Is patient responsible for payment?

[Honest1956]

What is the name of your state?
Maryland

Doctor perform breast reduction on patient. Doctor knew insurance did not cover this procedure but patient did not know. Doctor had initially called patient insurance company and was told that patient insurance does not cover procedure. Doctor performed procedure anyway. Should patient be held liable for payment of procedure including hospital stay? Thanks.What is the name of your state?

[lealea1005]

Originally Posted by Honest1956

What is the name of your state?
Maryland

Doctor perform breast reduction on patient. Doctor knew insurance did not cover this procedure but patient did not know. Doctor had initially called patient insurance company and was told that patient insurance does not cover procedure. Doctor performed procedure anyway. Should patient be held liable for payment of procedure including hospital stay? Thanks.What is the name of your state?

Depends. Was the breast reduction considered cosmetic or was there a medical reason for having it done? Was your surgeon in network with your health plan?

Breast reduction is usually expensive. I cannot imagine that they would proceed with the surgery without securing payment.

[Honest1956]

Considered cosmetic surgery.

[You Are Guilty]

Originally Posted by Honest1956

What is the name of your state?
Maryland

Doctor perform breast reduction on patient. Doctor knew insurance did not cover this procedure but patient did not know. Doctor had initially called patient insurance company and was told that patient insurance does not cover procedure. Doctor performed procedure anyway. Should patient be held liable for payment of procedure including hospital stay? Thanks.What is the name of your state?

Legally, patient has two options:
1- Pay the bill (or risk collections/lawsuit); or
2- Request the boob(s) be re-installed back to their original state.

[lealea1005]

Originally Posted by Honest1956

Considered cosmetic surgery.

Don't know of any insurance plans covering cosmetic surgery.

I'd take YAG's advice and pay the bill.

[moburkes]

This patient would have been responsible for the surgery anyway. What person thinks that breast reduction surgery is covered without years of going back and forth with the insurance company? The surgeon would prefer to be paid, which means that insurance is preferable to a patient's bill going to collections for nonpayment. Unless YOU've spoekn to the insurance company, then you shouldn't have assumed that it was covered. Didn't you sign forms that stated that you were ultimately responsible for the payments?

[ecmst12]

It is the PATIENT'S responsibility to know the rules and requirements of his/her insurance plan to have procedures covered. Breast reductions will pretty much always always need to be pre-certified (in fact most insurances require precert for ANY surgeries these days) and while it shouldn't take "years of back and forth", they will have guidelines on whether it will be considered medically necessary or cosmetic, having to do with whether the patient has gouges in the shoulders from bra straps, whether there are back problems, the amount of tissue being removed, whether the patient is overweight, etc. It was your responsibility to call your insurance company to see what you and your doctor would have to do to get the procedure covered.

Now IF you had gone over the procedure with your doctor, and you understood that it would be considered an elective/cosmetic procedure, then the fact that your insurance would not cover it and you would be paying for it out of your pocket was implied.

Bottom line, any way you look at it, you are responsible for the bill.

[moburkes]

Agreed 100%. I only know of a handful of cases, but in all of them, the patient all fought for years to prove the benefits of the surgery, even with gouges from bra straps.

[ecmst12]

The people I knew didn't have to fight that hard....the only thing that might be time consuming is that if the person is overweight, the insurance might want her to spend 6 months in a weight loss program to see if that improves the symptoms for her. But every case and every insurance company is going to be a little different.