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Peachy
12-05-2008, 09:41 PM
Since early last June I've happily been on Dr. Boachie's surgery schedule for January. The "predetermination letter" was sent to my insurance company (Blue Cross of Georgia - PPO) a few weeks ago, and I was told by Theresa, the billing lady for Dr. B, that it was my responsibility to find out from BC what they would pay. I've since talked to countless people at both BC of GA and Empire (BC of NY), but they all say they cannot give me that information.

This week I had a call from Theresa, who informed me that since I couldn't get an answer from BC, I would need to pay 50% of the surgical fee of $108,000 now! I am just reeling from this! I was told back in June that a prepayment would be required, but the figure mentioned at that time was considerably less than $54,000 and one that I could have managed. I know several people who've had surgery with Dr. B, but none of them paid anything in advance. I asked her why I was being singled out. She said I wasn't, but that since I have an individual policy, it will pay less than a group policy.

My husband and I are not wealthy people, and we don't happen to have $54,000 in cash. So now, after waiting 6 months and after counting on surgery with this doctor, it looks like I'll have to start all over again in a search to find a surgeon who can help me. Needless to say, I was devastated. I felt like the rug had just been pulled out from under me. I didn't post until today because my eyes were so swollen from crying, I could barely see the computer screen. But, today I feel better...and a bit stronger...and I will just do whatever I have to do, and if that means starting over, I will. Actually, I don't fault Dr. Boachie for this; he's certainly free to charge whatever he wants. Perhaps the majority of his patients are able to pay these amounts.

I would like to ask any of Dr. Boachie's patients if you had to pay part of your fee up-front, and if so, what percentage? In fact, has a patient of ANY other doctor had to pay in advance? I would appreciate any feedback that could help me understand this.

Peachy

pmsmom
12-06-2008, 07:57 AM
My dd is not a patient of Dr. Boachie, but I wanted to let you know that you will be in my thoughts and prayers. My eyes teared up when I read of your situation.

Is it possible that your insurance can contact the doctor's office directly with what they will cover? I know we were given the runaround with our insurance just trying to pay for getting 2nd opinions from out of network surgeons. One of the doctor's offices did write a letter, but I think it was dd's general dr. who intervened for us and got the insurance co. to accept our insurance co-pay.

Also, is there a top surgeon in your network that you could work with? I know in our case, our original insurance was not going to pay for the consults we had with 2 surgeons b/c they were "out of network." Fortunately, dh's insurance will be changing as of Jan. 1, so we will be able to have one of those surgeons follow our dd's case.

Please keep us posted!

Take care,
Marian

mariaf
12-06-2008, 08:58 PM
Peachy,

I am so sorry you are going through this. This is not the first time someone has posted about Boachie's office (this "Theresa" in particular) treating patients in this way. I would be upset too, being asked to come up with $54,000!!!

It must be especially hard having to deal with this during a time that is already stressful.

Funny, I know that Dr. Boachie, quite generously, gives his services at no charge to patients in his native country....yet such a different policy here in the U.S.

Best of luck to you - I hope you can work something out with Boachie's office....or alternatively, that you can find another surgeon that your are comfortable and who will work with your insurance company (there are plenty of doctors who WILL do that)!

txmarinemom
12-07-2008, 01:49 AM
Peachy, this is my #1 issue with Boachie's office ... "The Wrath of Theresa". It's ridiculous.

Are you a first timer or revision?

There are other options for both.

Peachy
12-07-2008, 05:33 PM
When I said I didn't fault Dr. Boachie for this, I didn't mean in any way to imply that I blame Theresa. I truly do not! I believe she's only doing her job, and that has to be very hard for her at times - especially when she asks for a sun of money that may be out of reach for some of us, and then the patient begins to blubber on the phone, as I did :(.

Marian, what a sweet note! Now don't you be tearing up; I've done enough of that for both of us! No, Blue Cross won't tell Theresa what they'll pay either, only that I'm covered. I saw two in-network docs, but had no confidence in either.

Maria, thanks for the good thoughts!

Pam, I'm a first-timer for surgery T-2 to S-1.

I think I was so upset because I'd been counting on Dr. B and the January date for so long. Also, being a paranoid person, it just seemed to me that I was being treated differently from other patients.

Thanks, guys, for your notes. I'm still wondering if there's anyone who has paid in advance.

Peachy

Susie*Bee
12-07-2008, 05:56 PM
I've been thinking of you too, Peachy, and how disappointing (to the nth degree) this whole thing must be to you. You have probably already tried explaining to BC that Boachie's office will require you to pay in advance if you aren't able to find out how much they will pay for your surgery. It just seems like there needs to be a patient's advocate somehow... but not sure if that's a possibility. Best wishes with making some progress-- either with the insurance/Boachie situation or in finding someone else you will have confidence with. BTW, BC did pretty well for me, and we sure didn't have to pay anything in advance.

debbei
12-08-2008, 06:08 AM
Hi Anne,

Unfortunately, for out-of-network coverage, I think that it is probably on an individual case basis, and depends on the insurance plan. Mine happened to be a very good plan. I hope and pray for you that you can get this all figured out and have your surgery in January as you planned and counted on.

Keep us posted, ok?

theizzard
12-08-2008, 06:35 AM
This is exactly why I am not able to have Dr. Boachie do my surgery and why I am going to see Dr. Rand in Boston next Monday. I met with Boachie at the beginning of October and was told that I would not be able to schedule surgery unless or until i could get my insurance Personal Choice (Blue Cross) to tell us exactly what they would be willing to pay. Unfortunately, I haven't received my letter from Dr. Boachie's office with the necessary codes to turn over to my insurance company for an exact code by code amount of what they would pay. I spent about 4 hours in the office between xrays and the examination and waiting, to be told by Theresa that unless I could either pay up front for the surgery or get my insurance company to commit for a certain amount of money, then I may as well get another doctor. They in fact gave me the name of Dr. Donaldson in Pittsburgh as another doctor. I had never heard of him either personally or on this listserv, and 5 minutes of research told me that Dr. Donaldson did his internship with Dr. Boachie. I couldn't find much else about him and he wasn't included as a provider for my insurance although Dr. Rand in Boston is. I apologize for such a long post but this is the first time i have seen in print what I knew I was dealing with. After my visit with Boachie, I posted about this and asked if anyone had to pay up front before surgery was performed. You are the first person who had a specific $ amount. I am very sorry this happened to you and I too would be devastated. I am angry about the whole process and I am reeling because it is all about money. If I had any extra money I could perhaps bargain my way into surgery but I don't. At the time of the visit they had no problem taking my $450 for the visit but it is obvious they have been burned by patients who have had surgery and could not or would not pay anything so that now unless as a patient you provide proof to them of what you will pay, you are sh** out of luck.
best wishes to you peachie.
avis

lelc2002@yahoo
12-10-2008, 06:56 PM
Peachy- Maybe Cathie(Bsprings) will come on the forum as she had some scares with her insurance. I thought she might of had Blue Cross.
Why is your insurance co. saying they will not give you an answer? what is their reason, increasing costs or something else???
By the way, I have met Theresa several times on my visits to Dr. Boachie's office and she is a FINE individual!!!!! Why blame her when it seems to me it is the insurance companies causing the problems here.
I would demand an answer from my insurance company..
This brings to mind the movie "Sicko" by Michael Moore, I could go on & on &on on insurance co.s.....Ly

loves to skate
12-10-2008, 07:24 PM
It seems to me that the Doctor's office should be contacting the insurance company instead of the patient. After all, the patient could say that the insurance will pay whatever he or she thinks the Doctor wants. I also believe that there are many other superb Doctors out there that do excellent scoliosis surgeries so I don't understand why so many people on this forum think that Dr. Boachie is the only surgeon to go to. Is he God? I personally think that he is greedy, not accepting people that can't afford to pay so much money out of pocket. How much money does any one Doctor have to make! That is my opinion and I'm sticking to it.
Sally

Peachy
12-10-2008, 08:51 PM
Ly,

I agree with you 100% about Theresa. Please see Post #5 above. I said I absolutely do NOT blame her for my problem.

Peachy

mariaf
12-10-2008, 09:14 PM
Peachy- Maybe Cathie(Bsprings) will come on the forum as she had some scares with her insurance. I thought she might of had Blue Cross.
Why is your insurance co. saying they will not give you an answer? what is their reason, increasing costs or something else???
By the way, I have met Theresa several times on my visits to Dr. Boachie's office and she is a FINE individual!!!!! Why blame her when it seems to me it is the insurance companies causing the problems here.
I would demand an answer from my insurance company..
This brings to mind the movie "Sicko" by Michael Moore, I could go on & on &on on insurance co.s.....Ly

Hi Lynne,

Just to clarify, not necessarily in this case (but in several other cases I have read about here), I think the problem was not so much that the insurance company wasn't giving an answer, but that they were giving one in "percentages". From my experience with several different insurers we have had over the years, that's quite typical, to say they will cover 80% of a procedure, for example. I have heard, as I said, of several cases where Boachie's rep wanted a firm dollar amount, rather than a percentage - perhaps because sometimes insurers have "caps" to the dollar amounts they will pay, I don't know.

Hopefully, Peachy can get her insurer to quote a percentage (I can't believe they won't even give a percent of what the plan covers - it has to be listed in the policy somewhere); and hopefully Boachie's office will accept that.

Again, I could be wrong, but I think Boachie has a dollar figure in mind that he wants (here it's $54,000) which is "guaranteed". Also, (and I am not bashing his office or anything like that) but I do find it strange that this issue keeps coming up over and over again only with this office. I have not read or heard of this same issue coming up, at least not with any frequency, with other doctors. So, logic tells me that the issue could be not with the various insurers, but rather with his practices (of course, he's free to run his office any way he chooses and to charge whatever fee he wants).

(I also agree with the person who said that the doctor's office should contact the insurance company to discuss what will or will not be covered, not the patient.)

I just hope one way or the other, the issue is resolved so others don't have this added stress in the future.

Best regards,

Singer
12-11-2008, 06:56 AM
Here's my take on the whole Boachie/insurance situation:

1. You avoid ALL of the hassle if you live in New York and/or have New York-based insurance (as I do).

2. He funnels a lot of money back into his FOCOS foundation, and makes no secret of the fact that he is committed to raising as many funds as possible for it.

3. He is in great demand and therefore does not have to hassle with the insurance companies. That's his perogative.

4. I agree with Sally that he is not God, and while he is certainly excellent, there are other great surgeons out there who subscribe to insurance plans. I hesitate to call him greedy, though --- certainly he's not more greedy than any of the other surgeons out there who are raking in the bucks. I believe that to a great extent, scoliosis surgeons earn their salary; it's a gruelling surgery that demands huge amounts of skill and physical stamina.

mariaf
12-11-2008, 12:54 PM
2. He funnels a lot of money back into his FOCOS foundation, and makes no secret of the fact that he is committed to raising as many funds as possible for it.

Yes, I (and proably a lot of others) are aware that while Boachie charges a lot of money to his patients WITHIN the U.S. and does NOT accept insurance from them, he offers his services AT NO CHARGE to patients in his native country.

Of course, he has every right to do that - it is, as you say, his perogative. Nobody could argue that.

Having said that, I think that double standard doesn't sit well with a lot of folks here in this country, where he makes his living.

Singer
12-11-2008, 02:50 PM
I totally understand this. But let's remember that most people in Ghana are at a severe financial disadvantage compared to the rest of us, and many of the kids he operates on suffer from curves resulting from tuberculosis and other diseases that are more treatable in the U.S.

I would actually love to hear what Dr. B himself has to say on this subject but unfortunately I don't have the guts to ask him, heh-heh.

Speaking strictly of his expertise now, I think his reputation as a world-class surgeon is deserved. But the almost-mythical status he has generated on this Forum is distorted.

All is not lost if someone is not able to avail themselves of Boachie's services.

mariaf
12-11-2008, 04:54 PM
I would actually love to hear what Dr. B himself has to say on this subject but unfortunately I don't have the guts to ask him, heh-heh.


I, too, would love to hear what he has to say.

There was some debate a while back about whether or not Dr. B was aware of the tactics and policies of those running his office. Of course he is! He MAKES the policies. I was amazed that anyone would think that a surgeon wasn't aware of the financial practices of his office.

It would be like saying the principal of a school wasn't aware of the rules the teachers were telling the students they had to follow. The principal MAKES these policies.

I work for a large firm and believe me, those at the top know exactly what policies are being implemented - there may be others "enforcing" the policies (i.e., doing the "dirty work"), but the guys at the top MAKE the policies.

I don't blame Theresa either - she's just doing what she's told.

Pooka1
12-11-2008, 05:15 PM
(snip)I believe that to a great extent, scoliosis surgeons earn their salary; it's a grueling surgery that demands huge amounts of skill and physical stamina.

You're not kidding.

Totally agree.

These guys earn their pay.

sharon

Peachy
12-11-2008, 05:42 PM
Thanks to all who have written and offered me support and suggestions. I greatly appreciate each and every one.

I had a call from Theresa, who said she had spoken to Dr. B. who was back from being out of the country. She said that part of the procedure codes that were sent to BC also covered the fees for another surgeon who would be assisting on the anterior portion of my surgery. Here's the good part! The other surgeon is IN MY NETWORK, so, after my deductible, BC should pay ALL his fee! Due to this, Theresa reduced the amount of the deposit I'm required to pay. It still will not be easy, but it is now something I think we can somehow manage.

Maria, you're right that Theresa needs a "dollar amount". We know what percentage BC will pay, but what I can't find out is what they "allow" for each procedure code (sometimes called "reasonable and customary"). I believe that this is also somewhat dependant on the city where the services are performed. Georgia BC tells me that they "do not have access to that information" since my bills must first go to BC of NY; then, BC of NY says they can't give me any info since I'm not THEIR member and they don't know what my policy provides. Eventually, I persuaded GA BC to sent up a conference call for me with NY BC, and they did. NY BC said they cannot determine what is allowable until after the surgery and the final bills are presented to them. I truly wonder if anyone has ever been able to receive a "dollar amount" from any insurance company of what would be paid BEFORE this surgery.

Avis,
You sound so much like me! I went back and read your October posts and see that we're certainly in the same boat. Keep us posted on how your visit with Dr. Rand goes next Monday. I'm thinking you live in Philadelphia, so the following may not work for you, but it MIGHT be a way around this "out-of network" problem for some of us:

When I was on the conference call with both BC's, I overheard something that truly surprised me. The NY rep asked the GA rep how they handled cases like mine where the "provider" is out-of-network. The GA rep said that "if there is no provider for a particular procedure within a 50-mile radius of the insured, then the insured can request in writing that the out-of-network provider be considered by BC as in-network"!!! In my case, there isn't anyone within 50 miles of me to perform this surgery, so I am definitely going to fight to have Dr. B paid as if in network! It may not work, but I'll grasp at any straw.

Peachy

mariaf
12-11-2008, 07:55 PM
Hi Peachy,

That IS good news! Sounds like a lot of hard work and cutting through red tape on your part, but so long as it pays off for you in the end, it will be worth it. I don't think we, the patients and parents, should have to be doing all this back and forth with the insurance companies, but it seems if we don't, nobody will do it for us.

Best of luck and please keep us posted!

pmsmom
12-11-2008, 08:38 PM
When I was on the conference call with both BC's, I overheard something that truly surprised me. The NY rep asked the GA rep how they handled cases like mine where the "provider" is out-of-network. The GA rep said that "if there is no provider for a particular procedure within a 50-mile radius of the insured, then the insured can request in writing that the out-of-network provider be considered by BC as in-network"!!! In my case, there isn't anyone within 50 miles of me to perform this surgery, so I am definitely going to fight to have Dr. B paid as if in network! It may not work, but I'll grasp at any straw.

Peachy

Sounds like things are looking up! :)

Keep us posted!

Take care,
Marian

theizzard
12-12-2008, 05:51 AM
Hi Peachy,
We certainly are similar which was why i wrote when i saw your story. unfortunately, i live within 50 miles of people who do the surgery and I have seen 2 other doctors. I am just not sure I want them especially after meeting with DR. Boachie. One difference is that I wasn't allowed to book a surgery until I received Theresa's letter and forwarded it to my insurance to see what they would pay. Had i been allowed to schedule surgery I would have worked my tail off with the insurance company. To those who have questioned whether Dr. Boachie knows how his office runs the practice, he absolutely knows how it is run and i am sure it runs as he wants it to run. He is treated by his staff as a God and in a way he is. Dr. Boachie was there when Theresa explained to me the financial procedure and he slipped a note to her with the name of Dr. Donaldson as a referred surgeon. Dr. Donaldson being a doctor who did his fellowship or internship (i am not sure which) with Dr. Boachie. From the time I arrived I was treated really well with great respect. I had xrays and met with Dr. Boachie, where he looked at me and told me what my back needed. They had a major problem in reading the cds that I had brought them but finally figured it out. I felt like I was being groomed for surgery and then WHOP! I met with Theresa and the bubble of surgery by Boachie was burst. The train ride home was spent in silence.
I am happy for you Peachy, and hope your surgery gives you your back back to you without pain.
avis

mariaf
12-12-2008, 08:50 AM
2. He funnels a lot of money back into his FOCOS foundation, and makes no secret of the fact that he is committed to raising as many funds as possible for it.


I just wanted to add that I think I have figured out why the concept of Dr. B charging so much to his U.S. patients and then funnelling some of the money back into his FOCUS foundation is not an easy one for me to grasp.

I have been dealing with Shriners Hospitals for about 5 years now as my son is a patient. They help countless kids without insurance and/or whose families have little or no money and/or who would otherwise not be able to receive treatment for their scoliosis (or other conditions) were it not for Shriners. HOWEVER, the big difference is that they don't overcharge those of us who CAN pay (or who have insurance) in order to do that.

Once again, Dr. B is free to do whatever he likes with his money and his services; but in my book his "charity" work, while still commendable, warrants less praise than he would otherwise deserve because he's doing it partly at the expense of his patients in the U.S.

Strictly my opinion, of course.

theizzard
12-12-2008, 07:41 PM
mariaf,

I definitely agree with you regarding his charity work and how it gets funded. It is unconscionable to me that if you have a heap of cash you can avoid jail even if you kill someone, and at the same time, you can pay for the best medicine that money can buy. It makes me so upset to have to deal with these inequities.
down now from mini-soap-box
avis:eek:

mariaf
12-12-2008, 08:37 PM
Hey Avis,

That's usually ME on the soapbox - LOL!

I think the older I get, the more these inequities get under my skin.

Best,

theizzard
12-13-2008, 08:05 PM
I wish i could sneak into Shriners as a little child to get my back fixed. I mean I am short and getting shorter all the time why not?:eek:
avis

mariaf
12-13-2008, 09:02 PM
Yeah, Avis, I can't tell you how many times I"ve heard someone say "gee, I wish Shriners treated adults".

Best of luck to you!

LisaMS
12-28-2008, 04:14 PM
In reading through these replies, it looks like no one has said they needed to pay up front. With most insurance in the US, you have an out-of-pocket maximum amount that you pay in a year. Sounds like the issue is that he's out-of-network, and then the out-of-pocket maximum doesn't always apply (or it's higher). In my case, I chose a surgeon who is in-network, and they never even asked me to check on insurance before the surgery--they did that directly. That's what they should do, even if they're out of network. Then we found out that the hospital I was scheduled for was out of network, which meant I'd have to pay about $2500 more out-of-pocket. So I scheduled at the in-network hospital (which I had a lot of problems with, but I survived and am recovering well).

On my insurance, there is a very reasonable out-of-pocket maximum even for out-of-network providers. Could you check to see what yours is? The only other option I can see is asking BC to recommend someone who is qualified to do this who IS in-network. I personally would not want to have surgery with someone who thinks he is God, because I would think he would tend not to ever doubt himself or allow others to question him (even if they see something wrong in the operating room). Most surgeons who do this surgery regularly are highly qualified and skilled.

Good luck getting this sorted out! I have found the insurance aspect of this surgery the most stressful part in some ways. Long story, but I'm having an audit done of all my claims this year because they keep denying all my claims, even though all were pre-approved and in-network. Can't wait to see what they say when they get the surgery bill. Luckily, my human resources person at work is intervening on my behalf.

Karen Ocker
12-28-2008, 06:35 PM
Here are articles describing the new reality-nothing to do with scoliosis docs in particular


http://www.newsobserver.com/news/health_science/story/984981.html

http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2007/09/21/MNQ0SA6F3.DTL

http://www.mindfully.org/Health/2008/Demand-Cash-Hospitals28apr08.htm

mariaf
12-28-2008, 07:44 PM
Hi Karen,

I read the first article and it seems to be talking about patients being asked to pay "their share" (for example, a small co-pay) upfront. I think that's different than the issue here we were discussing, where patients are asked to lay out large amounts (tens of thousands in some cases) "in case the insurance doesn't cover" the surgery fee, etc.

The article does mention things like MRI's where I know from experience that the patient's share alone can be a few hundred dollars, but that's still not thousands.

Thankfully, I have not found this to be the norm "yet". My husband recently had an MRI and we were billed AFTER the fact. Our insurance paid their share and then we were billed a few hundred (around $350 I think) which remained as "our responsibility".

theizzard
12-29-2008, 10:57 AM
I think the problem is that Dr. Boachie knows that when he bills to an out of network insurance they will substantially reduce what he asks for and pay what they believe is the Usual Customary fee. Then he makes the decision to either bill the patient for the rest before surgery or not bill them depending on what the out of network will pay. I guess he used to rely on patient's paying their fare share after surgery, but they stiffed him royally so he is responding in kind so to speak. In something like this, having out of network benefits, like i have covering 70% of uc takes me out of the game because it won't be enough for his practice. I have requested b/c tell me what they will pay according to dr. boachie's projected surgery costs.
avis:D