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  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
    Location
    Southern CA
    Posts
    2,224
    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

  3. #3
    Join Date
    Jan 2008
    Location
    Oregon
    Posts
    1,162
    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 50
    Oct 2010 fusion T8-sacrum w/ pelvic fixation
    Feb 2012 lumbar revision for broken rods @ L2-3-4
    Sept 2015 major lumbar A/P revision for broken rods @ L5-S1


    mom of Leah, 15 y/o, Diagnosed '08 with 26* T JIS (age 6)
    2010 VBS Dr Luhmann Shriners St Louis
    2017 curves stable/skeletely mature

    also mom of Torrey, 12 y/o son, 16* T, stable

  4. #4
    Join Date
    Jun 2011
    Location
    Southern CA
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    2,224
    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

  5. #5
    Join Date
    Jan 2008
    Location
    Oregon
    Posts
    1,162
    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 50
    Oct 2010 fusion T8-sacrum w/ pelvic fixation
    Feb 2012 lumbar revision for broken rods @ L2-3-4
    Sept 2015 major lumbar A/P revision for broken rods @ L5-S1


    mom of Leah, 15 y/o, Diagnosed '08 with 26* T JIS (age 6)
    2010 VBS Dr Luhmann Shriners St Louis
    2017 curves stable/skeletely mature

    also mom of Torrey, 12 y/o son, 16* T, stable

  6. #6
    Join Date
    Nov 2010
    Location
    British Columbia
    Posts
    918
    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
    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

  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
    Jun 2011
    Location
    Southern CA
    Posts
    2,224
    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

  10. #10
    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.

  11. #11
    Join Date
    Nov 2010
    Location
    British Columbia
    Posts
    918
    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

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