Question on HealthCare Provider. Uneasy feeling

[TMAZ]

My wife has developed an Iatrogenic condition after Nasal surgery. We found a ENT specialist in OH that is willing to see her and treat her condition.

My question is that I read a couple of times that this doctor bills his patient for the procedure and says its not covered by Insurance. He uses Alloderm to bulk up the tissue in the nose to recreate proper air dynamics.

Alloderm is cadaver dermis and is used by other doctors for Nose repair and so forth. I am sure my insurance would cover the OR and the Anesthesia but perhaps not the Alloderm.

I read that he bills the patient because he does not want to submit a diagnosis that will give any leverage to sue another doctor for malpractice. I am not sure if this is true just read a few statements on the internet.

What is everyone's thoughts? I always try to check on things myself and will do my own research but looking for advice.

[hlh]

My wife has developed an Iatrogenic condition after Nasal surgery. We found a ENT specialist in OH that is willing to see her and treat her condition.

My question is that I read a couple of times that this doctor bills his patient for the procedure and says its not covered by Insurance. He uses Alloderm to bulk up the tissue in the nose to recreate proper air dynamics.

Alloderm is cadaver dermis and is used by other doctors for Nose repair and so forth. I am sure my insurance would cover the OR and the Anesthesia but perhaps not the Alloderm.

I read that he bills the patient because he does not want to submit a diagnosis that will give any leverage to sue another doctor for malpractice. I am not sure if this is true just read a few statements on the internet.

What is everyone's thoughts? I always try to check on things myself and will do my own research but looking for advice.

This sounds very suspicious to me.

More likely, he forces you to pay out of pocket because he has had difficulty getting insurance companies to cover this procedure... which is probably not proven to be effective. If he makes you pay up front, I would be very worried your insurance would not pay for ANYTHING (including the entire operating room procedure). His excuse for not ?submitting a diagnosis that might assist a lawsuit is non-sensical and is irrelevant for submitting claims to insurance. There is no such diagnosis as "iatrogenic nasal problem". That's not how insurance works.

You must call your insurance program on your own and find out if this is covered, since you will be submitting the claim yourself. You will have to have a diagnosis (and the code associated with it) and all of the procedures (and procedure codes) etc... to ask if they will cover it, and then to submit the claims yourself. If he is afraid to submit them, why would you think that it will work if you submit them?

Honestly, my worry is that this doctor is taking advantage of desperate patients. Call me cynical..... I would only go to a highly reputable doctor at a major medical center to address your wife's problem.

I hope that you have another doctor (local ENT? her primary care doctor?) that is helping to give you advice.

[TMAZ]

He is very reputable and works for a very good Hospital system and so forth. The procedure he does does not always work as the alloderm can be absorbed by the body and then it is all for not.

I am suspcisious but I cant help to be as most people do not have money to just see who they want and so forth. I can submit the claim myself and not worried about that and I will call my insurance carrier.

Actually, I am an IT Manager in Healthcare so I know how it all works. I just dont want my wife to get caught up thinking he is the only provider out there that can save her from her symptoms.

[swh2007]

My wife has developed an Iatrogenic condition after Nasal surgery. We found a ENT specialist in OH that is willing to see her and treat her condition.

My question is that I read a couple of times that this doctor bills his patient for the procedure and says its not covered by Insurance. He uses Alloderm to bulk up the tissue in the nose to recreate proper air dynamics.

Alloderm is cadaver dermis and is used by other doctors for Nose repair and so forth. I am sure my insurance would cover the OR and the Anesthesia but perhaps not the Alloderm.

I read that he bills the patient because he does not want to submit a diagnosis that will give any leverage to sue another doctor for malpractice. I am not sure if this is true just read a few statements on the internet.

What is everyone's thoughts? I always try to check on things myself and will do my own research but looking for advice.

It could be true but I have to question a doctor who would rather his patients over-pay than take a chance on them suing another doctor based upon his correct and honest diagnosis. But I have seen doctors take such positions.

A friend of mine went to a top notch ent in NYC because the local docs would not or could not do something he needed......

[Bonnette]

This doesn't sound right to me, TMAZ. From the standpoint of treatment, it shouldn't matter who or what brought about your wife's condition - insurance should be billed by the doctor who aims to correct the current problem, period.

I wouldn't pay out of pocket for any legitimate operative procedure. At the very least, the ENT you're dealing with should call the insurance company and get a statement from them about what they will pay, based on deductibles, etc.; you can remit the difference, once the insurance company has paid its part. If insurance won't cover any portion of this treatment, I would seek out another ENT for a second opinion about what this doctor plans to do; but then, I would get another opinion anyway, since your wife's case is complicated (I remember a previous post about this).

This doctor's argument for full payment up-front (i.e., that the treatment doesn't always work) sounds specious to me, since no operation has a 100% success rate; insurance will usually pay a predetermined amount for procedures that have scientific merit and some kind of track record.

[TMAZ]

I did a little more digging and did call his office and talk to his billing person. I found that they submit the treatment plan to the insurance for review first and see if the procedure will be covered. If not they have two options... You pay for the treatmentout of pocket or try to appeal with your insurance company. This sounds legitmate to me and is normally how the system works.

[TMAZ]

It could be true but I have to question a doctor who would rather his patients over-pay than take a chance on them suing another doctor based upon his correct and honest diagnosis. But I have seen doctors take such positions.

A friend of mine went to a top notch ent in NYC because the local docs would not or could not do something he needed......

We found out that the cause of her issues is a botched surgery. However, the original ENT says nothing is wrong so we took it to a Director of Otolyrangology here at one of the Teaching Hospitals. He pointed out the issues but said that he has not seen this before so has never corrected it but said he can because the theme of the correction is the same as in other areas in the nose. I decided to just take her to the name that keeps coming up that is the expert in this type of condition. I figure why go through all of the BS and just to straight to the Top. I was just worried about finances and so forth.

Since, she was burnt by the original ENT its hard to trust them again for her so I battle with that. All and all I believe this is the right decision.

[Bonnette]

I did a little more digging and did call his office and talk to his billing person. I found that they submit the treatment plan to the insurance for review first and see if the procedure will be covered. If not they have two options... You pay for the treatmentout of pocket or try to appeal with your insurance company. This sounds legitmate to me and is normally how the system works.

Good, TMAZ. That sounds right to me, too.

[Bonnette]

We found out that the cause of her issues is a botched surgery. However, the original ENT says nothing is wrong so we took it to a Director of Otolyrangology here at one of the Teaching Hospitals. He pointed out the issues but said that he has not seen this before so has never corrected it but said he can because the theme of the correction is the same as in other areas in the nose. I decided to just take her to the name that keeps coming up that is the expert in this type of condition. I figure why go through all of the BS and just to straight to the Top. I was just worried about finances and so forth.

Since, she was burnt by the original ENT its hard to trust them again for her so I battle with that. All and all I believe this is the right decision.

I hope that this procedure will completely correct your wife's condition, and that she will have a swift recovery.

[swh2007]

We found out that the cause of her issues is a botched surgery. However, the original ENT says nothing is wrong so we took it to a Director of Otolyrangology here at one of the Teaching Hospitals. He pointed out the issues but said that he has not seen this before so has never corrected it but said he can because the theme of the correction is the same as in other areas in the nose. I decided to just take her to the name that keeps coming up that is the expert in this type of condition. I figure why go through all of the BS and just to straight to the Top. I was just worried about finances and so forth.

Since, she was burnt by the original ENT its hard to trust them again for her so I battle with that. All and all I believe this is the right decision.

Yep, sounds right. If the doctor actually committed mal-practice, then there's a separate decision to make. There's a statute of limitations, although I cannot remember the Mo time limit. Too many years...

[TMAZ]

We saw the doctor in Cleveland. Right away he said that it would be 10k for him to do the procedure. I of course questioned why they would not bill insurance and why charge the patients up front?

He said that the Hospital system he is with will not let him do the procedures and bill the insurance because they lose money. The Hospital has a contract with the insurance companies so lets say the procedure is 10k but the contract says that the insurance would only have to pay a total of 2k then the Hospital loses money on this procedure because the implant material is more than 2k itself.

He explained that the Hospital will not allow him to do this procedure unless the patients pay the cash up front.

Now my dilema is getting 10k for this procedure. Also, their is not any guarantee with any surgery that it will be 100% successful but I guess that is the chance we have to take.

[SCI-Nurse]

Since they deal only in cash, I would expect 1) a discounted rate and 2) arrangements for a time payment plan through the hospital or physician. This must be a for-profit hospital I assume.

(KLD)

[TMAZ]

KLD- Its in Cleveland and I think its a teaching Hospital so I assume it is a for Profit Hospital.

[SCI-Nurse]

Most teaching hospitals are not-for-profit, including many university hospitals, district or county hospitals, and Veterans Affairs Medical Centers, as well as those owned by private foundations.

(KLD)

[TMAZ]

So we did find out that my wife has Empty Nose Syndrome. The doctor we saw in
Saint Louis was very matter of fact in telling us that there is not any standard of care for her condition and that everything is experimental to try to aid her misery.

She is very eager to get something done to help her but goes from optimistic to pessimistic every day. I can appreciate that for sure. She is looking into Stem Cells and PRP and PRL therapies but given my own experience and in reading our forum we are a long way off from this providing the solution. I think all we an do at this point is go ahead with the Alloderm implant to her back to good. Certainly, there is not any cure but if we can get her to a comfortable place again it would certainly be worth the time and money.