Insurance Case
Bill had his left knee replaced in 2021 by another surgeon, and it became infected. Dr. Ramkumar removed the infected hardware and placed an antibiotic-eluting device in December 2023. Bill was in the hospital for six days and then recuperated at home and began physical therapy. He did not receive a bill for the surgery until nine months after the surgery (mid-September of 2024), at which point the hospital claimed that he owed $54,451. He initially disregarded the bill until he received another invoice in October of 2024. At this point, he contacted his insurance company and was on the phone for hours while the insurance company reviewed the invoice with various managers. The agent then informed him not to pay the bill because they would work it out on the back end; she confirmed this again with an email and phone call the next day.
A few days later, he received another call from the insurance company stating the invoice was to cover a percentage of the total bill that was “out of network”. Bill had five recent “in network” surgeries at the same hospital, so he did not believe this was correct. The insurance company promised to resolve the problem, but Bill continued to receive letters, emails, and texts from the hospital stating that he needed to pay the outstanding bill. Worse, Bill was months away from undergoing a second, planned surgery with Dr. Ramkumar to remove the antibiotic device and re-implant a new knee replacement now that he was finally infection free. After several weeks of being harassed for payment and a great deal of personal stress, especially with another upcoming surgery at the same hospital, Bill continued to follow-up with the insurance company. The dispute was finally resolved.
How did this impact patient care and recovery?
Managing complications around failed joint replacements are challenging medically, surgically, and socially. Experiencing a complication like infection after joint replacement is life-altering and carries worse survivorship odds than several common cancers. The gold standard in a young, healthy, and active person with an infected total knee replacement is a two-stage operation, where the first is to eradicate the infection and preserve the limb with an antibiotic eluting device so that it can still be functionally used. This is followed by a second procedure to re-implant the knee once the infection is eradicated.
Dr. Ramkumar performed Bill’s first surgery to eradicate the infection and salvage the limb after the devastating complication while under the care of another surgeon and was prepared to perform the second procedure. Instead of focusing on healing and preparing for the next surgery, Bill W. was forced to spend his personal time and break time at work fixing clerical confusion between the hospital and insurance company.
Insurance billing errors between the two procedures created emotional and psychological distress when Bill’s focus should have been to prepare for his second surgery. Instead, he was busy dealing with false bills from the first surgery. Because of the chaos in billing between hospital and insurance company, Bill was worried he’d have to consider foregoing the second surgery re-implanting his knee and just lead a sedentary life.
While this bill ultimately did not delay the surgery, it was falsely given to a patient halfway through his fight to save his leg, in error. This underscores the importance of a surgeon’s role in advocating holistically for every patient; in this case, (1) to fix another surgeon’s complication, (2) ensure that a limb-threatening operation can be cared for expeditiously, and (3) navigating the extreme financial pressures of urgent surgeries. Despite the copious and clear documentation from Dr. Ramkumar and his office, clerical errors between the hospital and patient’s insurance company happen. It’s frustrating for both the patient and Dr. Ramkumar.
Other Patient Implications
With today’s financial pressures, patients must be proactive in understanding and advocating for their insurance coverage, especially when facing complex and costly surgeries. Dr. Ramkumar understands that navigating billing errors without support can feel overwhelming, particularly for those who feel disempowered or marginalized. This fear can deter patients from pursuing essential follow-up procedures, potentially putting their health—and even limbs—at risk if surgeries are delayed or canceled due to financial concerns. Dr. Ramkumar is committed to supporting patients in getting the care they need in timeframes that support the best patient outcomes.
