Patient Provides their own durable medical equipment as not covered by insurance and still gets hit with an EOB for the Assisting Surgeon being out of Humana’s network

This is pretty sad as here we have the “informed patient” shopping for crutches, an ice machine, etc. to bring to the hospital with them as they were not covered items, and they still get hit with an EOB for an assisting surgeon who was not in the network. They did their homework, did everything they could to keep the cost down and still got caught up in balance billing. They had everything including the physician therapy verified too for after the procedure, and not many go to that extent, but being we have the non trusting insurance situation have today, you can still end up being taken over the coals with the best of planning.

The day of surgery may been a day with many occurrences going on at the hospital as well, perhaps the scheduled assisting surgeon was not available for whatever reason, or perhaps another assistant was selected after the fact. The patient has no control over this at all, so again this is something Humana should have taken up first with the assisting surgeon I would think, or perhaps they had and instead of paying the claim, once more passed on a balance billing. It’s no wonder we have a medical compensation plan that is trusted by few and despised by all. Some utilization should have been up on this one to investigate. What a hassle for the patient who went above and beyond what a normal patient would do and still get stuck. Make one wonder too about how cheap do they go on providing crutches too, which is not a huge expense. As Forest Gump stated “it’s like a box of chocolates, you just don’t know what you are going to get”, and that pretty speaks for almost any healthcare insurance coverage today. BD

When Jay had his first knee surgery in January last year, we knew that we would have to pay our $3000 deductible before our health insurance benefits kicked in. We also ended up paying for his crutches, ice machine, and knee brace, because they were supplied by an outside vendor that wasn’t in Humana’s network.

Then in October, he had surgery on the other knee. It was a similar procedure, and we were well prepared. We packed up his ice machine, crutches, and brace, and brought them to the hospital with us. We explained to the nurses and the billing department that we were bringing our own durable medical equipment because we didn’t want to end up in an out of network situation again. We spent 15 minutes in the billing department prior to the surgery, going over everything. We verified that our benefits had been confirmed with Humana, and that nothing had changed about the network agreements. We knew that the surgeon, anesthesiologist, and physical therapy department were all in network with our health insurance, along with the hospital and orthopedic clinic facilities. We were assured that since we had met our deductible back in January, this second surgery would be covered 100% (we have an HSA with 100% coverage after the deductible). It was authorized by Humana, and all was good to go.

The codes on the EOB said that the bill was for “surgical services” and that the surgeon was not in the Humana network. So his fees were being applied to our out of network deductible. After all of the effort we went through to make sure that we wouldn’t get hit with another out of network charge, it’s frustrating to find out six months after the fact that a doctor who isn’t in our network was involved in some way with Jay’s knee.