Insurance Woes

[Disney Ella]

The problem is that for years you could go to a hospital participating in your insurance plan and know that all services provided by everybody you saw would be covered. Obviously, people assume based on past experiences that this will be the case on their next visit. Since this has changed, hospitals IMO have an obligation to inform people that they could be facing huge bills even though they thought they were doing exactly what their insurance company required.

As many people have pointed out, you are stuck in a real emergency. If you need emergency surgery, the hospital will call the surgeon on call without any regard to the type of insurance you have and even if you are lucid enough to request that they only call a doctor who accepts your insurance, I bet they would laugh in your face.

This is a serious consumer issue that needs to be fought.

 

[chrissyk]

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.

My plan book just isn't that specific about what constitutes an "emergency". They do say to call your Dr. after you have gone to the ER, though. I have a feeling that most insurance is non-specific about what constitutes an emergency so they have more wiggle-room to refuse to pay a claim.

 

[bicker]

This is a serious consumer issue that needs to be fought.

What do you mean, "fought"? There really are only two choices: Either medical professionals have a right to operate as a business, and enter into contracts with patients that they can reasonably expect to have enforced, or medical professionals are public servants, whether publicly employed or not, and subject to provide whatever services patients need, without any reasonable assurance that they'll be compensated as promised. Like I said earlier, I'm not even sure which approach works best. Clearly, many folks feel the US system (the former) is better than the Canadian system (the latter).

 

[WebmasterAlex]

What do you mean, "fought"? There really are only two choices: Either medical professionals have a right to operate as a business, and enter into contracts with patients that they can reasonably expect to have enforced, or medical professionals are public servants, whether publicly employed or not, and subject to provide whatever services patients need, without any reasonable assurance that they'll be compensated as promised. Like I said earlier, I'm not even sure which approach works best. Clearly, many folks feel the US system (the former) is better than the Canadian system (the latter).

Well that's fine but it should be a two way street. If they are going to operate as a business they should fall under the same consumer protection laws as any other business. A consumer has the right to be informed of charges, costs etc prior to services being rendered.
Let's say I take my car to a dealership and I have purchased an extended warranty. I go to pick it up and they inform me that I owe 2000.00 dollars because the mechanic working on it didn't accept that warranty. People would be up in arms. In this case the hospital should make it CLEAR (yes I know it's in the really fine print) that you may face additional charges because some doctors do not accept certain insurance plans. They should inform you prior to treatment which doctors don't and your options. My insurance is in my chart the Doctor should be under obligation to notify me of that AND his pricing prior to begining any treatment.

 

[Disney Ella]

We as consumers definitely need to fight practices that advantage of us when we are at our most vulnerable. Bicker, you can talk about reasonable business practices all you want, but the fact is that this is not a smart way to treat customers, not if you want return customers.

If a particular group of doctors is listed in an insurance company directory as a participating provider, but in fact only two out of five doctors are actually participating, there needs to be a big sign at the front desk and patients need to be informed when making an appointment that Drs. B & C only accept X and Y insurance. Hospitals should also be disclosing this fact since, as I mentioned before, this is a recent development that not many people are aware of until they get the bill.

And yes we should fight this attempt to deceive us. Granted our options are limited, but newspaper articles exposing this practice would at least allow more of us to be informed since the healthcare providers don't feel it is necessary to inform us before hitting us with a big bill.

 

[Free4Life11]

How do you find out if a doctor accepts your insurance?? Is there a search you can do? This all seems just plain NUTS.

The government should require all doctors to inform ALL patients of what insurance they DO and DO NOT accept BEFORE anything is done, even so much as a simple visit. On the same not, insurance companies should be required to inform their customers that while a hopsital may be in-network, if doctors at the hopsital do not accept their insurance, etc.

They should have plain language laws or whatever they're called for the hospitals and doctors. Like how the credit card copmanies have to put that information in a table in simple language and they make the interest %'s large enough to read.

At my university health center they have a big sign that says they only accept Blue Cross and University Insurance. That should be required of every doctor and hospital, if it isn't already.

 

[bicker]

Well that's fine but it should be a two way street. If they are going to operate as a business they should fall under the same consumer protection laws as any other business. A consumer has the right to be informed of charges, costs etc prior to services being rendered.

When practical. The problem is that, in many cases, they often truly don't know, and therefore can only refuse treatment, which is impractical in many situations. I suspect that that's why medical services are exempt from those provisions to the extent they are.

Bicker, you can talk about reasonable business practices all you want, but the fact is that this is not a smart way to treat customers, not if you want return customers.

If every supplier treats you in the same manner, then these practices have no effect on the number of return customers. It is an industry issue, and needs to be addressed, if at all, as an industry issue. Remember, I'm indifferent with regard to whether the issue is addressed. My point is simply that "this is the way it is now" and if you want to change it you need to change society, basically, you need to put different people into government, you need to successfully bring about a different political perspective within the general public.

And yes we should fight this attempt to deceive us. Granted our options are limited, but newspaper articles exposing this practice would at least allow more of us to be informed since the healthcare providers don't feel it is necessary to inform us before hitting us with a big bill.

They make you sign something informing you of this before they render service (in non-critical emergencies).

Newspaper articles would be great, as a warning. This discussion is great, as a warning. That's different from the practice "being fought" IMHO. Sorry I misunderstood.

 

[chrissyk]

Hospitals should also be disclosing this fact since, as I mentioned before, this is a recent development that not many people are aware of until they get the bill.

And yes we should fight this attempt to deceive us. Granted our options are limited, but newspaper articles exposing this practice would at least allow more of us to be informed since the healthcare providers don't feel it is necessary to inform us before hitting us with a big bill.

I completely agree with this. My contention all along is that people simply aren't made aware that this can even happen, and they have NO REASON to suspect that it can happen until it does happen to them. If you go to an in-network hospital, referral in hand, you are under the impression that this is a COVERED visit. You'd have no reason to think otherwise, because that is the way that your health insurance proports (sp?) to work. You wouldn't find out otherwise until you got the big bill in the mail. That IS deceptive. The consumer is not being informed that this is even a possibility until after the services are rendered. Something is just not right about that.

 

[Mackey Mouse]

I agree with Disney Ella myself. I am not sure how we are suppose to be mind readers and know who is covered, who isn't covered. If it had not happened to me with that anesthesiologist thing, him not being covered, I would not have known. I was having a procedure, I had done my homework about the Doctor doing the procedure and the facility where it was being done, how did I know he would pick someone to administer anethesia who was not covered...

At least, I did fight it and my insurance did cover it as they knew I did not have a choice of who was working that day administering anesthesia for the facility.

The other thing I was going to say here is when you have a major illness, the insurance companies, the hospital, the doctors bombard you with bills....I learned early on not to pay anything until they had finished going back and forth, by they I mean the insurance company and the hospital.....I just kept everything in a neat pile and let it settle.......finally when the insurance company had paid their end and it was final, I then paid what we had to fork over. You pay all this money for insurance, but they do not make it easy for you when you are very sick.

 

[bicker]

I just dug out my old Blue Cross benefits package, to check into how little or how much warning insurance companies provide about this.

• Please note: if a preferred provider refers you to another provider for covered services (such as a lab or a specialist) make sure the provider is a preferred provider in order to receive benefits at the in-network level. If the provider you use is not a preferred provider, you're still covered, but your benefits will be covered at the out-of-network level, even if the preferred provider refers you.

I found this warning in no less than three different places in the materials.

I couldn't find any indication that all services provided within in-network hospitals would be in-network services. Maybe Blue Cross doesn't offer that. What does the provision in your insurance actually say about that?

BTW, Blue Cross, at least makes it very easy to check who is and is not in a certain network, online. Of course, it would be still easier to simply ask, before having services provided.

 

[Mackey Mouse]

That is all well and good if your doctor appt and/or hospitalization is a planned one and you have time to check everyone out.

What if it is indeed an emergency, you are alone, maybe unconscious...then is it just your tough luck. Or try this scenario, it is an emergency, you are conscious, but really hurt, your family is with you, but they are only thinking about you and how you are doing...........who is responsible then to ask the right questions..

"Wait, do not stitch me up yet.....do you take Blue Cross??? you don't, oh can you find another emergency room doctor, who does....oh no one does, ok....give me some gauze, I will try and go to another emergency room."

I know silly, but scary just the same.

 

[chrissyk]

I found something similar in the fine print on my insurance company's website, as I posted before. Hence I guess that the insurance company has covered itself so to speak. You'd have to be looking for that information to find it, though. It's just not obvious from the benefits breakdown that they give you at open enrollment (the one that says "in-network" hospital at 100%, "out-of-network" hospital at 80%, etc.), or in the member handbook that I have for my HMO for that matter.

What I really want to know is what happens in the event of an emergency. It's all well and good to get a referral and have time to research the insurance affiliation of Dr. that you are going to see. However, it is not possible to do so if you're brought in in an ambulance, bleeding and unconcious. What if you're operated on by an "out-of-network" physician? Are you due for a huge bill? Is there a cap on the amount that you'd have to pay for the year out-of-pocket? My insurance doesn't even appear to have a cap per year on out-of-network services, so if you're unlucky enough to have an accident and you end up being worked on by an out-of-network surgeon, you're probably screwed.

This is why I'm honestly wondering if everyone would be better off with high-deductable insurance that at least caps your exposure at 5K or 10K a year. Yes, you'd have to pay that much out-of-pocket each year, but you'd be protected much better financially in the event of a catastrophic emergency.

 

[AllyandJack]

You're covered if it's an emergency. I think in this case, the issue is that time lapsed between the injury and treatment and another doctor was seen before going to the hospital. I can't remember if the OP went to the ER or not, but there is definitely a difference between going to the ER and walking in for an x-ray that has been "planned".

I do think the hospital has an obligation to make sure the doctor treating the patient is a provider on their policy or inform that patient that the only doctor there isn't a provider and let the patient decide what to do next.

If I select a doctor, then it's up to me. If I go to a providing hospital and I'm assigned a doctor or doctors, I think the hospital should have some responsibility.

 

[bicker]

(the one that says "in-network" hospital at 100%, "out-of-network" hospital at 80%, etc.)

However, that's not what it says, at least not that I could see. What it says is "in-network provider" and "out-of-network provider" -- I didn't see any reference to "hospital" in the coverage detail.

 

[WebmasterAlex]

With modern computer systems it would be a ridiculously simple matter for each doctor to know whether he was covered under a patients insurance plan. The problem is the hospitals don't WANT things to work that way, they prefer the present system. With enough consumer outcry and newspaper articles etc etc that could easily change. Patients should be given the option to be informed PRIOR to incurring charges if they are going to be treated by an out of network doctor or as I said just cross out where it says they can do that and write in you want to be informed. In an emergency they still HAVE to treat you and you will drive the ER staff completely insane.

 

[vivilasvegas]

Your insurance can't say that an entire hospital is in or out of network. It will state if the physician group you see in the hospital is in network or out of network.

A hospital can be comprised of lot of different groups.

Anyways, I like PPO much better than HMO. More choices.

 

[chrissyk]

Well, you definitely learn something every day. I was under the impression that a certain facility in my town was my "in-network" hospital because that's the way the insurance presented it to us. The "open enrollment" sheets come from the "benefits insourcing" company, so perhaps they're not typed up by the insurance company

If you have an HMO and you're unlucky enough to get into an emergency accident where you get seen by an out-of-network group/Dr./surgeon/whatever, are you up a creek Right now, we are only offered the choice of being on the HMO. I'm very seriously thinking of opting out of it and buying our own high-deductable health insurance. I've been considering this for a while for other reasons, but now I'm even more interested in light of the fact that our exposure could potentially be so high with the HMO.

 

[vivilasvegas]

Well, you definitely learn something every day. I was under the impression that a certain facility in my town was my "in-network" hospital because that's the way the insurance presented it to us. The "open enrollment" sheets come from the "benefits insourcing" company, so perhaps they're not typed up by the insurance company

If you have an HMO and you're unlucky enough to get into an emergency accident where you get seen by an out-of-network group/Dr./surgeon/whatever, are you up a creek Right now, we are only offered the choice of being on the HMO. I'm very seriously thinking of opting out of it and buying our own high-deductable health insurance. I've been considering this for a while for other reasons, but now I'm even more interested in light of the fact that our exposure could potentially be so high with the HMO.

If you are brought to a hospital where you think you might be out of network, make sure you call your insurance as soon as possible. Most will cover the ER visit. I don't know what happens after that. I do know that once we had to transfer to "our" hospital after my mom ended up in the ER.

I agree, it's a big pain in the butt.

 

[AllyandJack]

I have a PPO now, but my HMO papers said to go to the nearest ER in the event of an emergency and it would be covered.

 

[Melrosgirl]

thanks for the responses. I refuse to let this one go. DH says he'll fight this a bit more and if nothing can be done, lesson learned. We'll then see if the out of network doctor will be willing to make a $ deal to settle this. (Our insurance company says the amount he is charging is above and beyond normal for the little bit of work he did.) We'll see. thanks!