Am I responsible to pay a doctor's surgical assistant's bill because they are not covered by my Health plan?

Question

I recently had knee surgery. My doctor was a provider for my Health plan so I was not responsible for his fees. However, he decided to solicit the help of an assistant from a group who was not in the plan's network. He did this without asking me and now I am to pay over 1200.00 to this Surgical Services Group! Am I responsible? I feel the doctor knew what insurance I had and should have consulted with me before the surgery about using them.

Answer 1

Surgical Assistants are usually considered part of the operating room staff (I have one or two of them in the OR whenever I am performing surgery). They are considered part of the "Surgical Team", and it should have been billed by the hospital as such (even if they used an outside contractor). That is one of the many benefits of surgery in a hospital.

If your surgery was in an "Outpatient Surgical Center", the insurance companies do not consider them "operating rooms" they consider them "procedure rooms" (just like in a doctor's office, or in a plastic surgery office), even if they are fully equipped Operating Rooms. So, if this was the case, then it is covered as a "surgical procedure done in a medical office" instead of a "surgical procedure done in a hospital". So that can make a big difference as far as the insurance companying paying ("Surgical Center" versus "Hospital Operating Room"), since you do not mention where you had the surgery... I just thought I would bring that up. Some people think that an "Outpatient Surgery Center" is cheaper than a "Hospital Operating Room", but when it comes to insurance companies it can be much more out of your own pocket. Again, I do not know if this is the case in your situation, but I thought it was important to bring up.

When you signed the "admission papers" when you went in for your surgery, you promised to pay for all bills submitted by the Hospital and by any of their Subcontractors. If you read all that small print very closely, you will find that spelled out in rather clear legal terms (but small print since they have so much to put on one 8.5" x 11" piece of paper).

When you signed the "surgical consent papers", more than likely it also spells out the liability and that if needed outside medical and nursing personnel can be brought in (this is to make sure that the surgery is DONE RIGHT, better to have the right staff with the right tools doing the job... then someone who may get "over their head" if things get into trouble, given the major problems that can occur during even a basic surgical procedure such as a tonsillectomy when a general anesthetic is used, let alone one like knee surgery which can have so many problems (fat embolisms, blood embolisms, deformity, failure of the procedure to work in your specific anatomy, that is why some consent forms are in small print and are many pages long (if they were in 10 or 12 point print, they could be up to 30 pages long).

I am a medical intern and I am in a Trauma Surgery rotation as a surgeon. I do not deal with consents. I do not deal with billing. I do not deal with "elective surgeries" (as most knee surgeries are considered by the insurance companies, unless your leg is literally falling off). But sometimes I have a bunch of time between surgeries (after you have been in the operating room for 10 hours on one patient, they want you to get a bit of rest for a few hours before you go on to another patient, and if your adrenaline is up, it is impossible to sleep). So I have read all the forms up close, and as a person who is NOT A LAWYER, I can see how they spell out how they cover the hospital's rear in both the admissions and consent papers. In fact, the admissions paper that you signed is actually a "blanket consent" for EVERYTHING except a specific procedure (that is why you do not need to sign a consent form when they do an EKG, or draw blood, et cetera because it is covered in your "admissions form").

So if the surgery was done in a Hospital, ask their billing department to talk with the Surgical Services Group and see if they are willing to submit the bill to the insurance company for you (most hospitals will). That way the insurance company pays the approved hospital, and the hospital pays the Surgical Services Group. Most "Outpatient Surgery Centers" on the other hand WILL NOT do that for you. That is when it is time to call your surgeon.

If the hospital does not help, or you had your surgery done in an Outpatient Surgery Center, you can ask your doctor's billing department to contact the Surgical Services Group and ask if they can do the billing. Then the Doctor's Office bills the insurance company, and then they pay the Outpatient Surgery Center.

Last option from the "medical" end is to have the Surgeon himself (this can take MONTHS, since if he is a busy surgeon, he does not have the time to spend hours upon hours on the phone to do this), call the insurance company and talk with their Medical Director to get the bill submitted.

But, one would think that the Surgical Assistant was NOT AN AFTERTHOUGHT, so it should be in the pre-approval procedures that were part of your surgery.

Then one final option, get a lawyer (this is the VERY EXPENSIVE ROUTE), since even if you lose you can be responsible for "non-legal fees" [Legal fees are those bills that are for the LAWYER'S services.... that does not count a Paralegal's services, photo copies, filing fees, et cetera that can be well over $1200.00]. But if you win, your insurance company will pay the money, the legal fees, and non-legal related lawyer's office fees, as well as the filing fees. But that means you have to go to court, you must testify. You must have your doctor testify (time is money), each "expert witness" that is brought in can be much more than $1200.00
so that can be a nightmare. But if your lawyer and the insurance company lawyer's (they will have many more than you have), "strike a deal" make sure that all "legal costs" are covered so you do not have anything coming out of your pocket. Sometimes for such a small amount of money, just a "lawyer's letter" will get them to "cut a check"... but depending on the insurance company (HMO's like Kaiser Permanente are FAMOUS for taking even a "$20 error", that is TWENTY DOLLAR error, to trial. This is because they have in-house counsel whose job is just to deal with lawsuits all the time, they are paid a salary, and they get bonuses for every suit they win, and if they win, the loser pays all the expenses from the trial, so it is a windfall for Kaiser).

So try the hospital first, try to avoid the lawyers. But legally with the admissions form you filled in, I would read it very closely. It probably says that you are agreeing to pay any and all bills submitted by them and their sub-contractors that are refused by your insurance company, and if your insurance company refuses to pay any of the bill you are responsible for the entire bill. In that case, if the hospital does not work with you, you can end up having the Surgical Services Group submit the $1200.00 to a Collections Agency, and messing up your credit. So in the end you may still be stuck paying for the bill out of your own pocket.

But to answer your specific question "Am I responsible?" the answer is in the "admissions paperwork" that you signed, and I would bet "dollars to donuts" that in it you signed away that answer, and it is a resounding... YES. That is the entire point of all the paperwork you sign when you are admitted. The HIPAA privacy notice, the "blanket consent" for nursing and testing and examinations, and all of the other paperwork are secondary as far as the admitting person is concerned.

Answer 2

FYI as an assistant we are unable to apply to be in network. I have done over 7,000 procedures. Our bills go out and you see the EOB. I and EVERY assistant I know only get what insurance give us.. Also, If we bill out 10,000 you can bet we are lucky to get $500. In rare cases and not one that I am even aware of the assistant bills for anything at all. Also, we do have intense training with 100's of hours to be there as well as have tp pay for malpractice and apply with a fee to even work in the OR.

Answer 3

Definitely call your surgeon and discuss it directly with him/or his office. Tell them that you did not ok this and he should have made sure that the assistant was in your network. They can't just go around and spend your money without your approval! But legally; you are responsible for this charge. Sucks I know; they did that with all my tests I just went through I wasnt able to choose whether the ppl that read the tests were in my network or not and I have to pay the bill regardless. They shouldn't be able to do get away with stuff like this!

Answer 4

Every surgical procedure should be precertified to the insurance company... I think you should explain your issue to the dr... Dr's know how the system works, trust me(I work in a hospital). He should NOT have asked that assistant to assist in the surgery not knowing if it would be paid, that was not fair to you at all!!! Talk to the dr, tell him the situation!

Answer 5

No!!! you chose the doctor to do the surgery, he chose the assistant, its like you hire a contractor to build a home for 100,000 dollars, he then hires a sub contractor to do the brick layout, he pays them with the money you paid him!! But you must read the paper work you have signed, that may be where they got you

Answer 6

Don't pay anything to those American ******* bloodsucker doctors and assistants. **** them allllllllllllllllllllllllllllllllllllllllllllllllllllllllllll

Answer 7

Sadly, yes.

If you signed the consent form, you are responsible for whatever fees are not covered by your insurance.

Answer 8

One thing is that if he would have used another surgeon for the procedure it would have cost double what the original surgeon charged

Answer 9

you have to pay for anything involved in the procedure.. its sad that you have to pay but I'm sure your Dr knew what was best.

Answer 10

Yes.