Anesthesia out of network, facility and surgeon in network

[aneftp]

My buddy (private Aetna insurance) is having elective shoulder rotator cuff ortho surgery at outpatient center

very good surgeon and one of the big 3 very profitable amc (in networks with Aetna) pulled out of the center recently (they won’t take a loss and facility wouldn’t subsidize anesthesia). So smaller amc has contract and trying to bill out of network

Thought the non surprise billing act stopped this. I know how the game works. The smaller amc will over charge Aetna say $6000 for a 90 min procedure and have the insurance settle for $4000. But the patient gets stuck with the bill since it’s a high deductible

Advice?

1. Abort planned procedure , find another surgeon?
2. Have surgeon operate in the hospitals (big amc in network anesthesia)
3. Offer to pay the smaller amc cash for the anesthesia portion. He’s willing to pay $2000 cash to amc. AMC right now won’t take the $2000 cash for 90 min of anesthesia time.

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[CopaceticOne]

What did you tell him to do?

 

[aneftp]

What did you tell him to do?

He’s waiting on amc to get referred to higher level response.

It maybe illegal (Medicare) to pay portion cash for one service and have rest bill Medicare.

But this is commercial insurance so no real rules.

 

[psycho-matic]

My buddy (private Aetna insurance) is having elective shoulder rotator cuff ortho surgery at outpatient center

very good surgeon and one of the big 3 very profitable amc (in networks with Aetna) pulled out of the center recently (they won’t take a loss and facility wouldn’t subsidize anesthesia). So smaller amc has contract and trying to bill out of network

Thought the non surprise billing act stopped this. I know how the game works. The smaller amc will over charge Aetna say $6000 for a 90 min procedure and have the insurance settle for $4000. But the patient gets stuck with the bill since it’s a high deductible

Advice?

1. Abort planned procedure , find another surgeon?
2. Have surgeon operate in the hospitals (big amc in network anesthesia)
3. Offer to pay the smaller amc cash for the anesthesia portion. He’s willing to pay $2000 cash to amc. AMC right now won’t take the $2000 cash for 90 min of anesthesia time.

Yes, SURPRISE billing for planned procedures is not allowed. This means that the AMC has to verify his insurance and get back to him no later than 48 hours before the procedure with a written estimate of what his out of network costs will be. He can 1. sign it and agree to pat the out of pocket rate. 2. Seek care in-network. If they don't provide that written notice to him no later than 48 hours before the procedure, then they can't bill him for out of network. That would be a surprise bill.

 

[aneftp]

Yes, SURPRISE billing for planned procedures is not allowed. This means that the AMC has to verify his insurance and get back to him no later than 48 hours before the procedure with a written estimate of what his out of network costs will be. He can 1. sign it and agree to pat the out of pocket rate. 2. Seek care in-network. If they don't provide that written notice to him no later than 48 hours before the procedure, then they can't bill him for out of network. That would be a surprise bill.

Surgery is Monday

So he was just informed this morning of insurance for anesthesia being out of network

So they are following the law.

 

[nimbus]

As a patient, I would pick option 2.

 

[Howard888]

Wow…this is what that surgery center gets for not paying a stipend. Patient should walk. Have surgery with same surgeon at hospital or different ASC or a different surgeon. As flawed as no surprises act is the intention of protecting patients was correct. Arbitration should decide payment between provider and payer and patient shouldn’t have to pay out of pocket.

All that said they are saying he has that choice to pay more for there. He should call surgeon and explain this to him and ask for surgery at hospital or different asc and say the no surprises act should be in effect here and this amc is, albeit legally, asking patients to pay versus paying for arbitration

 

[aneftp]

As a patient, I would pick option 2.

That’s what I texted him tonight.

 

[ambiturner]

That’s what I texted him tonight.

Agree with option 2. Also tell him to tell the surgeon, who may or may not have ownership in the surgicenter, that their poor anesthesia decision cost them the case.

 

[psycho-matic]

On the other hand, if this surgeon is better than others, may be worth the extra money.

 

[dantt]

In this scenario, the new anesthesia company will bill a high out of network rate but will typically settle with the patient for a smaller reasonable amount. Standard play.

Many surgeons will not offer option 2.

 

[aneftp]

In this scenario, the new anesthesia company will bill a high out of network rate but will typically settle with the patient for a smaller reasonable amount. Standard play.

Many surgeons will not offer option 2.

Yes. Agree but this is a very scary thing for surgery centers. Especially lucrative surgery centers. We are talking over 55-60% commercial insurance that a big amc (the most lucrative one) pulled out. Because the surgery center is in denial about rising cost of anesthesia salaries needed to provide services.

Another poster asked about doing your own billing. As blade mention. Don’t do it. Anesthesia is a losing billing battle now.

I did speak to one of my friends who’s regional director and he said they are getting subsides from 50% of their for profit surgery centers these days.

 

[Shimmy8]

Many anesthesia groups will agree to the previous in network rates if you communicate with them in advance. They’d rather have that than fool with arbitration and the risk of not getting paid at all.

 

[Hoya11]

My buddy (private Aetna insurance) is having elective shoulder rotator cuff ortho surgery at outpatient center

very good surgeon and one of the big 3 very profitable amc (in networks with Aetna) pulled out of the center recently (they won’t take a loss and facility wouldn’t subsidize anesthesia). So smaller amc has contract and trying to bill out of network

Thought the non surprise billing act stopped this. I know how the game works. The smaller amc will over charge Aetna say $6000 for a 90 min procedure and have the insurance settle for $4000. But the patient gets stuck with the bill since it’s a high deductible

Advice?

1. Abort planned procedure , find another surgeon?
2. Have surgeon operate in the hospitals (big amc in network anesthesia)
3. Offer to pay the smaller amc cash for the anesthesia portion. He’s willing to pay $2000 cash to amc. AMC right now won’t take the $2000 cash for 90 min of anesthesia time.

Why would amc want a subsidy if the place has good payer mix and is busy ? I know many ascs that are profitable with good anesthesia rates and no subsidy. Doesn’t make sense.

Also doesn’t make sense that they won’t take 2k for the procedure. We have good rates and with a block and GA that’s not too far off from what we get for that case.

I would go somewhere else that is covered. Seems like something is up there

 

[Maverikk]

Why would the surgeon not take it to a hospital where it's covered. He/she bills the same either way, yes it may take up some of his inpatient crowd block time but most aren't that involved with their scheduling

 

[aneftp]

Why would the surgeon not take it to a hospital where it's covered. He/she bills the same either way, yes it may take up some of his inpatient crowd block time but most aren't that involved with their scheduling

He owns the surgery center. That’s why. Want the facility fees.

 

[circleK]

Surgeon needs to be made aware that the anesthesia group isn’t taking common insurance plans for the area or she/he will have many angry patients going forward. I’m surprised this isn’t a bigger issue there. Your friend is lucky he has you to ask about this, most ppl have no one they know in health care to understand their options.

 

[psycho-matic]

Years ago, I went to a surgery center whose anesthesia was OON, but they offered to bill me at my in-network rate for their fees. They may work with you and be willing to do something like that, but your mileage may vary. I sought an out-of-state surgeon for a rare problem and may have just went along with it if they were going to bill me out of network rates.

On the other hand, back when I was naive and didn't know much about insurance, I sought out the best spine surgeon and went out of state for that surgery. My surgeon fee was only $1500 with insurance. I didn't know there would be a separate anesthesia bill and didn't even think to ask if the surgery center anesthesia was in-network. I got a bill for $6,000 from the anesthesia group. Talk about a shocker. Live and learn. Glad you can't get surprised with a bill like that anymore.

 

[dantt]

Why would the surgeon not take it to a hospital where it's covered. He/she bills the same either way, yes it may take up some of his inpatient crowd block time but most aren't that involved with their scheduling

Many surgeons find ASC far more efficient for their schedules and the thing about financial stake.

 

[cchoukal]

Agree with option 2. Also tell him to tell the surgeon, who may or may not have ownership in the surgicenter, that their poor anesthesia decision cost them the case.

I like this option. The surgeon, who was inevitably part of the decision on anesthesia subsidies, should feel the pain of that decision by losing out on their ownership cut of this case by having to do it in the hospital for pro-fees. Not sure it's wise to start off with such an adversarial confrontation when you're about to have them cut into you, but this is what feels right.

 

[kidthor]

As a patient, I would pick option 2.

#2 for sure. It seem unconscionable to have (good) insurance and then have to pay several thousand dollars for anesthesia.

 

[aneftp]

So my buddy will have surgery as scheduled
They agreed on $1100 anesthesia cash price which isn’t too bad. For block and 90 minutes

But they said if any complications they will bill the insurance company out of network. I think that’s reasonable. Because they do charge the insurance company 6k like I previously mention and negotiate downwards from there out of network.

 

[caligas]

So my buddy will have surgery as scheduled
They agreed on $1100 anesthesia cash price which isn’t too bad. For block and 90 minutes

But they said if any complications they will bill the insurance company out of network. I think that’s reasonable. Because they do charge the insurance company 6k like I previously mention and negotiate downwards from there out of network.

Good outcome. Now tell him to demand exparel.

 

[aneftp]

Good outcome. Now tell him to demand exparel.

He did fine today.

Didn’t ask what he got in his block.