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Hi Pf, (This is is California)
In January, my wife had gall bladder surgery to remove said gall bladder. We have have Blue Shield via my employer and the doctor and hospital were both in-network. We had the usual consultation with the doctor beforehand, went over the surgery, recovery time, things to expect and look out for etc….
Day of the surgery, everything went fine and no issues/complications were communicated to me, this surgery was out-patient so my wife was released that day. Fast forward three weeks and I get this letter from American Surgical Professionals stating that, “it was necessary” for a surgical assistant to be brought in and the assistant was supervised and acted under the direction of the our doctor. The doctors name was included in the letter. I looked them up and they are a vascular surgeon at an out-of-network hospital. The letter said we will try and bill your insurance, but this is unlikely covered. Sure enough, blue shield denied the claim in an EOB we received from them.
I’ve talked to family and friends who had a plethora of procedures/surgeries and they have never heard of this. I googled around a bit, and see that there are several lawsuits for this practice, which is clearly a scam. I also saw the Oregon passed a law forbidding this practice.
My plan was to start with my insurance company and ask why this was denied. Then speak with the hospital and ask them why is was “necessary” for the completion of the surgery. Do I have any other recourse here? Any help would be appreciated.
Edit: GALL bladder, not gull bladder
Contact the department of managed health care’s help center and file a complaint (1-888-466-2219). In California, a law was recently passed that makes balance billing by out of network providers at in network facilities a violation of California law (with some exceptions).
You can be charged the in network fee or cost share. You can’t be charged the out of network charges unless the provider (doctor/assistant) gets a valid waiver from you. And the waiver generally must be made prior to the day of the surgery.
The specific California law on point is Health and Safety Code Section 1371.9.
Edit: the phone number is the number on the DMHC website at www.dmhc.ca.gov.
Edit2: Link to law – https://codes.findlaw.com/ca/health-and-safety-code/hsc-sect-1371-9.html
Edit3: An easier to read FAQ on the topic as the law may be hard for non attorneys to parse through. Note that AB72 is basically the assembly bill that became the law in Section 1371.9 of the health and safety code –https://www.losangelesmedicine.org/wp-content/uploads/2017/06/AB72-Q-A.pdf
I feel compelled to tell you only because you typed it twice – it's gall bladder, not gull bladder.
After you talk to the insurance and they do not pay for it, call the hospital billing department and let them know that you did not consent to this. Ask them to drop the issue.
If they do not, ask for the head person (director of the hospital)and ask that person what can be dont about this illegal practice. If that does not work, let them know that you will be talking with your attorney over this issue. A lot of the time, if they hear the words lawsuit, attorney, and scam practices, they will back down. File a Better Business Bureau complaint.
I have had this happen to a friend of mine and they dropped the issue.
Also go over your portion of the hospital bill with a fine toothed comb for ANY and all possible misbillings that just "slipped" by them when they bill you. Double meds. Extra "fees" etc