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.
Over the last few months, we’ve seen numerous EOBs from Humana for the second knee surgery. Everything seemed to be going great until we got the most recent one earlier this week. It indicated that we would be responsible for $1473 that was billed by a doctor that neither of us had ever heard of. 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.
Jay called and spoke with a very helpful claims rep at Humana who suggested that we appeal the decision and try to get Humana to cover the charges as if they were in network. So we have written an appeal letter and we’ll see what comes of it.
We assume that the doctor listed on the EOB was an assistant surgeon who helped during the procedure. Neither of us can recall meeting him. We understand that surgeons need assistants, and we know that a variety of people are probably helping out during any medical procedure, even though the patient may only know one of two of them. But while it’s all fine and good for a surgeon to have assistants, doesn’t it seem that those assistants should be part of the same health insurance networks as the primary surgeon? 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.