Sketchy use of CPT codes, "Faulty" tools, and Surgeon changing the type of surgery I get while I am unconscious? (AZ, UHC choice-plus HSA)
Hi All, I am scheduled for Tubal Ligation on the 26th of this month. I think my surgeon is doing something that could be fraudulent or is ethically questionable in terms of insurance coding, billing, and the surgery being performed changed after I am unconscious.
The laparoscopic, female sterilization surgeries my UHC Commerical choice-plus HSA plan covers 100% (in compliance with ACA) are: 58615 (tubal ligation via a device), 58670 (tubal ligation via fulguration), and 58671 (tubal ligation via occlusion).
While a bilateral salpingectomy is the best surgery, it is not covered 100% by my insurance, and as I have a high deductible, don’t make a lot of money, and am going to be kicked off of my parent’s insurance soon, I need to have the affordable surgery.
Last week I met with my surgeon, and the surgery I discussed with her was for fulguration, in which tongs are used to grasp and burn tissue. In the meeting with my surgeon, she said that “sometimes the tongs at Banner (where I am having my surgery done) don’t work, so I will just do a bilateral salpingectomy if the tongs don’t work.” At first, I thought this was possibly a *wink*wink* way for her to tell the insurance that because one of the tools wasn’t functional for the surgery, that she HAD to do the bisalp, and because I didn’t consent to that surgery, perhaps the insurance would pay for it.
However, things became more muddled as when I spoke to the surgery scheduler, she said I was getting a tubal occlusion surgery, and I corrected her, that no, I was having a tubal ligation done via fulguration, which has a different code. She said the code didn’t matter and that’s just how they code things there (wtf). She also mentioned again that the tongs often don’t work at Banner, and that I may be billed for the bisalp instead, if the surgeon isn’t happy with the tongs. At this point I’m worried, but I said I would wait for the two estimations.
The scheduler called me yesterday and said that the fulguration was indeed 100% covered, but that the bisalp was only covered 70% after I meet my deductible ($5,000). She didn’t have a number for what the end bill would look like, and all she told me was that the price I would pay upfront for the surgeon to do the bisalp was only $609.
HOWEVER: because UHC doesn’t consider the bisalp preventative, and it is not covered 100% at not cost share to me, that means I would be responsible for the anesthesia fees, the facility fees, and anything else Banner decides to tack on. So I was like, “ok then we really have to do the fulguration method, I can’t swing all the other fees.” The scheduler said she would put it in my notes that I “prefer” the fulguration.
The Scheduler called again today, and the way she said it (I can’t remember exactly because I was upset) was something to the effect of, “I spoke with the surgeon, and she is happy to TRY the tongs but that if they don’t work she will do a bisalp.” but the WAY she said it, or some of the other words she used, made it sound very clear that surgeon was just going to do the bisalp, because its what she preferred.
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Question Time:
How common are “Faulty tools” in surgery causing changes in the type of surgery performed, and thus large billing changes to the patient?
Can I explicitly state I do NOT want the bisalp surgery if the tongs are non-functional? (why don’t they f*cking test them before putting me under if this is such a problem!?)
What are my rights for rejecting alternate surgery if the one I want cannot be performed?
Why wouldn’t they just have a nurse get another tool to replace the faulty tool?
Is it common to bill 58670 (fulguration) as 58671 (occlusion)?
Why would they use the wrong CPT code?
Thank you for your time, and your help. I don’t know what to do, so any thoughts you have on any of these questions is very helpful to me.
