Use this book to learn and exercise your options.

Let’s assume that you are referred to a surgeon and after a thorough consultation, you want a Laparoscopic Hernia repair. You can query your insurance company with a procedural code supplied by your surgeon and ask for an out of network allowance and payment. The person on the phone is unlikely to provide you with a clear and accurate answer. First, that person who probably has little medical or surgical knowledge, will try to convince you to seek out an in-network surgeon, Dr. X and Dr Z who are listed as doing laparoscopic hernia repairs. They have no idea which technique, the success rate or the experience of that surgeon. In fact, the accomplished surgeon that you consulted and chose may have taught the insurance company’s surgeons a year or two previously. The insurance company interferes with your decision so that the very low in-network fee will replace the out-of-network fee. Then they interject that you should avoid out of network expenses. You did expect and plan these expenses when you purchased this policy that allows you this choice in this situation. Now you have to decide again. Are apples the same as oranges because they cost less?

Then they quote you an allowance that seems lower than what the first surgeon led you to expect. You decide to negotiate with your surgeon to “get IT for less.” You may be angry that the allowance is not close, after all you were told that this is the “usual and customary fee.” Understand that each insurance company has a different “usual and customary fee” for different products (policies) and these fees have little to do with anything more than an arbitrarily chosen percentile of average fees during some remote year based on the companies analysis of profit for each product. You may not have the highest level of reimbursement because you chose not to pay the highest premium. Sometime these companies quote the wrong allowance, possibly because of the training of personnel, possibly to continue harassment.

For many years, companies depended on limited savvy on the part of physicians and patients. Now, physicians also have computers and can track payments for specific services by specific companies. Ask your surgeon for examples of the inconstant “usual and customary fees” for the same service.

In summary, making decisions about specialty care in the year 2000 requires self-education and knowing who will guide you to your best choice of options. Special interests have serous impacts on decision-making and quality of care.

    A. Douglas Heymann,
    MD, FACS.
    Over 50 years of experience.

    Dr. Heymann

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