Insurance Billing

[tbaker5]

What is the name of your state (only U.S. law)? Washington

I need to have abdomial surgery to remove scar tissue, which is covered by my insurance. At the same time, I am considering having gastric bypass, which is NOT covered by my insurance. Does anyone know how this should be billed to insurance, so that they have to pay for the part of the surgery that is insured? How is this handled?

[momm2500]

the bill will go to the insurance with the proper procedure codes that classify each different procedure. an insurance company will also ask for the operative report and most likely determine that a percentage of the operating room and hospital bill will be used for the gastric bypass and possibly deny that portion of the bill too.

[lkc15507]

I agree, the procedures would likely be subject to "multiple surgical procedure reductions" likely present in a health plan. (I use likely simply because I have no knowlege of the acual plan, but it would be commonplace for a plan to have those provisions.) I don't personally handle multiple surgical reductions frequently, but I do some. My concern here is that from the two procedures described, the GB would be the primary procedure and the scar tissue the secondary procedure, thus causing the greatest reduction in the covered procedure.

The reason that I say this is twofold. 1) Some plans will consider the most expensive procedure the primary and in this case I belive that would be the GB. 2) Other plans might consider in order of surgical significance. IE, if you do a simple laparotomy for scar tissue release, could the GB be incidental to that surgery. NO. On the other hand, if you do a GB, could scar tissue release be incidental to the GB. YES. That would also, in my opinion make the GB the primary procedure resulting in the greatest reduction to the covered procedure. Whereas if the scar tissue release were performed alone, likely covered at full benefits. (Again assuming that it is covered and the GB not as you posted.) Now to really add insult to injury here, you posted "abdominal surgery". I assume an actual open procedure and not laparoscopic, ie minimally invasive with cameras. Then we have to consider whether the GB is laparoscopic or open. What I mean by this is that if laparoscopic scar tissue release is appropriate, yet you choose open scar tissue release based upon wanting to have an open (Roux NY) GB, you're likely to have it all denied.

I am not at all advocating that one subject themselves to two separate invasive procedures for the sake of money, however, I am suggesting that you discuss this thoroughly with your physican and insurer. I would suggest that you request a predetermination from the insurer (with the help of the surgeon) which procedure would indeed be considered the primary. Especially with consideration of open vs. laparoscopic issues. Best to you, lkc15507