ACL Reconstruction - Post Op Surgeons Fees

[Mark Watkins]

Hi there,

I recently had a ACL reco which has gone well. My concern is that the Surgeon is continually wanting me to go back & have the knee checked by him.(It has been 10 weeks since the Op & I have been back to see him 4 times). Each time I see him he spends about 2 minutes examining it, says it's all going to schedule & then charges me. I was of the belief that post op check up's were free but when I ask, his secretary says the're not. Whilst I appreciate his diligence in ensuring the knee is ok, I can't help but feel I am getting ripped off by booking me in for unnecessary appointments. My Physio (who also happens to know the best Knee Surgeon in Australia) says the re-hab is going fantastic & tends to agree with me. I am thinking of not returning to the Surgeon & just letting my Physio control my Rehab.

I would welcome comments from anyone.

cheers,

Mark.

[injuryupdate]

Definitely there are no Medicare rebates for post-op surgery fees for operations in Australia. Therefore most surgeons don't levy any charges for post-op visits and instead will package the anticipated post-op charges into the surgical fee.

It is definitely illegal for a surgeon to issue a seperate Medicare fee for post-op treatment.

I'm not sure on the legality of the surgeon warning in advance that after care visits will attract an additional non-Medicare related fee.

I would actually imagine that the Health Insurance Commission would look fairly dimly on this practice, if the initial operation fee was billed with a Medicare item number, e.g. 49536, 49539 or 49542 for knee recos. This is because Medicare does NOT identify that this item can be split into operation and after-care components. That is, if you have paid a surgeon's bill for an item number 49536 then you have already paid for normal after-care, i.e. post-op visits to check that the knee is OK.

A fair question is what constitutes normal after-care and this is where the surgeons might argue for a loophole. Obviously taking stitches out at 10 days post-op is normal after-care. Does checking the knee at 4 months constitute normal after-care?

I would suggest that it does, if the visit relates entirely to assessing post-operative progress.

I have heard surgeons bitch about the after-care rules but it really does fall on deaf ears as far as I am concerned. The Medicare system is set up for surgeons to make a hell of a lot of money out of operating. If Medicare fees are broken down into 'hourly' rates then the fees for operating are generally ten times higher than those for consulting. Yet consulting doctors have to absorb all practice costs into their fee (i.e. pay for rent, secretary/receptionist, consumables etc.) yet the surgeons have all costs paid by the patients under separate billing arrangements (private health insurance etc.), other than indemnity insurance.

I wouldn't suggest that you go as far as reporting your surgeon to the Health Insurance Commission for double charging you for post-op visits, but you could throw out an invitation for him to cut his own throat along the following lines:

If you haven't paid the account, send it back and say, "I believe you have already charged me for after-care for this operation in the following account, which I paid on ....., (attach your 49536 or whatever) so I don't believe that this bill is due. If you already have paid, and the surgeon gave you a receipt, send it back asking for a refund along the same lines.

If the surgeon gave you a receipt with a Medicare item number for a standard visit for you to claim at the Medicare office (e.g. item 105) and all he did was a post-op check, and he did not write "Not normal after-care" on the invoice, then this is a SERIOUS breach of Medicare/HIC regulations. The HIC complaints department would be very keen to hear if this was the case.

If there was a bill but an admission that the bill did not attract a Medicare benefit, then whether this was legal or not might depend on whether it was spelt out very clearly before you had the operation. If the surgeon said that the fee would be, say $1500, plus $50 for every post-op visit, then I don't think that the HIC would like it, but I don't really think that any formal complaint could be made. If people started complaining about this then the surgeons could probably just jack their fees up by the maximum number of post-op visits expected (e.g. to $2000) and then offer refunds if you didn't require many visits.

One other circumstance in which I think that your surgeon's billing may be flirting with illegality is if he was part of a 'No gaps' scheme. It would be a blatant way to dodge the no gaps obligations if the surgeon was in such a scheme but then hit you up for non-rebatable payments when you came for post-op visits.

[Mark Watkins]

Thanks for all that info, very helpful indeed & it confirms my suspicions. I really don't want to take the matter any further so I'm not thinking of lodging a complaint, in fact I'd rather not have any further dealings with the surgeon. My question now is at 10 weeks post Op is there any need to see the surgeon again?

[Alla]

Hi Mark,

I'm sorry that you've had this bad experience. Im 8 weeks post op, and I visited my surgeon at the 2.5 week mark, and have to go back at the 12 week mark as well for a checkup. Other then that I've been having visits to the PT regularly (although he's on hoidays at the moment). I'm told that I dont have to pay for the visits within the 3 months post op... and I certainly didnt get charged for the 2.5 week check. My surgeon sent me home with heaps of paper work about what I should be doing and how I should be progressing, and at the last visit said.... you'll be running next time you see me in 10 weeks.

It might be worth having a check at the 12 week mark then letting it go for a while. I guess it depends on how you feel that you are progressing. For me, I need the reassurance that Im doing ok.... I dont know what I'd do in your situation... maybe be guided by your PT as to whether you need a check up?? Hope you work it out....

Alla

[jess]

Thanks for all that info, very helpful indeed & it confirms my suspicions. I really don't want to take the matter any further so I'm not thinking of lodging a complaint, in fact I'd rather not have any further dealings with the surgeon. My question now is at 10 weeks post Op is there any need to see the surgeon again?

Most important thing is that you have a good result. If you end up with a stable knee that you can play sport on you can probably be very happy with the surgeon even if he was expensive, as you have the rest of your life to put up with any knee problems.

However, surgeons do well enough out of the system without needing to rort it further, so if bills were sent that shouldn't have been you have every right to bring this to their attention.

Hope the knee continues to go well.

[injuryupdate]

From the Medicare schedule:

T8.7 Aftercare (Post-operative Treatment) T8.7.1 Section 3(5) of the Health Insurance Act states that services included in the Schedule (other than attendances) include all professional attendances necessary for the purposes of post-operative treatment of the patient (for the purposes of this book, post-operative treatment is generally referred to as "after-care"). However, it should be noted that in some instances the after-care component has been specifically excluded from the item and this is indicated in the description of the item. In such cases benefits would be payable on an attendance basis where post-operative treatment is necessary. In other cases, where there may be doubt as to whether an item actually does include the after-care, this fact has been reinforced by the inclusion of the words "including after-care" in the description of the item. T8.7.2 After-care is deemed to include all post-operative treatment rendered by medical practitioners and need not necessarily be limited to treatment given by the surgeon or to treatment given by any one medical practitioner. T8.7.3 The amount and duration of after-care consequent on an operation may vary between patients for the same operation, as well as between different operations which range from minor procedures performed in the medical practitioner's surgery, to major surgery carried out in hospital. As a guide to interpretation, after-care includes all attendances until recovery from the operation (fracture, dislocation etc.) plus the final check or examination, regardless of whether the attendances are at the hospital, rooms, or the patient's home. T8.7.4 Attendances which form part of after-care, whether at hospitals, rooms, or at the patient's home, should not be shown on the doctor's account. When additional services are itemised, the doctor should show against those services on the account the words "not normal after-care", with a brief explanation of the reason for the additional services. T8.7.5 Some minor operations are merely stages in the treatment of a particular condition. Attendances subsequent to such operations should not be regarded as after-care but rather as a continuation of the treatment of the original condition and attract benefits. Items to which this policy applies are Items 30219, 30223, 32500, 34521, 34524, 38406, 38409, 39015, 41626, 41656, 42614, 42644, 42650 and 47912. Likewise, there are a number of services which may be performed during the aftercare period of procedures for pain relief which would also attract benefits. Such services would include all items in Groups T6 and T7 and Items 39013, 39100, 39115, 39118, 39121, 39127, 39130, 39133, 39136, 39324 and 39327. T8.7.6 Where a patient has been operated on in a recognised hospital as a public patient (as defined in Section 3(1) of the Health Insurance Act), and where aftercare is directly related to the episode of admitted care for which the patient was treated free of charge as a public patient, the aftercare should be provided free of charge as part of the public hospital service. However, post-operative attendances by a private medical practitioner at a place other than the hospital may attract Medicare benefits on an attendance basis, subject to the hospital meeting its responsibilities under the 1998-2003 Australian Health Care Agreements relating to the provision of public hospital services. T8.7.7 hen a surgeon delegates after-care to a local doctor, Medicare benefit may be apportioned on the basis of 75% for the operation and 25% for the after-care. Where the benefit is apportioned between two or more medical practitioners, no more than 100% of the benefit for the procedure will be paid.



My interpretation of this would be that any consults that you needed to book in for at the TIME OF SURGERY would constitute after-care and therefore an item 105 would NOT be valid.

However, if your surgeon saw you at the 3 or 6 month mark and you both decided that you had recovered well from the operation, he or she could then discharge you from care for that operation.

If your knee (or whatever body part had been operated on) flared up at a later date, whether or not it was related to the previous episode, you could return to see the surgeon with a new referral and could be charged an item 104 (initial attendance).

Any surgeon charging an item 105 AFTER surgery (without a new referral) is treading on thin ice, because it suggests that there has been no new problem since the surgery (and perhaps that the consultation is therefore aftercare).

[Unregistered]

My surgeon has given me a 6 week,6 month and 9month post op appointmrnt for free