Results 1 to 15 of 15

Thread: Usual and Customary Rate

  1. #1
    Join Date
    Mar 2011
    Posts
    52

    Angry Usual and Customary Rate

    Do any of you know where BCBS gets their UCR from? I swear they must be on something. Shriner's did my son's surgery, filed with BCBS and according to BCBS UCR for Spinal Fusion Surgery is under $4800!!!! Needless to say I am appealing that low ball price. True, I do not have to pay the difference because it is Shriner's, but it burns me up that they are trying to cheat Shriner's. I almost feel like filing a Class Action against them for fraud when the in network hospitals are charging upwards of $30K according to their cost estimator. So BCBS is either lying about that or they are cheating Shriner's either one seems crooked.

  2. #2
    Join Date
    Jun 2011
    Posts
    1,968
    My last surgery was over one million dollars and the hospital took less than $200,000 dollars . According to my surgeon, half of that million is in back, my rods and
    screws. I have BCBS as well
    Melissa

    Fused from C2 - sacrum 7/2011

    December 8, 2014 - Another Broken Rod Surgery

    February, 2015 - Right Knee Replacement

  3. #3
    Join Date
    Jan 2008
    Location
    Oregon
    Posts
    1,032
    Hi there,

    I am pretty sure this amount is the surgeon's fee only. My surgeon's fee for approx 8-9 hours of surgery was around $9000 I believe. So I am actually not at all surprised if this is the amount BCBS pays as usual and customary.

    The other hundreds of thousands of dollars Melissa mentions are hardware and OR supplies (around $90,000 for me including BMP), the OR charges, anesthesia charges, anesthesiologist's fees, recovery room (charged by the minute), the hospitalization itself (daily room charge), medications, PT, labs, x-rays, etc etc. That all adds up to tons of money. It is surprising how little the surgeon actually gets paid.

    My entire surgery and hospitalization was around $200,000 all together.

    I am sure BCBS will process the rest of the charges separately.
    Gayle, age 47
    Boston brace as a teen for AIS
    Oct 2010 fusion T8-sacrum w/ pelvic fixation, TLIF at L4/5.
    Feb 2012 major A/P revision for broken rods


    mom of Leah, 12 y/o, diagnosed Jan '08 with 26* thoracic JIS (age 6)
    4/08 26 degrees, brace 16 hrs/day
    9/08 17 deg. OOB - brace discontinued
    9/09 30 deg, resuming brace
    5/10 VBS Dr Luhmann Shriners St Louis
    5/14 stable 4 yrs post-op, 14* T

    also mom of Torrey, 9 y/o son, 12* T, decreasing spontaneously (from 19*)

  4. #4
    Join Date
    Jun 2011
    Posts
    1,968
    Quote Originally Posted by leahdragonfly View Post
    Hi there,

    I am pretty sure this amount is the surgeon's fee only. My surgeon's fee for approx 8-9 hours of surgery was around $9000 I believe. So I am actually not at all surprised if this is the amount BCBS pays as usual and customary.

    The other hundreds of thousands of dollars Melissa mentions are hardware and OR supplies (around $90,000 for me including BMP), the OR charges, anesthesia charges, anesthesiologist's fees, recovery room (charged by the minute), the hospitalization itself (daily room charge), medications, PT, labs, x-rays, etc etc. That all adds up to tons of money. It is surprising how little the surgeon actually gets paid.

    My entire surgery and hospitalization was around $200,000 all together.

    I am sure BCBS will process the rest of the charges separately.

    My first surgery was $300,000 in NC. It was about am 8 hour surgery
    Melissa

    Fused from C2 - sacrum 7/2011

    December 8, 2014 - Another Broken Rod Surgery

    February, 2015 - Right Knee Replacement

  5. #5
    Join Date
    Jan 2008
    Location
    Oregon
    Posts
    1,032
    Melissa,

    I am quite sure the $300,000 amount is a compilation of charges, not the surgeon's fee. I am sure the surgeon got paid a fraction of that amount, and I think that is the amount referenced in the OP.
    Gayle, age 47
    Boston brace as a teen for AIS
    Oct 2010 fusion T8-sacrum w/ pelvic fixation, TLIF at L4/5.
    Feb 2012 major A/P revision for broken rods


    mom of Leah, 12 y/o, diagnosed Jan '08 with 26* thoracic JIS (age 6)
    4/08 26 degrees, brace 16 hrs/day
    9/08 17 deg. OOB - brace discontinued
    9/09 30 deg, resuming brace
    5/10 VBS Dr Luhmann Shriners St Louis
    5/14 stable 4 yrs post-op, 14* T

    also mom of Torrey, 9 y/o son, 12* T, decreasing spontaneously (from 19*)

  6. #6
    Join Date
    Nov 2010
    Location
    British Columbia
    Posts
    929
    How is your son doing btw!?
    Son 14 y/o diagnosed January 20th. 2011 with 110* Curve
    Halo Traction & 1st. surgery on March 22nd. 2011
    Spinal Fusion on April 19th. 2011

    Dr. Krajbich @ Shriners Childrens Hospital, Portland Oregon



    http://tinyurl.com/Elias-Before
    http://tinyurl.com/Elias-After

  7. #7
    Join Date
    Mar 2011
    Posts
    52
    Quote Originally Posted by Elisa View Post
    How is your son doing btw!?
    INCREDIBLE!!!! He started back to school with half Days one day and full days the other back on Sept 28th. He will finish his quarter of precalc and chemistry online before going back to full full days which should be end of this month. He is still having memory issues from the anesthesia, but his back is doing well and he has gotten back into his habit of wearing dress clothes every day. He is most upset that the doctors did such a good job that he will not have a big scar. He wanted to have a big scar and it is a beautiful think line down his back, kind of like a zipper. His local family doc said if it bothered him that bad, he could always get a tattoo to make it look more jagged. I think the zipper would be cooler. He is still having to use a chair in the shower as he is afraid he will fall (balance issues and all that), but he is really showing progress on a vast amount of things.

    How is yours? Pretty much back to normal yet?

  8. #8
    Join Date
    Aug 2011
    Location
    NYC
    Posts
    21

    Insurance - hospital costs

    Quote Originally Posted by mabeckoff View Post
    My last surgery was over one million dollars and the hospital took less than $200,000 dollars . According to my surgeon, half of that million is in back, my rods and
    screws. I have BCBS as well

    Do you mean you had to pay $200K for the one million dollars of costs or they charges one million and your insurance company settled with hospital for $200K. I am worried sick (still haven't decided on surgery as of yet) how am I going to pay for this. My surgeon doesn't take insurance, so I know I will have to pay most of his fee, and then wondering what I will have to pay out of pocket for all the hardware and hospital costs. I have Cigna now, but will possibly be switching jobs soon - and then I would have Aetna.

    Would appreciate your feedback. Thank you so much.

  9. #9
    Join Date
    Nov 2010
    Location
    British Columbia
    Posts
    929
    Quote Originally Posted by LokanasDad View Post
    INCREDIBLE!!!! He started back to school with half Days one day and full days the other back on Sept 28th. He will finish his quarter of precalc and chemistry online before going back to full full days which should be end of this month. He is still having memory issues from the anesthesia, but his back is doing well and he has gotten back into his habit of wearing dress clothes every day. He is most upset that the doctors did such a good job that he will not have a big scar. He wanted to have a big scar and it is a beautiful think line down his back, kind of like a zipper. His local family doc said if it bothered him that bad, he could always get a tattoo to make it look more jagged. I think the zipper would be cooler. He is still having to use a chair in the shower as he is afraid he will fall (balance issues and all that), but he is really showing progress on a vast amount of things.

    How is yours? Pretty much back to normal yet?
    Good to hear! The balance thing does take a bit of time. Not sure how many inches your son gained after surgery but mine was stretched up four inches so things like the kitchen/bathroom counters seemed lower and his judgment was a bit off when walking around b/c he used to kinda walk sideways and then all of a sudden he was walking forward. It was all very subtle and he adapted quickly but it was like he suddenly put on four inch heels, lol.

    He is coming up to six months post-op now and I admit that I've pretty much kept him in a glass case and won't allow him to do anything other than walk to and from school and around the house and yard. I cringe when he even picks up our beefy cat but then I tell myself to quit being a fanatic but it's hard not to be given all we've been through. I know I'll feel much better when he reaches the one year mark. And yes, he's pretty much back to normal and is in school full time but we live so close to the school that he comes home for lunch every single day and has a bit of a rest.
    Son 14 y/o diagnosed January 20th. 2011 with 110* Curve
    Halo Traction & 1st. surgery on March 22nd. 2011
    Spinal Fusion on April 19th. 2011

    Dr. Krajbich @ Shriners Childrens Hospital, Portland Oregon



    http://tinyurl.com/Elias-Before
    http://tinyurl.com/Elias-After

  10. #10
    Join Date
    Jun 2011
    Posts
    1,968
    Quote Originally Posted by Terrik View Post
    Do you mean you had to pay $200K for the one million dollars of costs or they charges one million and your insurance company settled with hospital for $200K. I am worried sick (still haven't decided on surgery as of yet) how am I going to pay for this. My surgeon doesn't take insurance, so I know I will have to pay most of his fee, and then wondering what I will have to pay out of pocket for all the hardware and hospital costs. I have Cigna now, but will possibly be switching jobs soon - and then I would have Aetna.

    Would appreciate your feedback. Thank you so much.
    No I have had no bills from my July surgery. The hospital settled with BCBS for $200,000. I did not have to pay anything. I have not gotten any other EOB's from
    BCBS for that surgery .
    Melissa

    Fused from C2 - sacrum 7/2011

    December 8, 2014 - Another Broken Rod Surgery

    February, 2015 - Right Knee Replacement

  11. #11
    Join Date
    Mar 2011
    Posts
    52
    BCBS got back to me:


    Procedure code 22804 was billed for $9,381.52 and we allowed $2,944.57
    Procedure code 22844 was billed for $3,907.37 and we allowed $1,210.00
    Procedure code 20936 was billed for $260.51 and we allowed $260.51
    Procedure code 20930 was billed for $387.64 and we allowed $312.44

    Procedure code 22804 is for the Arthrodesis, Posterior, for spinal deformity
    Procedure code 22844 is for the Posterior Segmental Instrumentation
    Procedure code 20936 is for the Autograft for spine surgery only
    Procedure code 20930 is for the Allograft for spine surgery only


    So this is the actual surgery. And they say that $4k is the UCR. I call bull on that one.

  12. #12
    Join Date
    Nov 2010
    Location
    British Columbia
    Posts
    929
    Quote Originally Posted by LokanasDad View Post
    BCBS got back to me:


    Procedure code 22804 was billed for $9,381.52 and we allowed $2,944.57
    Procedure code 22844 was billed for $3,907.37 and we allowed $1,210.00
    Procedure code 20936 was billed for $260.51 and we allowed $260.51
    Procedure code 20930 was billed for $387.64 and we allowed $312.44

    Procedure code 22804 is for the Arthrodesis, Posterior, for spinal deformity
    Procedure code 22844 is for the Posterior Segmental Instrumentation
    Procedure code 20936 is for the Autograft for spine surgery only
    Procedure code 20930 is for the Allograft for spine surgery only


    So this is the actual surgery. And they say that $4k is the UCR. I call bull on that one.
    I need a translation. What exactly is it that you're calling "bull"? Our system is so different up here and I am just curious to know what you mean.
    Son 14 y/o diagnosed January 20th. 2011 with 110* Curve
    Halo Traction & 1st. surgery on March 22nd. 2011
    Spinal Fusion on April 19th. 2011

    Dr. Krajbich @ Shriners Childrens Hospital, Portland Oregon



    http://tinyurl.com/Elias-Before
    http://tinyurl.com/Elias-After

  13. #13
    Join Date
    Jun 2011
    Posts
    1,968
    On my million dollar surgery, the UCR turned out to be less than $200,000
    Melissa

    Fused from C2 - sacrum 7/2011

    December 8, 2014 - Another Broken Rod Surgery

    February, 2015 - Right Knee Replacement

  14. #14
    Join Date
    Mar 2011
    Posts
    52
    I pulled the SC Medicare rates. According to BCBS, that is UCR. Funny how dr.'s are more and more refusing medicare cases if that is a fair rate.

  15. #15
    Join Date
    Feb 2012
    Location
    NC
    Posts
    129
    Quote Originally Posted by mabeckoff View Post
    My first surgery was $300,000 in NC. It was about am 8 hour surgery
    Melissa,
    Who did your surgery in NC?
    Scheduled for surgery with Dr. Lenke Oct. 2012
    53*T 71*L
    Surgery 10/05/2012 T4-pelvis
    Correction: looks perfect! Will find out how perfect at future appointments

Tags for this Thread

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •