Has anyone had to pay in advance?

[mariaf]

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]

(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]

Good News!

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]

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]

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]

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]

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]

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

[mariaf]

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]

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?
avis

[mariaf]

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]

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]

Paying up-front becoming more common around the country

Here are articles describing the new reality-nothing to do with scoliosis docs in particular


http://www.newsobserver.com/news/hea...ry/984981.html

http://www.sfgate.com/cgi-bin/articl.../MNQ0SA6F3.DTL

http://www.mindfully.org/Health/2008...als28apr08.htm

[mariaf]

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]

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