Beckers: HOPD Financially Rapes Retired Orthopod

[drusso]

Same surgery cost nearly 20 times more in HOPD than ASC in California​

Patsy Newitt - 19 hours ago


A retired orthopedic surgeon in Fresno, Calif., was charged nearly $4,000 more for a cataract surgery at a hospital outpatient department than his wife who received the same procedure at an ASC, Kaiser Health News reported June 27.

In December 2021, 73-year-old Danilo Manimtim, insured by Anthem Blue Cross of California, went to the HOPD of Saint Agnes Medical Center to receive the cataract surgery. Overall charges ended up being $9,084 for surgery, anesthesia, medical supplies, pharmacy and clinical laboratory services. Anthem paid $5,027 and initially billed Mr. Manimtim $4,057.

Four months later, his 66-year-old wife, Marilou Manimtim, had the same procedure at Fresno-based Eye-Q. Both patients had the same insurance coverage and both providers were in network, but Ms. Marilou ended up owing only $204.

"This is ridiculous, and it feels very unfair," Mr. Manimtim told Kaiser Health News. "How can it be so much more expensive than the surgical center? It’s walking distance away, and if I would have gone there, I would have saved myself a lot of money."

Mr. Manimtim’s insurance plan, the California Public Employees’ Retirement System, caps payment for outpatient cataract surgery at $2,000. After being contacted by Kaiser Health Network, Anthem reached out to the hospital seeking help for Mr. Manimtim.

Under Mr. Manimtim’s insurance plan, the physician is responsible for requesting an exemption from the $2,000 limit, which didn’t happen before the surgery. Anthem then asked the hospital and physician to consider the request after the surgery.

Saint Agnes spokesperson Kelley Sanchez told Kaiser Health News that the hospital later requested the exemption and that it was approved by Anthem.

The update would leave Mr. Manimtim with a $750 coinsurance bill, with Anthem covering a large portion of the remaining $4,057 bill.

---

Members don't see this ad.

 

[deleted185747]

Served ice cold

 

[SSdoc33]

Why do they continually refer to him as "Mr. Manimtim" if he is a doctor?

same reason the kids in my neighborhood call me by my first name?

 

[Agast]

How does a surgeon, of all people, not understand Site of Service? Has he never operated in a hospital

 

[RoloTomassi]

Anthem reached out to the hospital seeking help for Mr. Manimtim

How nice of them! Maybe they can help approve an MBB some day

 

[lobelsteve]

Why do they continually refer to him as "Mr. Manimtim" if he is a doctor?

same reason the kids in my neighborhood call me by my first name?

That's not what they call you.

 

[SSdoc33]

 

[bedrock]

How does a surgeon, of all people, not understand Site of Service? Has he never operated in a hospital

I'm often surprised how much orthopedists don't understand about how the financial side of what pays what and why.

They often just consider themselves too important (as surgeons) to get bogged down in the details...

 

[Doctodd]

he should have known....he probably did.

 

[Ferrismonk]

How does a surgeon, of all people, not understand Site of Service? Has he never operated in a hospital

Article said his plan was "California Public Employee's Retirement System". My guess is he was either university or hospital employed.

 

[Gauss]

Under Mr. Manimtim’s insurance plan, the physician is responsible for requesting an exemption from the $2,000 limit, which didn’t happen before the surgery. Anthem then asked the hospital and physician to consider the request after the surgery. ​

this is wild - notice how hospital and insurance company were able to redirect all the blame onto the operating surgeon because he didn't get an 'exemption' - whatever the F that even is, you would've assumed that's part of the preauth

 

[Gauss]

Article said his plan was "California Public Employee's Retirement System". My guess is he was either university or hospital employed.

CALPERS = CA state employee. UC is kept separate from CALPERS, but it says he's retired from clinical practice and currently reviewing state disability claims probably at EDD or DSS

 

[Agast]

this is wild - notice how hospital and insurance company were able to redirect all the blame onto the operating surgeon because he didn't get an 'exemption' - whatever the F that even is, you would've assumed that's part of the preauth

This reminds me of all the times a patient tells me “I talked to my insurance and they said the procedure would have been approved but you submitted it wrong” and I have a letter saying the procedure is considered experimental

 

[Ferrismonk]

This reminds me of all the times a patient tells me “I talked to my insurance and they said the procedure would have been approved but you submitted it wrong” and I have a letter saying the procedure is considered experimental

"They told me all you need to do is call them."

 

[Gauss]

"They told me all you need to do is call them."

or write a letter of medical necessity

 

[Agast]

"They told me all you need to do is call them."

I already did two peer-to-peers. My patient still thinks I can appeal to a higher power but I’m pretty sure at this point the devil has taken United Healthcare.

 

[callmeanesthesia]

I already did two peer-to-peers. My patient still thinks I can appeal to a higher power but I’m pretty sure at this point the devil has taken United Healthcare.

Patient must fail 6 weeks PT within the past 4 weeks, 4 medications we drew from a hat, and sacrifice a ram under the full moon?
Oh I’m sorry, we didn’t receive the procedure note for that blood sacrifice. You’ll have to repeat it.

 

[Ferrismonk]

Patient must fail 6 weeks PT within the past 4 weeks, 4 medications we drew from a hat, and sacrifice a ram under the full moon?
Oh I’m sorry, we didn’t receive the procedure note for that blood sacrifice. You’ll have to repeat it.

And it'll require a separate auth.

 

[Ducttape]

my fav - in order to qualify for an epidural, you need an MRI within 12 months.

but you can only order the MRI if the patient has failed the epidural.