Linda Brandwin, R.N. Linda Brandwin is a registered nurse and a medical billing and claims specialist. For the past 10 years she has worked directly with insurance companies to give advice and guidance to the health care consumer. Readers may send email or write Linda Brandwin at 5500 Single Oak Hill Ct., Woodbridge, VA 22192.

You may have to pay for your surgeon to have an assistant
Feb 4, 2005

Q: I just had back surgery. I met with the surgeon and he asked me to sign an agreement that if the insurance company did not pay for his PA, physician's assistant, I would. He told us that generally the insurance companies do pay.

I received my EOB from my insurance company which denied the payment of $844 for the PA because there was no contractual agreement for that.

I wonder if this is common practice among surgeons or was it dumb of me to sign this agreement.

A: Do not pay the $844 bill until you have thoroughly investigated this claim. If you are being pressured to pay this bill immediately because you will be turned over to collection, make a small partial payment. There are too many issues you need to look into before this bill is paid.

Generally, a PA, or physician's assistant, is just that…someone assisting a physician. The PA is helping the physician with his work so the physician can do other work. Usually the PA is employed by the physician, receives payment from the physician and his services are not reimbursable from the health insurance companies. The PA is assisting the surgeon during the operation. A surgeon can not charge the insurance company for the surgery and then charge again for the PA's service. The surgeon elected to have the PA assist him during surgery even though the hospital provides a surgical team.

There can be an exception to this. If the surgery involves a procedure which requires highly specialized skills that a hospital can not provide, then an insurance company would pay for the special skills of the surgeon's PA.

Just keep in mind, usually, PA's do not provide reimbursable services. I am sure there can be further exceptions to this; I am just stating what is most commonly seen.

Before I go any further, if your surgeon is not a contracted provider with your health insurance company, he may charge whatever he wants for whatever he wants. You will be obligated to pay all of his charges.

If your surgeon is a contracted provider you need to call your insurance company representative. You must find out if the surgeon can charge you for the PA's services. Your EOB stated that the charge was denied. Did it state whether you were responsible for the charge? It is possible that the surgeon could be in conflict with his provider's contract if he is charging you for a service which the insurance company does not recognize as a legitimate benefit of your plan.

If you find out that the surgeon can not charge you for the PA's services, ask to speak to the insurance company's supervisor so she can give you the proper advice and guidance. Document all calls.

The other issue involved is whether the agreement is legal and binding between you and your surgeon regarding the payment for the PA's services. If this signed agreement remains an issue after you have spoken to your insurance company, you may find it necessary to speak to a lawyer or seek legal aid assistance. You may also need to contact your state's attorney general's office.

When something does not make sense, question it. If you do not understand something, question it. Unfortunately when people are facing the emotional stress of surgery, they are not thinking as clearly and methodically as they normally would. Don't ever hesitate to question your physician or your insurance company. And, remember, you can always get a second opinion. There is not a competent surgeon anywhere that would not encourage or welcome you to get a second opinion to make you feel more comfortable.