Sky Facial Plastic Surgery Inc

We are deeply troubled that the patient feels mislead. Our office and our biller's office have attempted to
reach her at least three times to try resolve the matter with her directly, but our communication was ignored.
We pride ourselves on being transparent with our patients. The...

Financial Policy that is in our new patient
paperwork (which the patient signed) and the "Working with Your Insurance" part of the pre-op packet
(which the patient received prior to the surgery) are all designed with that in mind.
The patient had two procedures done by our surgeon. The two procedures are completely separate in terms of
billing and that is where the source of the confusion lies.
(1) FUNCTIONAL procedure- improves difficulty breathing, which the patient reported.as being severe,
and insurance usually pays a portion. This is why on the initial visit we gave her hope that her insurance
would pay a portion of the surgery, and they did. As explained in the Financial Policy and pre-op packet, our
office, the surgery center, and the anesthesiologists separately bill the patient's insurance carrier after the
surgery. After the insurance company pays their portion, the patient then receives the final bills with the
amount that the patient is responsible for paying. These are the bills the patient is currently concerned about.
(2) COSMETIC procedure - addresses the appearance of the nose and insurance does NOT help pay for this.
When patients need surgery to improve breathing, they often elect, like this patient did, to get the Cosmetic
procedure done at the same time as the Functional procedure because this makes the Cosmetic procedure
much more affordable (about half the usual price). It costs us less to perform an "add-on'' Cosmetic
procedure and we pass that savings on to the patient. Cosmetic procedures are paid in full prior to surgery.The patient has paid in full and is not receiving any bills for this procedure.
Our records show that we saw the patient on 6/14113 for a consultation, 11/27/13 to go over the pre-op
packet, 12/12/13 for surgery.and 12/18/13,1/20/14 and 4/21/14 for post-op follow up visits.
The patient was originally referred to us by a colleague who was performing a functional septoplasty and
turbinate reduction on this patient. He wanted us to perform an adjunct functional rhinoplasty to improve the
patient's breathing. The colleague does not perform this surgery. During the initial consultation on 6/14/13,
the records state that the patient requested cosmetic changes to her nose and was interested in what could be
done to make her nose "more appealing." Based on the patient's consultations with both physician offices,
the Surgery Plan was for the referring physician and our surgeon to jointly perform the Functional
procedures required to address the patient's medical problems and for our surgeon to perform an "add-on''
Cosmetic procedure to address the patient's requested cosmetic changes.
On 9/11/13, the Medical Assistant documented in the patient's chart that the patient gave verbal authorization
to proceed with the Surgery Plan. but was confused about which part of our surgeon's billing would be
covered by insurance. The chart notes clearly state that we told the patient that "the functional part would be
covered by insurance, but the cosmetic portion would not. The conversation concluded with the patient
saying that she understood.
On 9/16/13, we called her insurance company for the Functional procedure to be perfonned by our surgeon,
and they told us that the patient would be responsible for 15% of the fees. The chart notes indicate that on
9/17/13 our Medical Assistant called and explained the patient's insurance benefits to her. During that
conversation, the patient expressed confusion and the Medical Assistant again clearly stated that there were
two parts being performed by our surgeon: a "cosmetic portion and functional portion." Once again, the
patient verbalized understanding.
On 11/27/13, at the pre-op appointment we reviewed again the estimate for the add-on cosmetic procedure in
addition to bow we would work with her insurance for the functional procedure. This information was also
included in her pre-op packet, which she took home.
On 12/11/13, the day before surgery, the patient called expressing further concern over the financials. The
chart notes indicate that the patient "was under the impression that [our surgeon] was strictly cosmetic" and
we again explained that our surgeon would be doing a functional portion to improve her breathing in addition
to the "strictly cosmetic" portion of "making her nose look pretty." We also explained that we could certainly
do just the Cosmetic procedure, but that without the functional component, the price for the Cosmetic
procedure would double. After two additional lengthy conversations that day, the patient again gave verbal
authorization to proceed with the Surgery Plan already in place.
The insurance and billing process can be confusing, and we always take ample time to explain to patients
what costs they may be responsible for and can expect. The procedures performed for this patient are
common for our office and usually require three routine discussions about the financials. In this case, we
went beyond what is customary to try to make sure that the patient had a clear understanding of the
financials. The chart documentation shows that we explained the financial responsibilities a total of 14 times.
As indicated above, most of the conversations revolved around explaining the difference between the
Functional and Cosmetic billing. The verbal discussions were further supported by the written material that
the patient received and signed, including the Financial Policy, the Estimate for the Cosmetic procedure, and
the pre-op packet that explained how we would work with her insurance company for the Functional
procedure. The patient verbalized understanding of the fmancial process and elected to proceed with the
Surgery Plan.
On 5/23/14, the patient emailed our office about her current concerns. After reviewing her chart, I responded
the same day with a very clear explanation that the bills she is now receiving are for the Functional
procedure and have nothing to do with the $4,100 payment the patient made prior to surgery. I explained that
the $4,100 payment she made prior to surgery was for the add-on Cosmetic procedure, which insurance does
not cover. Since the patient seemed especially concerned about the bill from the surgery center, I took
particular care to explain that the bill she is receiving from the surgery center is for the Functional procedure.
Our office already paid the surgery center for the Cosmetic procedure, and the surgery center confirmed this
fact directly with the patient. I closed the email by saying that I would have our biller call the patient directly
to resolve her concerns. The patient did not respond to my email or to the phone message left by our biller.
On 6/2/14, the patient's insurance company called our office to try to understand the patient's concerns. I
explained what had transpired. The insurance company confirmed that our billing was above board. The
representative said that she was going to call the patient back and explain everything. I told the
representative that we had reached out to the patient to resolve the matter directly, but that she hadn't
responded. I emphatically urged the representative to tell the patient that we are happy to work with her, but
she needs to call our biller to notify him of her concerns. I gave the representative the biller's contact
information to give to the patient. The patient did not follow up with our biller.
The bottom line is that the patient's breathing has significantly improved due to the Functional procedures
that were performed by both our surgeon and the referring physician. As is customary, the two surgeons
billed the insurance company individually for the Functional procedures (they each performed different
operations on the nose; there was no duplicate billing) and now the patient is being billed for the amount that
she is responsible for, per her contract with her insurance carrier. The patient also elected to have an add-on
Cosmetic procedure done in conjunction with the Functional procedure. As is customary, the patient paid up
front and in full and is not receiving any bills for the Cosmetic procedure. Again, if the patient had elected
for our surgeon to perform only the Cosmetic procedure without the functional component. as she states in
her letter. then the Cosmetic fee would have doubled. She is paying considerably less since she elected to
have the Cosmetic procedure as an "add-on," done in conjunction with the Functional portion.
Our excellent reputation in the community is extremely imporrant to us, and we take all complaints seriously.
Again, we regret that this patient was not satisfied, but the records clearly support our diligence in trying to 
resolve this matter. I hope that the patient elects to call our biller.
Sincerely,
[redacted] N. [redacted], MBA
Vice President

Review: When I first went to a consultation to Dr. [redacted]'s office for a "nose job" I was informed that my insurance could potentially cover the surgery I was having.Then when their office called me to schedule I asked again if my insurance would cover, after asking a few times I was told my insurance would not cover at all because my surgery was considered "cosmetic". It turns out they did submit a claim to the insurance. I feel very mislead by that. According to the estimate I received from Dr. [redacted]'s office titled "Cosmetic with Functional Rhinoplasty Estimate" on 6/14/13 it states that the estimate is valid for 6 months from the date, I had surgery on 12/12/14 which is within the 6 months yet they had me sign another estimate on the pre-op visit (11/27/13) which even though the total amount dropped, the surgeon fee increased by $900. I signed the new estimate without them informing me of the changes. Skyfacial is sending me an additional 2 bills; one for $220.21 and the other for $60 to cover for the "breathing portion" first of all Dr. [redacted] was aware that at the same time I would be having a procedure with the ENT surgeon for the sinus problem "breathing portion" I did not ask Dr. [redacted] to do anything else other than to get rid of a bump I had.Also according to the amount ($4,100) I paid Dr. [redacted]'s office before having surgery, the estimate also states that $900 of that was for the operating room.The surgery center is charging me a total of $686.88 for the operating room which I have to pay out of pocket.I called the surgery center to find out if Dr. [redacted]'s office paid and they said yes however they could not disclose the amount. First of all there is a difference of $213.12 from what the surgery center is billing than what Dr. [redacted]'s office charged me.Blue Cross/Blue Shield had informed me that I should get 3 bills when it comes to surgery: 1 from surgeon, 1 for facility charge and 1 from the anesthesiologist.Why would Dr. [redacted] include the operating room if the surgery center would be billing me?Desired Settlement: I feel defrauded and mislead by all these mishaps. All I want like I mentioned on the email I sent to Dr. [redacted]'s office on 5/22/14 is for them to refund me the $900 of what they charged me for the operating room so I can pay the surgery center. Also, I would want Skyfacial to void the additional charges of $220.21 and $60 since first of all they were aware I was having surgery w/the ENT specialist to fix the breathing problem and besides their estimate states "Cosmetic w/Functional Rhinoplasty".

Business

Response:

We are deeply troubled that the patient feels mislead. Our office and our biller's office have attempted to

reach her at least three times to try resolve the matter with her directly, but our communication was ignored.

We pride ourselves on being transparent with our patients. The Financial Policy that is in our new patient

paperwork (which the patient signed) and the "Working with Your Insurance" part of the pre-op packet

(which the patient received prior to the surgery) are all designed with that in mind.

The patient had two procedures done by our surgeon. The two procedures are completely separate in terms of

billing and that is where the source of the confusion lies.

(1) FUNCTIONAL procedure- improves difficulty breathing, which the patient reported.as being severe,

and insurance usually pays a portion. This is why on the initial visit we gave her hope that her insurance

would pay a portion of the surgery, and they did. As explained in the Financial Policy and pre-op packet, our

office, the surgery center, and the anesthesiologists separately bill the patient's insurance carrier after the

surgery. After the insurance company pays their portion, the patient then receives the final bills with the

amount that the patient is responsible for paying. These are the bills the patient is currently concerned about.

(2) COSMETIC procedure - addresses the appearance of the nose and insurance does NOT help pay for this.

When patients need surgery to improve breathing, they often elect, like this patient did, to get the Cosmetic

procedure done at the same time as the Functional procedure because this makes the Cosmetic procedure

much more affordable (about half the usual price). It costs us less to perform an "add-on'' Cosmetic

procedure and we pass that savings on to the patient. Cosmetic procedures are paid in full prior to surgery.

The patient has paid in full and is not receiving any bills for this procedure.

Our records show that we saw the patient on 6/14113 for a consultation, 11/27/13 to go over the pre-op

packet, 12/12/13 for surgery.and 12/18/13,1/20/14 and 4/21/14 for post-op follow up visits.

The patient was originally referred to us by a colleague who was performing a functional septoplasty and

turbinate reduction on this patient. He wanted us to perform an adjunct functional rhinoplasty to improve the

patient's breathing. The colleague does not perform this surgery. During the initial consultation on 6/14/13,

the records state that the patient requested cosmetic changes to her nose and was interested in what could be

done to make her nose "more appealing." Based on the patient's consultations with both physician offices,

the Surgery Plan was for the referring physician and our surgeon to jointly perform the Functional

procedures required to address the patient's medical problems and for our surgeon to perform an "add-on''

Cosmetic procedure to address the patient's requested cosmetic changes.

On 9/11/13, the Medical Assistant documented in the patient's chart that the patient gave verbal authorization

to proceed with the Surgery Plan. but was confused about which part of our surgeon's billing would be

covered by insurance. The chart notes clearly state that we told the patient that "the functional part would be

covered by insurance, but the cosmetic portion would not. The conversation concluded with the patient

saying that she understood.

On 9/16/13, we called her insurance company for the Functional procedure to be perfonned by our surgeon,

and they told us that the patient would be responsible for 15% of the fees. The chart notes indicate that on

9/17/13 our Medical Assistant called and explained the patient's insurance benefits to her. During that

conversation, the patient expressed confusion and the Medical Assistant again clearly stated that there were

two parts being performed by our surgeon: a "cosmetic portion and functional portion." Once again, the

patient verbalized understanding.

On 11/27/13, at the pre-op appointment we reviewed again the estimate for the add-on cosmetic procedure in

addition to bow we would work with her insurance for the functional procedure. This information was also

included in her pre-op packet, which she took home.

On 12/11/13, the day before surgery, the patient called expressing further concern over the financials. The

chart notes indicate that the patient "was under the impression that [our surgeon] was strictly cosmetic" and

we again explained that our surgeon would be doing a functional portion to improve her breathing in addition

to the "strictly cosmetic" portion of "making her nose look pretty." We also explained that we could certainly

do just the Cosmetic procedure, but that without the functional component, the price for the Cosmetic

procedure would double. After two additional lengthy conversations that day, the patient again gave verbal

authorization to proceed with the Surgery Plan already in place.

The insurance and billing process can be confusing, and we always take ample time to explain to patients

what costs they may be responsible for and can expect. The procedures performed for this patient are

common for our office and usually require three routine discussions about the financials. In this case, we

went beyond what is customary to try to make sure that the patient had a clear understanding of the

financials. The chart documentation shows that we explained the financial responsibilities a total of 14 times.

As indicated above, most of the conversations revolved around explaining the difference between the

Functional and Cosmetic billing. The verbal discussions were further supported by the written material that

the patient received and signed, including the Financial Policy, the Estimate for the Cosmetic procedure, and

the pre-op packet that explained how we would work with her insurance company for the Functional

procedure. The patient verbalized understanding of the fmancial process and elected to proceed with the

Surgery Plan.

On 5/23/14, the patient emailed our office about her current concerns. After reviewing her chart, I responded

the same day with a very clear explanation that the bills she is now receiving are for the Functional

procedure and have nothing to do with the $4,100 payment the patient made prior to surgery. I explained that

the $4,100 payment she made prior to surgery was for the add-on Cosmetic procedure, which insurance does

not cover. Since the patient seemed especially concerned about the bill from the surgery center, I took

particular care to explain that the bill she is receiving from the surgery center is for the Functional procedure.

Our office already paid the surgery center for the Cosmetic procedure, and the surgery center confirmed this

fact directly with the patient. I closed the email by saying that I would have our biller call the patient directly

to resolve her concerns. The patient did not respond to my email or to the phone message left by our biller.

On 6/2/14, the patient's insurance company called our office to try to understand the patient's concerns. I

explained what had transpired. The insurance company confirmed that our billing was above board. The

representative said that she was going to call the patient back and explain everything. I told the

representative that we had reached out to the patient to resolve the matter directly, but that she hadn't

responded. I emphatically urged the representative to tell the patient that we are happy to work with her, but

she needs to call our biller to notify him of her concerns. I gave the representative the biller's contact

information to give to the patient. The patient did not follow up with our biller.

The bottom line is that the patient's breathing has significantly improved due to the Functional procedures

that were performed by both our surgeon and the referring physician. As is customary, the two surgeons

billed the insurance company individually for the Functional procedures (they each performed different

operations on the nose; there was no duplicate billing) and now the patient is being billed for the amount that

she is responsible for, per her contract with her insurance carrier. The patient also elected to have an add-on

Cosmetic procedure done in conjunction with the Functional procedure. As is customary, the patient paid up

front and in full and is not receiving any bills for the Cosmetic procedure. Again, if the patient had elected

for our surgeon to perform only the Cosmetic procedure without the functional component. as she states in

her letter. then the Cosmetic fee would have doubled. She is paying considerably less since she elected to

have the Cosmetic procedure as an "add-on," done in conjunction with the Functional portion.

Our excellent reputation in the community is extremely imporrant to us, and we take all complaints seriously.

Again, we regret that this patient was not satisfied, but the records clearly support our diligence in trying to

resolve this matter. I hope that the patient elects to call our biller.

Sincerely,

[redacted] N. [redacted], MBA

Vice President