Insurance Woes

[bicker]

Does a person need to ask each physician that comes to see them in the hospital if they are on their insurance plan

Yes. It might seem illogical and impractical, but only from our perspective. If we were to put ourselves in the shoes of medical service providers, it would appear to be the best way of running their business. As long as this country insists on medical service being run as a business, it will be run as a business. I personally see benefits to both approaches, as a business and as an entitlement. There are so many pros and so many cons to both approaches, that I really don't care which is the winner, or even if we decide to change back and forth every few decades. However, I do believe it is unreasonable to expect to pay into the system as if it is a business (paying for very specific coverage), but then expect the system to cover you as if it were an entitlement (being covered in a more blanket manner).

Would a person actually be better off with high-deductable health insurance that caps the out-of-pocket max at 5K or 10K a year in that case?

Well your question pre-supposes that there aren't even more direct alternatives. For our insurance, there is no "in-network" or "out-of-network". All there is is reasonable-and-customary. My employer pays the difference between that and what whichever doctor we choose (or are assigned, as in the OP's case) charges. The problem is that not everyone has every different kind of insurance available to them, and even beyond that, many people wouldn't prioritize health insurance highly enough to pay for that kind of coverage, until, of course, they need that level of coverage.

 

[tar heel]

100% of the anesthesiologists -- they're all in the same group -- at our local hospital are not in my insurance plan, DH and my kids' insurance plan or most other insurance plans. I would never have any kind of elective surgery at that facility.

We learned this the hard way when DH went to the hospital pain clinic for a shot. He was referred by his doctor, the hospital and that clinic are in our plan -- imagine our surprise when we find out the visit cost us $1,200?

BTW, his doctor subsequently scheduled him for an MRI and he called and asked about insurance coverage across the board. They told him they couldn't guarantee it b/c contracts were rengotiated all the time. He went to hospital 20 miles away instead.

 

[chrissyk]

Yes. It might seem illogical and impractical, but only from our perspective. If we were to put ourselves in the shoes of medical service providers, it would appear to be the best way of running their business. As long as this country insists on medical service being run as a business, it will be run as a business. I personally see benefits to both approaches, as a business and as an entitlement. There are so many pros and so many cons to both approaches, that I really don't care which is the winner, or even if we decide to change back and forth every few decades. However, I do believe it is unreasonable to expect to pay into the system as if it is a business (paying for very specific coverage), but then expect the system to cover you as if it were an entitlement (being covered in a more blanket manner).

I see what you're saying, but if you're paying for health insurance that states that this particular hospital is in-network, you would not assume that you had to ask each Dr. at that hospital whether or not they were in-network. I don't think that that's an entitlement mentality...I think that that's common sense. Most people would not think that way, because they're insurance is telling them "go to this specific hospital and it will be covered as in-network treatment". If the insurance companies would go so far as to educate people about the possibility that they could inadvertently see an out-of-network Dr. even at an in-network hospital, that would be a different story. Until I read this thread, I'd never heard of such a thing.

Well your question pre-supposes that there aren't even more direct alternatives. For our insurance, there is no "in-network" or "out-of-network". All there is is reasonable-and-customary. My employer pays the difference between that and what whichever doctor we choose (or are assigned, as in the OP's case) charges. The problem is that not everyone has every different kind of insurance available to them, and even beyond that, many people wouldn't prioritize health insurance highly enough to pay for that kind of coverage, until, of course, they need that level of coverage.

This type of insurance is actually what I am talking about. The high-deductable insurance allows the "reasonable and customary" rate and either the consumer or their employer pays the difference up to the maximum out-of-pocket on their insurance for the year. This type of health insurance is actually CHEAPER than the common employer-sponsored HMO/PPO insurance in many cases. I think that this is the way that healthcare is going...I hope so, anyways. I'd hate to try to straighten out a hospital bill that is peppered with out-of-network charges when the hospital itself was in-network!

 

[tar heel]

I agree totally with chrissyk -- this isn't "entitlement mentality," it's "common sense." The problem in our case is that the hospital is not REQUIRING as part of their contract that the only anesthesiologists on staff participate in insurance plans. The other problem is that the insurance company is not REQUIRING the hospital as part of their contract to provide contract anesthesiologists.

You can't have surgery without anesthesia. There's no logic in a set-up in which the hospital and surgeon are in an insurance plan and the anesthesiologist isn't.

 

[chrissyk]

I agree totally with chrissyk -- this isn't "entitlement mentality," it's "common sense." The problem in our case is that the hospital is not REQUIRING as part of their contract that the only anesthesiologists on staff participate in insurance plans. The other problem is that the insurance company is not REQUIRING the hospital as part of their contract to provide contract anesthesiologists.

You can't have surgery without anesthesia. There's no logic in a set-up in which the hospital and surgeon are in an insurance plan and the anesthesiologist isn't.

Exactly. Do these anesthesiologists accept NO insurance at all? That would cause every patient who has surgery at that hospital to incur a big bill! I think that if enough people went elsewhere, the hospital would either look for new anesthesiologists who accepted insurance or otherwise compel the current anesthesiologists to do so. It is 100% illogical to get a referral from your Dr., go to an in-network hospital for surgery, and subsequently find out that the anesthesiologist wasn't covered after all. You really can't have surgery w/o anesthesia!

For kicks, I just looked at the website of the local in-network hospital in our health plan. This disclaimer was at the very bottom of the page:

<Providers are independent contractors in private practice and are neither employees, agents, nor apparent agents of ******** Plans. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change without notice. Providers are solely responsible for the services provided under this program.>

Nice, huh? I guess that it's the patient's responsibility to make sure that every Dr. that they see in the hospital takes their health plan. That might be difficult if you're unconcious, so you'd better think ahead of any emergency and call the major groups that have privledges at your "in-network" hospital regularly Give me a break! The healthcare system in this country is so fractured it's not even funny. It would be a full-time job to correctly fight to settle a hospital bill that is billed both in and out of network. Now I see how people with health insurance end up in bankrupcy.

 

[bicker]

this isn't "entitlement mentality," it's "common sense."

As repeated discussions, on these boards, with colleagues at work, with acquaintances in various venues, it is clear that there is no such thing as "common" sense. Everyone has their own "sense" and any commonality is strictly coincidental.

The problem in our case is that the hospital is not REQUIRING as part of their contract that the only anesthesiologists on staff participate in insurance plans. The other problem is that the insurance company is not REQUIRING the hospital as part of their contract to provide contract anesthesiologists.

And good thing too, because then the hospital may have trouble ensuring that they have enough professionals on staff, or if not, may be deterring the best professionals from considering associating with the hospital.

And to what end? These "problems" aren't problems until the patients show they're important enough, by choosing hospitals based on how patient-friendly their financial arrangements are, regardless of the situation, or by voting legislators into office who will pass anti-business regulations on hospitals addressing such situations. "Grossly patient-unfriendly" don't necessarily constitute "problem," the way things are today.

 

[chrissyk]

I don't even think that this is a matter of being patient-unfriendly in most cases. It's a matter of changing the rules in the middle of the game. If your insurance tells you that you will be covered if you get a referral from your PCP and you go to this particular in-network hospital for your surgery, then you expect to be covered. You don't expect to find out that you are only covered for only SOME of the services that were incurred as part of that surgery. The insurance company should not list a hospital as in-network if they can't guarantee that the providers at that hospital are in-network. Perhaps if hospitals started losing their insurance contracts, they'd make different, more "patient friendly" choices.

 

[bicker]

If your insurance tells you that you will be covered if you get a referral from your PCP and you go to this particular in-network hospital for your surgery, then you expect to be covered.

If you have proof that they said precisely that, then you should be golden. I would bet, though, that the insurance company didn't say precisely that.

Perhaps if hospitals started losing their insurance contracts, they'd make different, more "patient friendly" choices.

More likely, we would have fewer choices, or at least fewer good choices.

 

[OhMari]

I love dealing with Insurance companies-especially when the Dr's clinic is sending you notices to notify your insurance company. (Haven't heard from your insurance company in over 90-120 days.)

 

[chrissyk]

So it's a matter of semantics, then? The insurance company words their contracts so the average person would believe that they are getting covered treatment at an in-network facility when that might not be the case. That is reprehensible at best.

As for "choices," the problem is more along the lines of the fact that people don't realize that they are making a choice when they go to the in-network facility that their insurance company dictates to them. They believe that they are following the insurance company's rules in terms of getting a referral and going to the correct in-network facility, and they STILL get billed for uncovered services. Unless someone read a thread like this, they would simply have no reason to question the insurance-acceptance policies of each physician that they saw at the in-network hospital.

 

[WebmasterAlex]

I have to wonder how many of these cases have actually been fought out in court. I would love to hear from a lawyer on this. If you are charged by a doctor who did not inform you that he would not accept the insurance why do you have a legal obligation to pay him?

What would happen if you wrote on the form you sign agreeing to pay
"I wish to be informed of any out of network charges prior to services being rendered"

 

[bicker]

So it's a matter of semantics, then? The insurance company words their contracts so the average person would believe that they are getting covered treatment at an in-network facility when that might not be the case. That is reprehensible at best.

When represented in that manner, yes, of course it would sound reprehensible. However, generally, it's not a matter of semantics, and there is no intent to deceive. Rather, generally, it is a matter of the supplier delivering what was promised, rather than what was expected. It's the way every complicated commercial transaction works in our economy.

Go to disneyshopping.com. On the front page is a statement showing PJ Pals for "AS LOW AS $7.99". Some consumer might expect that the pictured product is $7.99. It's not. It's $12.99.

Go to amazon.com. On the front page is an ad with bold, red lettering saying "FREE Super Saver Shipping." In small, light-grey lettering is the notation "Restrictions Apply."

Go to tivo.com. On the front page is an offer for a TiVo for less than $50, again in bold, red lettering -- this time in large type. In small, grey lettering below is the "Click offer for details" notation.

I would love to hear from a lawyer on this. If you are charged by a doctor who did not inform you that he would not accept the insurance why do you have a legal obligation to pay him?

That's why they make you sign a statement saying you'll pay the entire charge, regardless of insurance arrangements. The patient is always 100% responsible to the hospital and doctors. The insurance is an agreement between the patient and the insurance company; it isn't a three-way agreement.

What would happen if you wrote on the form you sign agreeing to pay "I wish to be informed of any out of network charges prior to services being rendered"

There is a legal principle that precludes individuals from making substantive changes to boilerplate contracts. I'd have to dig up the citations, and that might take a while. Does anyone have them handy? It is a strictly anti-consumer/pro-business legal principle, but it is the law of the land. Basically, it requires any changes to an offered contract to be explicitly agreed to by both sides (both sides must initial the change, for example), in order to have the force of law. Folks making such changes should understand that until they obtain such explicit agreement, they shouldn't express their own agreement to the contract-as-a-whole, or risk the contract being enforced as originally offered, rather than as they sought to amend it. (Beyond that, many of these contracts actually state that no changes to the printed contract are permitted.)

 

[chrissyk]

I have to wonder how many of these cases have actually been fought out in court. I would love to hear from a lawyer on this. If you are charged by a doctor who did not inform you that he would not accept the insurance why do you have a legal obligation to pay him?

What would happen if you wrote on the form you sign agreeing to pay
"I wish to be informed of any out of network charges prior to services being rendered"

Excellent questions! I especially like the last part. It would be a real shame if people had to start doing this, but it sounds like it might be necessary in light of situations like the ones on this thread. In the event of a serious accident or illness requiring hospitalization, someone is going to have to be a full-time advocate for the loved one who is hospitalized if situations like this become increasingly common. Our healthcare situation in this country is a real mess IMHO.

 

[Mackey Mouse]

Alex....very good point...I wonder what would happen if you did write that when you were signing. I bet it would throw many people in a complete hissy fit, all of them running into each other, trying to figure out what to do next.

I have a ppo and pretty much can go wherever I want providing they are in network. In network, they are covered 100%, out of network, which is what I find down here on Cape Cod, I think they might pay it at 80% and I pay the rest.

I love the ads for insurance companies...they care so....I was constantly on the phone with our healthcare, checking and rechecking, when my husband was ill. I am not only talking medical insurance, I am talking benefits with the companies that you devote your life to, it is not easy, but that is another story. You have to be vigiliant and constantly check.

 

[vivilasvegas]

And, I don't for an insurance company, I work for the doctors' group I belong to in the compliance department. But I have to deal with them a lot.

And also, be careful when going to the ER if you don't think it's an emergency.
They'll not pay for your whole visit there sometimes either!!

 

[AllyandJack]

I had this problem with my oral surgeon. I was on Blue Cross, but switched to Tufts. The hospital (Mass General) accepts Tufts. The group my doctor was in (oral and maxillofacial surgery) accepts Tufts. For some unknown reason, my doctor didn't. They told me this up front when I made the appointment. I ended up paying for the office visit, but having the x-ray covered.

Most of the time it's not the insurance company, it's the doctor who decides not to be a provider for that insurance company.

My parents are both medical billers and they always told me I am responsible for knowing my insurance - what it covers and who accepts it. However, when you're sent to a hospital or a clinic that is a provider, but there are hundreds of doctors there, how is it possible to do that research on your own? You can't realistically ask up front which doctor you're going to see and then call your insurance company (especially if it's a weekend) and ask if it's OK. IMO, the hospital/clinic has some obligation to tell you there is only one doctor and that doctor isn't a provider for your insurance. Then, you can make your decision.

I'd appeal it. It can't hurt.

 

[vivilasvegas]

When I get to work on Monday, I'm going to try and find out what you can do. Say you are in the hospital in intensive care, and your doctor who is covered, has another doctor do a consult on you, who isn't covered. You can't possibly ask then.

I'll ask our attorney on Monday what can be done about that and get back to you.

I don't think you can do anything if you had a chance to find another doctor. Meaning, if it wasn't an emergent case.

 

[chrissyk]

When I get to work on Monday, I'm going to try and find out what you can do. Say you are in the hospital in intensive care, and your doctor who is covered, has another doctor do a consult on you, who isn't covered. You can't possibly ask then.

I'll ask our attorney on Monday what can be done about that and get back to you.

I don't think you can do anything if you had a chance to find another doctor. Meaning, if it wasn't an emergent case.

How could you have had the chance to find another Dr. if you were already admitted to the hospital, though Even if you weren't in the ICU, would you be able to refuse this consult or that consult because the particular physician wasn't covered? This is even saying that you're lucid enough to know that you have to ask each person who comes into your room if they are on your insurance, too. I'm very curious as to what you can find out about a situation like this.

I can't imagine sitting in a hospital room, keeping written notes on who has seen me and whether or not they accept my insurance so I know if the billing is accurate at least. It sounds like that's what any patient needs to do, though.

 

[chrissyk]

And, I don't for an insurance company, I work for the doctors' group I belong to in the compliance department. But I have to deal with them a lot.

And also, be careful when going to the ER if you don't think it's an emergency.
They'll not pay for your whole visit there sometimes either!!

So who determines what is really an emergency, then In the OP's case, the child had a broken wrist. However, it had apparently been broken for some period of time before the pediatrician discovered this. Is this considered an emergency or not? IMHO a reasonable person would assume that a broken bone warrants a visit to the ER. However, could the insurance argue that it was NOT an emergency because it wasn't life threatening?

 

[vivilasvegas]

So who determines what is really an emergency, then In the OP's case, the child had a broken wrist. However, it had apparently been broken for some period of time before the pediatrician discovered this. Is this considered an emergency or not? IMHO a reasonable person would assume that a broken bone warrants a visit to the ER. However, could the insurance argue that it was NOT an emergency because it wasn't life threatening?

It should state in your plan what they will cover for the ER. Each plan is different, so I can't give you an answer.