Fear of professional fees are unfortunately one of the primary reasons why many Americans, in our opinion, are denied access to health care they require. Many people cannot afford costly fees and many attorneys and other types of advocates charge fees which are greater than the costs of the treatment being denied. Obviously, in that case, it would make no sense to hire such a person or firm.

Our office has worked very hard to make high quality services affordable to anyone who needs them. We have kept our overhead extremely low and have streamlined our file handling to maximize results for our clients. We'll discuss our various fee options with you on an individual basis, but our current structure starts under $500, depending on what you require.

While it is important that this office charge and collect a fair fee for the work that we do, we have never allowed someone’s ability to pay fees to be the final deciding factor as to whether or not we can help them. We don’t want anyone to not contact us simply based on an erroneous assumption that hiring us is too expensive. We will work hard, if necessary, to create a payment plan which meets your personal situation.     

     “We do accept many different cases involving reconstructive surgery after a bariatric operation. However, we closely examine these cases prior to accepting them so we can be sure that the surgery being requested truly is “reconstructive” and not cosmetic, the primary reason payers deny those cases. If you believe that you are being wrongfully denied reconstruction, please use the “Green Form.”

     The answer to this question is generally "Yes," but circumstances will differ from case to case. First of all, you must understand that you are retaining our services as a designated authorized "representative" to assist you with your appeal; we are not acting as an "attorney" on your behalf. In those instances, it is generally not necessary for us to be admitted to the bar for your state.

If we take on the matter as attorneys (rather than as lay advocates), we do have to be admitted to practice in the jurisdiction for that case. In those instances, we associate local counsel to assist with following the local rules and to sponsor our admission to that state’s bar for purposes of that particular case. That is called being admitted pro hac vice (for purposes of that case).

There are a few things to keep in mind. If you want us to help you with your appeal, you're not going to be obligated to file any type of lawsuit or arbitration or other type of litigated solution to the dispute. You're also never obligated to keep us as your attorneys if you wish to file such an action; in fact, we too retain the right to not move forward with a litigated case and, in some instances, we may be unable to take on that representation because we may be witnesses to the payer's conduct.     RETURN TO TOP

     For the person who is frustrated by the denial of surgery, this process will always seem too long. However, you do need to have some patience, as insurers do have certain timeframes within which they have to review and decide cases. Unfortunately, there isn't a general rule of thumb - like many things in this area, it differs based on the type of insurance and what laws may govern the Plans. Many times they have upwards of 30, 60 - even 120 days to make a decision after they have received the appeal. Because most plans have multiple levels of appeal, each with separate time periods provided to the insurance company, the process can be lengthy.

      There is nothing generally preventing you from doing that, although you need to be aware of a few things. Most insurance plans require pre-certification of an elective procedure, and bariatric surgery is always elective in nature. If you don't follow through with that preauthorization process, you've technically breached your contract and may face consequences that could include being unable to get your money back.

Perhaps the most compelling reason to avoid self-pay until there is no other choice is the issue of complications during surgery. While the cash pricing of the surgery may be attractive, you need to be quite sure who is responsible in the event of complications from that procedure which prolong your hospitalization. It is not uncommon for an anticipated 3-4 day hospital stay to become several weeks due to a foreseeable complication you've consented to before surgery. If the surgeon or hospital has not limited the cost of the surgery in such cases, your "cash price" might go from $20,000 to several hundred thousand dollars! Are YOU prepared to pay that kind of bill? If you aren't, you'd better clarify that can't happen before writing the check to that program.

You might respond, "my surgeon/hospital told me that even if there is a complication, at least my insurance will cover that, even if it doesn't cover the whole surgery..." That isn't always true...in fact, it is rarely true! Many policies include language similar to the following exclusion: "WE DO NOT COVER SERVICES OR CHARGES RELATED TO OR ARISING FROM UNCOVERED PROCEDURES". Even if the policy doesn't include that language, ask yourself what incentive the insurer has to volunteer to cover $100,000+ in medical bills if they have a chance of avoiding it? The best way to avoid these issues (and keep your money in your pocket) is to appeal until you've exhausted your appeal rights and then consider the cash payment option. We promise you that the surgeon or hospital will accept your payment later, even if it forces you to be more patient than you really want to be now that you've made the very hard decision to have bariatric surgery.      RETURN TO TOP

     It sure does...sometimes! Many patients don't have out-of-network benefits and so they are forced to seek out an in-network surgeon. That isn't a problem if the surgeon is well-qualified and experienced in performing bariatric surgery and has a full program and team he or she works with. It may be a problem that we can help you with if the insurer is trying to send you to an inexperienced general surgeon who is technically qualified to perform a bariatric procedure, but doesn't do it regularly...in those cases, we can often force them to pay an out of network provider as though in-network because of the lack of a qualified in-network alternative.

The other major difference it makes is the amount you'll pay out of pocket. Remember that part of what you get with managed care - type benefits are limits in choices. If you have out of network benefits, your insurer will likely pay a smaller percentage of the "usual & customary charges" for the procedure. You MUST remember that what the insurer considers "usual and customary" is always FAR LESS than what your surgeon's actual fees charged to you are going to be. An example: your out of network surgeon charges $8000 for her procedure. Your out of network benefits allow you 60% of the "usual and customary amount." You might go into surgery believing that you're going to pay $2400 because that is 40% of the surgeon's fee. You would likely be wrong. Your insurer believes "usual and customary" for this surgery is $2500 and will pay 60% of THAT AMOUNT. That would be $1500. Your surgeon is likely going to send you a bill for the entire balance of $6500, because she is entitled to "balance bill" you for her services (unlike most in-network providers who agree to accept the contracted amount regardless of their actual fee).

So be sure to understand your financial exposure to the surgeon, the hospital and all the other kind folks involved in your treatment. ... just because you've secured insurance coverage for your bariatric surgery, that doesn't mean you still won't be paying some out of pocket expenses!      RETURN TO TOP

     We no longer accept appeals for people seeking a couple of different types of surgeries. We don't handle requests for Vertical Banded Gastroplasty based on our personal and professional assessment that the LapBand^® is a far superior technology and procedure and that any patient seeking a VBG should, by all rights, be seeking out that better procedure.

     We also do not handle requests for the "Mini Gastric Bypass" (MGB), but for other reasons. After consulting with many other surgeons and many of the patients having problems due to bile reflux with this procedure, we remain unconvinced that we are serving a person's best interests by advocating for this procedure. Many patients we've discussed this procedure with have had it reversed or revised to a different weight loss operation because of those problems. Therefore, we are taking a very conservative "wait and see" approach to determine whether this procedure stands the test of time. We have turned away a great deal of business in this area so we assure you that it isn't to our economic advantage to take this position...but it remains the right decision for this office.