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wrongful prractic - signing consent form


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#1 trock1

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Posted 26 May 2012 - 06:37 PM

My story is below.  My two questions are listed at the end of the last paragraph.  NOTE: This is my first experience with surgery of any kind.


In January, 2012' I underwent micro surgery on my L4/L5 disc for relief of severe Sciatica.  The surgeon I selected was referred by a local Orthopedic Dr and was considered "in network" by my ins carrier.  I also made certain he was pre approved by the ins co (in writing) to avoid medical bills later.  However, two days before surgery i received a call from his office regarding the pre-op exam as well as informed by the receptionist that my surgeon was was"out of Network".   The following morning I called my ins company in a panic and was informed that his "in network" provider I.D. number was still on file with the ins co (which he was approved under) and that I should not worry about payment.


The morning of my surgery (7:30am),  I met with the surgery center admin Clerk who explained to my finance and I that the surgery center (my surgeon selected) was "out of network, but would accept what my insurance company paid them and not bill me.  When I received the EOB it stated the center billed for $44k and received $22k.  To date, I have not received any add'l bills from the center and hope not to.


After finishing up with the admin clerk,  I waited another 20 min before being called into the prep area to change into a hospital gown & cap and lay on a rolling bed.  At approx 8:15am, I was informed by the prep area nurse that the surgery would be delayed for 30 min for cleaning of the O R.  During the wait, three unknown medical personnel approached me at bedside (about 3 minutes apart), briefly introduced themselves and handed me clip board forms to sign.  Assuming they were part of my surgeon's personal staff (paid by him) I greeted them as my saviors to my severe back pain,quickly signed the forms without question or clearly reading and handed them back. The first woman informed me she would be monitoring my vital signs, a second young man said he was the anesthesiologist and a third young man said he was the assist surgeon.   Minutes after they walked away my surgeon walked up to the bed in his winter coat and said "are you ready to go!!" and five minutes later I was rolled into the O R.  The surgery lasted approx. 30 min, I rested for 15 min and was released to return home.


Approximately 30 days after surgery, I received a bill in the mail for $20,116.00 from a company representing the Asst. Surgeon.  When I contacted them I said, I don't understand why you are billing me due to the fact my surgeon was in network and he was the person that secured your service, not I. (I would have secured an "in network" Assistant for cost reasons as I did with the lead surgeon).  The following morning I contacted the ins co  confused/concerned and was informed that the asst's claim was paid $116.00 and the remainder due ($20k) was my responsibility.  They also said that the asst's claim was submitted under the same procedure codes as the lead surgeon and they do not pay two parties for the same procedure(s).  My question is: is this case considered in any way "wrongful practice" ?  How I was surprisingly approached  at bedside (in pain) to sign payment consent forms only minutes before my surgery?  My second question is: what if I had refused to sign any forms that morning, would my surgery have been canceled on the spot?


I appreciate your response on any pro's or con's. 



#2 Tax_Counsel

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Posted 27 May 2012 - 08:14 PM

You did not say in what state this took place, and that matters because state laws vary. That said, I have just a few general observations.

First, in a lot of hospitals it is common practice that the hospital does not directly employ the doctors. The doctors are independent contractors who bill you and your insurance separately. Each doctor may be independent, so each surgeon (if there is more than one) and the anesthesiologist may all be separate and bill separately. But that said, if the hospital is in-network with your insurance company, typically these folks will be in-network too. But if it isn't in-network (as was apparently the case here) then there's no reason to believe that any of these others would be in-network either. In any any event, it is your obligation to find out what the deal is before you show up for surgery. In particular for you in this circumstance, because you knew that your doctor and the surgery center were not in-network. So, while your doctor and the center agreed to take the insurance payment for the operation, you were on notice that there was an issue here. Your doctor's agreement only deals with his bill; it doesn't bind the other doctors. The same is probably true with the surgery center's agreement—if the doctors are all independent contractors, the center's agreement to accept the insurance as full payment wouldn't bind the doctors. In that situation, you want to ask how everything gets paid and who is in-network so you can make other arrangements if this surgical center isn't going to get you in-network providers for everything.

Second, it is frequently the case that each doctor who will be operating on you (including the anesthesiologist) will meet with you briefly and have you sign a consent form. The consent says you agree to let them perform their services in the operation, that you understand the risks of the procedure, and you accept those risks. It may also include agreement to pay for their services if that wasn't covered by the paperwork you signed with the hospital when you checked-in. Even if you are in pain when you go in, you need to read what they give you unless you truly are in no shape to do it, i.e. incompetent. Those forms are likely still good and enforceable even though you were in some pain when you signed them. I know the situation well myself. I've been in the emergency room in very severe pain and had forms stuck in front of me to sign. I took the time to at least skim them to see what kinds of things I was agreeing to before signing. It wasn't easy, and it wasn't exactly fun. (Although having something to concentrate on did help take my mind of the physical pain for a few minutes, I suppose that was something positive.) However, I was able to ensure that I wasn't going to be stuck with something unexpected after it was all over. If you refuse to sign, though, you may be sent home unless you are in a life threatening situation. They don't have to give you service if they are not assured of payment.

Third, I'd investigate why there were two doctors doing this operation. Your insurance company is trying to duck payment in part by claiming basically that the second guy wasn't needed. You might need to appeal the insurance company decision on that, but to do it, you'll need some evidence to back up that there was a need for him to participate in the operation. I have to believe the out-of-network payment would be more than $116. You ought to at least get the full out-of-network payment your contract calls for. Read your insurance contract carefully to make sure you are getting everything you are entitled to get. Sometimes you have to fight to get the insurance company to agree to pay it. I've done that a few times with my health insurance company.

Unfortunately, you didn't know how all this works and got caught unaware of the pitfall that was ahead of you. Had you known, the moment you started hearing the doctor and/or the surgical center was out-of-network, that would have set off the alarm bells that you might end up on the hook for fees not covered by insurance, potentially big fees. Most people never really read their insurance contracts and never really research to find out how medical practice works, and as a result they can get stuck paying for more than they should. If you know what your policy says and how things work, you are in a much better position to make good decisions and to bargain effectively. I realize that's not much help for you on this matter, but maybe it will help you if there is ever a next time.





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