copay.

If you’re really protected by the balance billing law in your state, I don’t see how it would be to your advantage to give them consent.
DIFAR31
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Re: Medical service provider asks for consent to pursue insurance company

Post by DIFAR31 »

quantAndHold wrote: Sat Jun 12, 2021 2:46 pm It sounds like you live in a state that doesn’t allow balance billing, and you have a 10% copay, and the insurance company allowed a $450 charge by the surgical assistant, but not the other $11k. Because of your state’s anti-balance billing law, the only way the surgical assistant is going to get more than $450 is by going after the insurance company. If they succeed, you will also be on the hook for a larger copay.

If you’re really protected by the balance billing law in your state, I don’t see how it would be to your advantage to give them consent.
A copay is a specific dollar amount as spelled out under the terms of the coverage, and will not change if the insurance approved amount increases. Co-insurance, on the other hand, is an amount owed by the patient and is based on a percentage of the amount approved. That will go up if the insurance approved amount increases.
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larrydmsn
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Re: Medical service provider asks for consent to pursue insurance company

Post by larrydmsn »

DIFAR31 wrote: Sat Jun 12, 2021 2:52 pm
quantAndHold wrote: Sat Jun 12, 2021 2:46 pm It sounds like you live in a state that doesn’t allow balance billing, and you have a 10% copay, and the insurance company allowed a $450 charge by the surgical assistant, but not the other $11k. Because of your state’s anti-balance billing law, the only way the surgical assistant is going to get more than $450 is by going after the insurance company. If they succeed, you will also be on the hook for a larger copay.

If you’re really protected by the balance billing law in your state, I don’t see how it would be to your advantage to give them consent.
A copay is a specific dollar amount as spelled out under the terms of the coverage, and will not change if the insurance approved amount increases. Co-insurance, on the other hand, is an amount owed by the patient and is based on a percentage of the amount approved. That will go up if the insurance approved amount increases.
Thanks. To clarify my portion of $45 in the Explanation of Benefits is my coinsurance but I haven't paid it yet since I haven't received the bill from the provider. quantAndHold made a good point that my coinsurance would increase if the provider is approved for more payment.
ann_l
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Re: Medical service provider asks for consent to pursue insurance company

Post by ann_l »

I would give them the consent. Your insurance company would not pay. Your hospital, who is much more familiar with medical billing, apparently thinks they should. After all, if the insurance company did not pay, the rest of the bill goes to you. and then you're calling the hospital saying I can't afford 11K and why would you make me pay that when I have decent insurance?

In what seems like a lifetime ago, I did some ancillary work with medical billing reimbursement. This language does not seem unfamiliar and the release of med records certainly isn't.
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quantAndHold
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Re: Medical service provider asks for consent to pursue insurance company

Post by quantAndHold »

ann_l wrote: Sat Jun 12, 2021 3:34 pm I would give them the consent. Your insurance company would not pay. Your hospital, who is much more familiar with medical billing, apparently thinks they should. After all, if the insurance company did not pay, the rest of the bill goes to you. and then you're calling the hospital saying I can't afford 11K and why would you make me pay that when I have decent insurance?

In what seems like a lifetime ago, I did some ancillary work with medical billing reimbursement. This language does not seem unfamiliar and the release of med records certainly isn't.
OP says they live in a state that has laws against balance billing. That makes a difference in this situation. I don’t know the specifics of that particular law in that particular state, but the gist of those kinds of laws is they can’t just bill OP for the $11k if the insurance doesn’t pay.
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larrydmsn
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Re: Medical service provider asks for consent to pursue insurance company

Post by larrydmsn »

ann_l wrote: Sat Jun 12, 2021 3:34 pm I would give them the consent. Your insurance company would not pay. Your hospital, who is much more familiar with medical billing, apparently thinks they should. After all, if the insurance company did not pay, the rest of the bill goes to you. and then you're calling the hospital saying I can't afford 11K and why would you make me pay that when I have decent insurance?
Thanks. I think I need to clarify it a bit. The surgery was done in a hospital but the "surgical assistant" service was provided by another provider. And I suppose New Jersey's No Surprise Billing act should prevent this provider from balance billing us. Will you change your opinion with this clarification?
lj3md
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Re: Medical service provider asks for consent to pursue insurance company

Post by lj3md »

Call the surgeons office. Speak with the billing person and ask them about that and see what they say. In most cases the PA works for the surgeon. There are places where the PA works for the hospital. That would also be the case if the surgeon was employed by the hospital instead of being in private practice. Then you would need to talk with the hospital.

There is a list of procedure codes that an assistant is allowed. The assistant can be a surgeon or a PA. If it is a surgeon, typically the first assistant surgeon would get about 16% of what the insurance company allowed for the primary surgeon. If a PA is used, the PA would collect about 85% of what a first assistant surgeon would collect. That would be around 13.6%.

In our practice, we use a PA to facilitate our day, but lose money, meaning that the PA is paid in my practice about 70k more per year than the PA collects.

You could also call your insurance company an ask them what is the allowable fee for the cpt code 44970 laparoscopic appendectomy and then figure out what the pa would collect, which would be around 13.6%.

In our office we take what the insurance allows and accept that as payment in full. I would speak with the practice billing person and if that was not helpful speak with the practice manager.

Hope this helps.
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larrydmsn
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Re: Medical service provider asks for consent to pursue insurance company

Post by larrydmsn »

quantAndHold wrote: Sat Jun 12, 2021 4:11 pm OP says they live in a state that has laws against balance billing. That makes a difference in this situation. I don’t know the specifics of that particular law in that particular state, but the gist of those kinds of laws is they can’t just bill OP for the $11k if the insurance doesn’t pay.
Thanks again quantAndHold!
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Re: Medical service provider asks for consent to pursue insurance company

Post by spammagnet »

How much assistance does a competent general surgeon need for a laparoscopic appendectomy?
LH82
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Re: Medical service provider asks for consent to pursue insurance company

Post by LH82 »

I'm not a general surgeon, so I don't do laparoscopic appendectomies, but I am a sub specialist surgeon. I know that lap appys are a simple surgery and don't require an assist. I can also say that 11k would be a very handsome fee for the PRIMARY surgeon to get paid for a complicated surgery. An assist typically gets just a fraction of the surgeon, and insurance often doesn't pay for an assist for simple surgeries.
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Re: Medical service provider asks for consent to pursue insurance company

Post by nalor511 »

I wouldn't sign it, seems like too many ways it could come back and bite you later.
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Re: Medical service provider asks for consent to pursue insurance company

Post by spectec »

I’d be inclined to send the consent form to my insurance company, asking them if I should sign it. I think we know what their answer would be, if they respond at all.

I’m the meantime, if I’m asked by the service provider why I haven’t returned it, I’d just tell them I’m waiting for my insurance company’s advice.
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ResearchMed
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Re: Medical service provider asks for consent to pursue insurance company

Post by ResearchMed »

LH82 wrote: Sat Jun 12, 2021 7:16 pm I'm not a general surgeon, so I don't do laparoscopic appendectomies, but I am a sub specialist surgeon. I know that lap appys are a simple surgery and don't require an assist. I can also say that 11k would be a very handsome fee for the PRIMARY surgeon to get paid for a complicated surgery. An assist typically gets just a fraction of the surgeon, and insurance often doesn't pay for an assist for simple surgeries.
What happens if a supposedly/predicted "simple surgery" suddenly becomse... "less simple" - and there wasn't an assistant surgeon already scheduled. (I'm not in the field, so I don't know how this works.)
What IF suddenly more help, and expert help, were needed?
There can't be "an assistant surgeon" standing by in the OR every time "just in case"...

In a large teaching hospital, would there be some senior resident on hand in hospital to race over and step in?
Or??
And in a smaller hospital?
:shock:

How does this work in OR emergencies?
And how does the insurance work/coordinate?

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scorcher31
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Re: Medical service provider asks for consent to pursue insurance company

Post by scorcher31 »

If this is a typical form that people sign before they see their physician, but was sent out later because your child needed emergent care I would sign it. If it is something different than that... I'm not really sure what I'd do/reccomend. I can tell you it is common to have an assistant in surgery. I would really want to know what would happen if ypu sign and if you don't and I feel like that is going to be tricky to figure out.
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larrydmsn
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Re: Medical service provider asks for consent to pursue insurance company

Post by larrydmsn »

Many great comments with very helpful advice. Thank you all.

The consent form doesn't appear to be a standard one that you sign before getting medical service. It says "I hereby instruct and direct my insurance company to pay the professional or medical benefits directly to <the surgical assistant service provider>. THIS CONSENT WILL BE A DIRECT ASSIGNMENT OF MY RIGHT AND BENEFITS UNDER THIS POLICY". As we all agree, the charge by this provider for surgical assistance was exorbitant and it was no surprise that the insurer BCBS would only pay a very small portion of it. The provider probably can only go after BCBS due to NJ's no surprise billing act, hence it is trying to get us on their side in their fight. Honestly I don't want to help this greedy provider if I don't have to. However since I'm not absolutely sure, I would like to know whether there is any way this provider can go after us if we don't give it our consent.
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Re: Medical service provider asks for consent to pursue insurance company

Post by BolderBoy »

RunningRad wrote: Sat Jun 12, 2021 2:26 pmI work in appeals for an insurance company, and we do not authorize exorbitant payment for this legal scam.
This really is a common ploy. A surgeon will have one of the practice's PAs assist. And all the practice PAs are intentionally out-of-network everywhere. Just a mechanism to try to suck more $$$ into the practice. Before I retired I used to see this in neurosurgical practices around here especially.

Glad to see that insurance companies are wise to it.
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TropikThunder
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Re: Medical service provider asks for consent to pursue insurance company

Post by TropikThunder »

“I’m sorry Mr or Ms Surgery Assistant, but I never requested your services. If the primary surgeon decided they needed help, they can pay you out of their fee. Good day. I said good day!”
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Re: Medical service provider asks for consent to pursue insurance company

Post by student »

spectec wrote: Sat Jun 12, 2021 7:44 pm I’d be inclined to send the consent form to my insurance company, asking them if I should sign it. I think we know what their answer would be, if they respond at all.

I’m the meantime, if I’m asked by the service provider why I haven’t returned it, I’d just tell them I’m waiting for my insurance company’s advice.
This seems very smart.
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Re: Medical service provider asks for consent to pursue insurance company

Post by fortunefavored »

larrydmsn wrote: Sat Jun 12, 2021 1:56 pm
runninginvestor wrote: Sat Jun 12, 2021 12:13 pm Three are several possibilities depending on whether the plan is self-funded. Just providing this link in case more knowledgeable people come across this thread and would be able to provide more specific action based on what NJ outlines.
Our insurer is BCBS which isn't a self-funded. So my understanding is that we are covered by the NJ no surprise billing law. Thanks.
Just to double-check on this.. you're under an ACA or a very small company plan? Many "self-funded" plans use BCBS/Anthem/etc to administer their plans.. but they're still self-funded.

Assuming you're 100% sure, I'd ignore the whole thing when/until there is more clarity on what they're trying to do.
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Re: Medical service provider asks for consent to pursue insurance company

Post by Nowizard »

In the same way that a provider can charge for an extended session rather than a standard session length that leads to insurance companies investigating the accuracy of the charge, so can a filing error by a provider lead to under payment. Regardless of the stated amount, insurance companies seldom pay the full amount of billed charges. It is relatively standard that providers intentionally bill at higher levels than a survey has revealed that any insurance company pays for specific services in order to capture the greater payments. The patient receives the benefit if the insurance does not cover full payment based on the provider's agreement with the insurance company. Billing requirements and regulations regarding surprise bills and out-of-network payment differs by state, of course. You probably have no liability if you give permission for an appeal by the provider but this is only a guess.

Tim
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larrydmsn
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Re: Medical service provider asks for consent to pursue insurance company

Post by larrydmsn »

fortunefavored wrote: Sun Jun 13, 2021 7:47 am
larrydmsn wrote: Sat Jun 12, 2021 1:56 pm
runninginvestor wrote: Sat Jun 12, 2021 12:13 pm Three are several possibilities depending on whether the plan is self-funded. Just providing this link in case more knowledgeable people come across this thread and would be able to provide more specific action based on what NJ outlines.
Our insurer is BCBS which isn't a self-funded. So my understanding is that we are covered by the NJ no surprise billing law. Thanks.
Just to double-check on this.. you're under an ACA or a very small company plan? Many "self-funded" plans use BCBS/Anthem/etc to administer their plans.. but they're still self-funded.

Assuming you're 100% sure, I'd ignore the whole thing when/until there is more clarity on what they're trying to do.
Thanks. I didn't use the correct wording in my original reply. Our BCBS coverage is through employment at a large company. I am pretty sure the company's plan is not self funded and should be covered by NJ's no surprise billing act.
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larrydmsn
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Re: Medical service provider asks for consent to pursue insurance company

Post by larrydmsn »

student wrote: Sun Jun 13, 2021 5:55 am
spectec wrote: Sat Jun 12, 2021 7:44 pm I’d be inclined to send the consent form to my insurance company, asking them if I should sign it. I think we know what their answer would be, if they respond at all.

I’m the meantime, if I’m asked by the service provider why I haven’t returned it, I’d just tell them I’m waiting for my insurance company’s advice.
This seems very smart.
I like this too. Thanks spectec
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Re: Medical service provider asks for consent to pursue insurance company

Post by fortunefavored »

larrydmsn wrote: Sun Jun 13, 2021 8:21 am
fortunefavored wrote: Sun Jun 13, 2021 7:47 am
larrydmsn wrote: Sat Jun 12, 2021 1:56 pm
runninginvestor wrote: Sat Jun 12, 2021 12:13 pm Three are several possibilities depending on whether the plan is self-funded. Just providing this link in case more knowledgeable people come across this thread and would be able to provide more specific action based on what NJ outlines.
Our insurer is BCBS which isn't a self-funded. So my understanding is that we are covered by the NJ no surprise billing law. Thanks.
Just to double-check on this.. you're under an ACA or a very small company plan? Many "self-funded" plans use BCBS/Anthem/etc to administer their plans.. but they're still self-funded.

Assuming you're 100% sure, I'd ignore the whole thing when/until there is more clarity on what they're trying to do.
Thanks. I didn't use the correct wording in my original reply. Our BCBS coverage is through employment at a large company. I am pretty sure the company's plan is not self funded and should be covered by NJ's no surprise billing act.
You really need to check this.. almost EVERY "large company" plan is self funded (of course "large" varies by perspective.. I'll arbitrarily say 5000+ employees.)

That's because they get rid of old/sick people so it ends up being much cheaper for them to manage their own risk pool and they have enough cash flow to handle the rare $1M claim.
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Re: Medical service provider asks for consent to pursue insurance company

Post by lazynovice »

fortunefavored wrote: Sun Jun 13, 2021 8:29 am
larrydmsn wrote: Sun Jun 13, 2021 8:21 am
fortunefavored wrote: Sun Jun 13, 2021 7:47 am
larrydmsn wrote: Sat Jun 12, 2021 1:56 pm
runninginvestor wrote: Sat Jun 12, 2021 12:13 pm Three are several possibilities depending on whether the plan is self-funded. Just providing this link in case more knowledgeable people come across this thread and would be able to provide more specific action based on what NJ outlines.
Our insurer is BCBS which isn't a self-funded. So my understanding is that we are covered by the NJ no surprise billing law. Thanks.
Just to double-check on this.. you're under an ACA or a very small company plan? Many "self-funded" plans use BCBS/Anthem/etc to administer their plans.. but they're still self-funded.

Assuming you're 100% sure, I'd ignore the whole thing when/until there is more clarity on what they're trying to do.
Thanks. I didn't use the correct wording in my original reply. Our BCBS coverage is through employment at a large company. I am pretty sure the company's plan is not self funded and should be covered by NJ's no surprise billing act.
You really need to check this.. almost EVERY "large company" plan is self funded (of course "large" varies by perspective.. I'll arbitrarily say 5000+ employees.)

That's because they get rid of old/sick people so it ends up being much cheaper for them to manage their own risk pool and they have enough cash flow to handle the rare $1M claim.
No, that is not why they are self-funded. Large companies can self-fund because they have a large population of employees and dependents to spread risk over and they have the reserves to absorb a few large claims. They do not need to pay an insurance company to reinsure that risk for them. They contract with an insurance company to access their network, process claims and provide wellness programs etc.
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larrydmsn
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Re: Medical service provider asks for consent to pursue insurance company

Post by larrydmsn »

lazynovice wrote: Sun Jun 13, 2021 8:39 am
fortunefavored wrote: Sun Jun 13, 2021 8:29 am
larrydmsn wrote: Sun Jun 13, 2021 8:21 am
fortunefavored wrote: Sun Jun 13, 2021 7:47 am
larrydmsn wrote: Sat Jun 12, 2021 1:56 pm
Our insurer is BCBS which isn't a self-funded. So my understanding is that we are covered by the NJ no surprise billing law. Thanks.
Just to double-check on this.. you're under an ACA or a very small company plan? Many "self-funded" plans use BCBS/Anthem/etc to administer their plans.. but they're still self-funded.

Assuming you're 100% sure, I'd ignore the whole thing when/until there is more clarity on what they're trying to do.
Thanks. I didn't use the correct wording in my original reply. Our BCBS coverage is through employment at a large company. I am pretty sure the company's plan is not self funded and should be covered by NJ's no surprise billing act.
You really need to check this.. almost EVERY "large company" plan is self funded (of course "large" varies by perspective.. I'll arbitrarily say 5000+ employees.)

That's because they get rid of old/sick people so it ends up being much cheaper for them to manage their own risk pool and they have enough cash flow to handle the rare $1M claim.
No, that is not why they are self-funded. Large companies can self-fund because they have a large population of employees and dependents to spread risk over and they have the reserves to absorb a few large claims. They do not need to pay an insurance company to reinsure that risk for them. They contract with an insurance company to access their network, process claims and provide wellness programs etc.
Thank you fortunefavored and lazynovice. Seems my understanding was incorrect. I will check this.
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Kenkat
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Re: Medical service provider asks for consent to pursue insurance company

Post by Kenkat »

My first call in this situation would be to my insurance company, asking about this claim and the form you’ve been asked to sign. I wouldn’t sign anything before I took this step.
lazynovice
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Re: Medical service provider asks for consent to pursue insurance company

Post by lazynovice »

I am not sure an easy way to tell in NJ. If you see that your plan is governed by ERISA, then it is self-funded. In my state, the ID card will say something like “regulated by the Dept. of Insurance” if it is not self funded.
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ResearchMed
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Re: Medical service provider asks for consent to pursue insurance company

Post by ResearchMed »

lazynovice wrote: Sun Jun 13, 2021 8:39 am
fortunefavored wrote: Sun Jun 13, 2021 8:29 am
larrydmsn wrote: Sun Jun 13, 2021 8:21 am
fortunefavored wrote: Sun Jun 13, 2021 7:47 am
larrydmsn wrote: Sat Jun 12, 2021 1:56 pm
Our insurer is BCBS which isn't a self-funded. So my understanding is that we are covered by the NJ no surprise billing law. Thanks.
Just to double-check on this.. you're under an ACA or a very small company plan? Many "self-funded" plans use BCBS/Anthem/etc to administer their plans.. but they're still self-funded.

Assuming you're 100% sure, I'd ignore the whole thing when/until there is more clarity on what they're trying to do.
Thanks. I didn't use the correct wording in my original reply. Our BCBS coverage is through employment at a large company. I am pretty sure the company's plan is not self funded and should be covered by NJ's no surprise billing act.
You really need to check this.. almost EVERY "large company" plan is self funded (of course "large" varies by perspective.. I'll arbitrarily say 5000+ employees.)

That's because they get rid of old/sick people so it ends up being much cheaper for them to manage their own risk pool and they have enough cash flow to handle the rare $1M claim.
No, that is not why they are self-funded. Large companies can self-fund because they have a large population of employees and dependents to spread risk over and they have the reserves to absorb a few large claims. They do not need to pay an insurance company to reinsure that risk for them. They contract with an insurance company to access their network, process claims and provide wellness programs etc.
[emphasis added]

Disregarding whether OP's health insurance is self-funded by employer or not, is it correct to state that "a large employer's self-funded health insurance plan is NOT covered by laws prohibiting these huge surprise billing amounts"?

ETA: I had not realized that health insurance is covered by ERISA for relevant employers. Thanks.

RM
This signature is a placebo. You are in the control group.
lazynovice
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Re: Medical service provider asks for consent to pursue insurance company

Post by lazynovice »

ResearchMed wrote: Sun Jun 13, 2021 8:53 am
lazynovice wrote: Sun Jun 13, 2021 8:39 am
fortunefavored wrote: Sun Jun 13, 2021 8:29 am
larrydmsn wrote: Sun Jun 13, 2021 8:21 am
fortunefavored wrote: Sun Jun 13, 2021 7:47 am

Just to double-check on this.. you're under an ACA or a very small company plan? Many "self-funded" plans use BCBS/Anthem/etc to administer their plans.. but they're still self-funded.

Assuming you're 100% sure, I'd ignore the whole thing when/until there is more clarity on what they're trying to do.
Thanks. I didn't use the correct wording in my original reply. Our BCBS coverage is through employment at a large company. I am pretty sure the company's plan is not self funded and should be covered by NJ's no surprise billing act.
You really need to check this.. almost EVERY "large company" plan is self funded (of course "large" varies by perspective.. I'll arbitrarily say 5000+ employees.)

That's because they get rid of old/sick people so it ends up being much cheaper for them to manage their own risk pool and they have enough cash flow to handle the rare $1M claim.
No, that is not why they are self-funded. Large companies can self-fund because they have a large population of employees and dependents to spread risk over and they have the reserves to absorb a few large claims. They do not need to pay an insurance company to reinsure that risk for them. They contract with an insurance company to access their network, process claims and provide wellness programs etc.
[emphasis added]

Disregarding whether OP's health insurance is self-funded by employer or not, is it correct to state that "a large employer's self-funded health insurance plan is NOT covered by laws prohibiting these huge surprise billing amounts"?

ETA: I had not realized that health insurance is covered by ERISA for relevant employers. Thanks.

RM
Most states that have laws allow self funded plans to opt in. Looks like NJ is one.

https://www.npr.org/sections/health-sho ... ederal-law

“A New Jersey law that went into effect last month allows self-funded plans to opt in to the state's balance billing dispute-resolution process. If a federally regulated plan decides to participate in the state program, doctors, hospitals and labs would be prohibited from balance-billing those consumers, and any disputes will be handled through a binding arbitration process.”

So now the question is did OP’s employer opt in?

The federal law goes into effect in January.
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larrydmsn
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Re: Medical service provider asks for consent to pursue insurance company

Post by larrydmsn »

ResearchMed wrote: Sun Jun 13, 2021 8:53 am
lazynovice wrote: Sun Jun 13, 2021 8:39 am
fortunefavored wrote: Sun Jun 13, 2021 8:29 am
larrydmsn wrote: Sun Jun 13, 2021 8:21 am
fortunefavored wrote: Sun Jun 13, 2021 7:47 am

Just to double-check on this.. you're under an ACA or a very small company plan? Many "self-funded" plans use BCBS/Anthem/etc to administer their plans.. but they're still self-funded.

Assuming you're 100% sure, I'd ignore the whole thing when/until there is more clarity on what they're trying to do.
Thanks. I didn't use the correct wording in my original reply. Our BCBS coverage is through employment at a large company. I am pretty sure the company's plan is not self funded and should be covered by NJ's no surprise billing act.
You really need to check this.. almost EVERY "large company" plan is self funded (of course "large" varies by perspective.. I'll arbitrarily say 5000+ employees.)

That's because they get rid of old/sick people so it ends up being much cheaper for them to manage their own risk pool and they have enough cash flow to handle the rare $1M claim.
No, that is not why they are self-funded. Large companies can self-fund because they have a large population of employees and dependents to spread risk over and they have the reserves to absorb a few large claims. They do not need to pay an insurance company to reinsure that risk for them. They contract with an insurance company to access their network, process claims and provide wellness programs etc.
[emphasis added]

Disregarding whether OP's health insurance is self-funded by employer or not, is it correct to state that "a large employer's self-funded health insurance plan is NOT covered by laws prohibiting these huge surprise billing amounts"?

ETA: I had not realized that health insurance is covered by ERISA for relevant employers. Thanks.

RM
NJ's law prohibiting balance billing governs only plans regulated by NJ state, i.e. fully-funded plans. Self-funded plans are federal regulated and hence that NJ law doesn't apply. Federal no surprise billing law will only take effect on Jan 1st, 2022.
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larrydmsn
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Re: Medical service provider asks for consent to pursue insurance company

Post by larrydmsn »

lazynovice wrote: Sun Jun 13, 2021 9:05 am Most states that have laws allow self funded plans to opt in. Looks like NJ is one.

https://www.npr.org/sections/health-sho ... ederal-law

“A New Jersey law that went into effect last month allows self-funded plans to opt in to the state's balance billing dispute-resolution process. If a federally regulated plan decides to participate in the state program, doctors, hospitals and labs would be prohibited from balance-billing those consumers, and any disputes will be handled through a binding arbitration process.”

So now the question is did OP’s employer opt in?

The federal law goes into effect in January.
I will have to check this with our company HR on Monday. Thank you!
Sagefemme
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Re: Medical service provider asks for consent to pursue insurance company

Post by Sagefemme »

My jaw is on the floor after reading about these charges! I do surgical assisting as a routine part of my job. I am employed by a doctor who does a fair amount of surgery, from simple (not needing an assistant) to complex (needing one and possibly even two assistants). If he were doing a surgery alone and it became complex, he would call me to come help; if I couldn't, or if he needed another fully qualified surgeon, someone else who was around in the OR complex would come. Surgeons tend to help each other out that way generally. If your son's appy seems to have gone well, or in a routine fashion, no assistant would have been scheduled or on stand-by or needed in any way that I can imagine.

We (my employer and I) constantly bemoan the low reimbursement for surgical assisting. Most of the time insurance pays a few hundred dollars for the assistant, even in long (3+ hours) cases. But that's just how it is--if the surgeon has a contract with an insurer, he or she is agreeing to take what they pay. The rates are negotiated prior to the event. It's never even close to what is billed.

I'm aghast about all this. So complex and impenetrable, even to those who work in this crazy industry! I agree with those who suggest aligning yourself with your health insurance company to battle this attempt at highway robbery!
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Lee_WSP
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Re: Medical service provider asks for consent to pursue insurance company

Post by Lee_WSP »

You are not under any obligation, legal or otherwise, to sign it. It is not a bill. It is a request for you to assign your rights to compensation by the insurer over to the surgical center.

File it away somewhere for a year and see if they even send you a bill (they shouldn't since they were compensated by the insurer).
RunningRad
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Re: Medical service provider asks for consent to pursue insurance company

Post by RunningRad »

Sagefemme wrote: Sun Jun 13, 2021 10:27 am My jaw is on the floor after reading about these charges! I do surgical assisting as a routine part of my job. I am employed by a doctor who does a fair amount of surgery, from simple (not needing an assistant) to complex (needing one and possibly even two assistants). If he were doing a surgery alone and it became complex, he would call me to come help; if I couldn't, or if he needed another fully qualified surgeon, someone else who was around in the OR complex would come. Surgeons tend to help each other out that way generally. If your son's appy seems to have gone well, or in a routine fashion, no assistant would have been scheduled or on stand-by or needed in any way that I can imagine.

We (my employer and I) constantly bemoan the low reimbursement for surgical assisting. Most of the time insurance pays a few hundred dollars for the assistant, even in long (3+ hours) cases. But that's just how it is--if the surgeon has a contract with an insurer, he or she is agreeing to take what they pay. The rates are negotiated prior to the event. It's never even close to what is billed.

I'm aghast about all this. So complex and impenetrable, even to those who work in this crazy industry! I agree with those who suggest aligning yourself with your health insurance company to battle this attempt at highway robbery!
You would be even more aghast at the $90-100k charges for OON assistant surgeon charges that I have seen. People bemoan the role of insurance companies and that they are a middleman who provides no added value, are obstructionist, are only interested in profit, etc. However, your friendly neighborhood hospital and provider may be equally or more guilty on the profit motive and will take whatever shots they can to get paid, hoping that something outrageous will slip through. Sometimes, when I am feeling especially cynical, I am of the opinion that the healthcare system is a tug-of-war between the Payer (government or insurance company) and the Provider (includes hospital, professionals, corporations, etc.), and the patient is simply the wallet that these two forces are struggling to control. Any true healthcare motive is secondary.
Few decisions in life motivated by greed ever have happy outcomes--Peter Bernstein, The 60/40 Solution
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larrydmsn
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Re: Medical service provider asks for consent to pursue insurance company

Post by larrydmsn »

Thank you Lee_WSP and Sagefemme. Yes the charge by the surgical assistant service was outrageous. From what we know, the surgery went smoothly and was completed as scheduled. I will call the primary surgeon to get more info on the assistant(s).
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galawdawg
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Re: Medical service provider asks for consent to pursue insurance company

Post by galawdawg »

larrydmsn wrote: Sun Jun 13, 2021 9:08 am
lazynovice wrote: Sun Jun 13, 2021 9:05 am Most states that have laws allow self funded plans to opt in. Looks like NJ is one.

https://www.npr.org/sections/health-sho ... ederal-law

“A New Jersey law that went into effect last month allows self-funded plans to opt in to the state's balance billing dispute-resolution process. If a federally regulated plan decides to participate in the state program, doctors, hospitals and labs would be prohibited from balance-billing those consumers, and any disputes will be handled through a binding arbitration process.”

So now the question is did OP’s employer opt in?

The federal law goes into effect in January.
I will have to check this with our company HR on Monday. Thank you!
I'd suggest this is the key issue. If you have absolutely no further obligation, responsibility or liability for any amounts due for this "surgical assistant" then I don't know of any reason why you should, or would want to, sign this document.

On the other hand, if you could be on the hook for anything not covered by your insurance provider, you may wish to speak with your own trusted attorney (a brief consultation shouldn't be too costly) to ascertain what possible possible benefits and problems could result from your signing that document.

Good luck, glad your son is okay.
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larrydmsn
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Re: Medical service provider asks for consent to pursue insurance company

Post by larrydmsn »

galawdawg wrote: Sun Jun 13, 2021 1:29 pm I'd suggest this is the key issue. If you have absolutely no further obligation, responsibility or liability for any amounts due for this "surgical assistant" then I don't know of any reason why you should, or would want to, sign this document.

On the other hand, if you could be on the hook for anything not covered by your insurance provider, you may wish to speak with your own trusted attorney (a brief consultation shouldn't be too costly) to ascertain what possible possible benefits and problems could result from your signing that document.

Good luck, glad your son is okay.
Thank you galawdawg. I agree with your analysis. Yes my son has fully recovered. Thanks.
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