How Can I Tell If My PS's Bill Is Legitimate After Insurance Coverage?

asked 9 months ago by Lauren218 in Boston, MA
Latest answer by Tiffany McCormack, MD
Question viewed 101 times
Tags: insurance

I received a post-trauma rhinoplasty to straighten my nose and a septoplasty. Insurance covered both procedures. I also had my tip reduced and a bump removed (not covered). The cost for rhinoplasty without insurance is $4600. I was billed $3800 and my insurance $3800 (for the septo-rhinoplasty). In my pre-authorization letter it said that the doctor is not permitted to bill me the difference between the billed amount and the BCBS "allowed amount." Is my PS's bill legitimate? What should I do?

5 answers to How Can I Tell If My PS's Bill Is Legitimate After Insurance Coverage?

Insurance vs cosmetic

This is a question you need to discuss with your surgeon. The cosmetic portion is never covered by insurance. You should have gone over your contractual obligations with him before this time. Insurance companies put these statements on their EOB, but this does not necessarily mean what it says. If your surgeon is out-of-network, he usually is required to bill you for the difference. In-network is another story.

Steven Wallach, MD
Manhattan Plastic Surgeon

Insurance payment

Insurance typically does not cover surgery to improve nasal appearance even as a result from trauma, only for medical/functional problems. The doctor is not allowed to bill you above the allowed amount for any work done for these medical/functional problems. If you and he agreed to additional cosmetic work during this procedure (bump, tip work) then you are responsible to pay this amount regardless of how much your insurance did or did not pay for the medical/functional work. more

Michael L. Schwartz, MD
West Palm Beach Plastic Surgeon

www.palmbeachface.com

Cosmetic AND reconstructive bills are different, and paid differently.

Many patients share your misunderstanding, and frankly, this is the "fault" of your insurance company, NOT your surgeon. You underwent a reconstructive rhinoplasty that included straightening and septoplasty to correct the post-traumatic visible and functional deformity and airway problems. This is the insurance-reimbursable portion of your surgery for which your surgeon "accepts" (by contract with your and many other insurance providers) what your insurance pays as... more

Richard H. Tholen, MD, FACS
Minneapolis Plastic Surgeon

Insurance Billing and Rhinoplasty

As you know, cosmetic rhinoplasty is not covered by insurance. The functional work, Septoplasty and fixing the traumatic changes, is generally covered. What is actually covered is based on your specific insurance plan and the relationship of your physician to that specific plan. The best way to get your question answered is to speak to your insurance representative and also speak to your surgeon's biller.

Philip Miller, MD
New York Facial Plastic Surgeon

www.drphilipmiller.com

Insurance and rhinoplasty

I think that your insurance company is saying that your surgeon is not allowed to balance bill over what they pay for their part of the procedure. In other words, if your insurance company pays $4000 for the reconstructive portion after he billed THEM $6000 then he is not allowed to turn around and bill you for the remaining $2000. It is confusing because you also had a cosmetic procedure which is completely separate. He is allowed to charge you a separate... more

Tiffany McCormack, MD
Reno Plastic Surgeon

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