I was recently presented, by a patient, with an invoice from another surgeon, for $14,500. This wasn’t a major procedure nor critical service. The symptoms were nasal congestion, itchy eyes, dermatitis, childhood asthma and tiredness. There was only one single sphenoid sinus cavity diseased, and this radiology change was probably unrelated to the patients allergic symptoms. Unfortunately, excessive fees rarely correlate with exceptional skill, care and service. $14,500 seams staggering! isn’t that the price of a small car? (maybe I’m’ getting old)…..but then a 30 second google search revealed that there are 3-4 new compact cars at that price and ten under $16000. The patient was upsold on a possible change to nasal bones but was not the reason he sought advice. The sinus surgery cost does not need to be excessive.
How as this situation come about?
There is no secret that Medicare rebates have not increased with the costs of living and this is especially true in Sydney, Australia. The health funds only pay a certain % on-top of the scheduled (or medicare) rate. Thus the Medicare Rates have become the basis for payments and, with Medicare rebates changing very little, the private health insurers have been happy to maintain the status quo.
Unfortunately, in nose and sinus surgery, the current codes are 30 years old in their description of services. What is performed in modern day sinus surgery can be basic but also can be very complex. Surgeons have used combinations of codes (often as many as 15) to describe the 2-3hour+ procedure that constitutes a complex or radical sinus procedure.
This situation has opened the door to abuse. Some surgeons code for multiple sinus interventions, which are either unnecessary or not even performed. Altruistically, this might have been done initially to ensure that the rebate to the patient and thus the final out-of-pocket costs were minimized for a relatively complex surgery involving time, skill and expertise.
However, for some providers, its has now become standard to both over-apply coding and give a large patient gap (out-of-pocket cost), and rarely for complex surgery. This not only undervalues those performing complex surgery, but is a financial burden to both patient and health system. Importantly, it represents, unnecessary surgery and poor professional decision making, at best, and medicare fraud when the surgery isn’t even performed, at worst.
How does a patient avoid paying excessive fees and worse still, unnecessary surgery?
Competent, skilled and benevolent surgeons rarely apply giant gap payments for essential services and care. Cosmetic and very elective procedures may be a different situation as the additional care, minor revisions and interventions that are often applied are factored into the initial fee.
Health funds do provide information, for members, of surgeons that are willing to provide a No Gap (meaning no additional expense) or Known Gap (meaning a fixed out-of-pocket cost) to patients. Some funds have strict policies that a surgeon can either be one or the other but not both, so please check. If surgeons have to apply a gap or out-of-pocket expense for a common sino-nasal procedure its usually in the $1,000-$2,500 range especially for procedures with a very low rebate.
If you believe that you’ve been given an excessive out-of pocket expense or are simply querying the appropriateness of whether sinus surgery is even necessary (extent or even if at all), then please contact us as we are happy to offer second opinions and reviews of clinical care. Its important to note that most surgeons are kind, caring and do their very best by their patients. In the fantastic profession that we work in, there are only a few clinicians that through, ignorance or greed, do the wrong thing.
Patient self-assessment of radiology to provide some framework as to what surgery maybe appropriate