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  1. #1
    Join Date
    Apr. 23, 1999
    Location
    Rosehill, TX
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    6,923

    Default PSA re health insurance

    my company recently changed our insurance - we are now with UHC = United HealthCare (and I'm told that Blue Cross works the same way - so two of the largest companies)

    the PSA is regarding Out-of-Network annual deductible limits

    our policy has a $3,000 annual out-of-pocket limit -- so I had assumed that in any given year the most I'd get hit with paying would be $3,000

    nope - not how it works

    had surgery recently (went well) - was with in-network doctor at in-network hospital and I asked eveyone before-hand if they were in UHC coverage -- all affirmative

    now have an EOC (explanation of benefits) come in from insurance showing an assistant surgeon as out of network with an accompanying charge to me of $14,000+

    how can this be you ask (as did I)?

    well you see, UHC reimburses providers at 110% of medicare rates (or if you prefer, medicare + 10%) and that is the ammount that is credited toward my annual out of pocket deductible - in this case $379

    so boys and girls - I would pay $14k to doctor but have only met $379 of my annual $3,000 deductible

    and at that rate (knowing that reimbursement rates vary widely but this is the one I have at hand) I'd have to pay out $114,000 before I met the $3,000 annual deductible -- isn't that a kick in the pants!

    so
    a) ALWAYS try to stay in-network
    b) if you must go to an out of network provider, negociate the rates ahead of time
    c) you will still get scr**ed by the insurance company


    (the above charges are currently in dispute so I don't yet know how much I will have to pay)
    Last edited by SGray; Oct. 31, 2012 at 11:18 AM. Reason: typo
    Nothing says "I love you" like a tractor. (Clydejumper)

    The reports states, “Elizabeth reported that she accidently put down this pony, ........, at the show.”



  2. #2
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    May. 17, 2000
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    Default

    OON charges have been trending that way for over a decade. They were always based on a fee schedule that the provider didn't have to adhere to (HIAA or MDR). But that fee schedule is about equal to a 50% mark up on retail, so most insurers have switched to x% of Medicare as something a little more reality based (think closer to invoice). The insurer could pay more but this is part of holding down costs. It saves a chunk of premium to anchor to the new schedule and everyone has to pay for the few that want to go out of network. Most employers were very happy with the change. Also most carriers I know of clearly state this in multiple places, EOBs, contracts, summary of benefits, and so on (it's one of the easiest things I ever found in competitor research).

    Note that if you have an emergency admission into a non par hospital (instead of an elective admission), if the provider chooses not to accept that fee schedule, it is generally between the insurer and the provider to work out terms of payment. The member is not supposed to be in the middle, although that doesn't always happen (but if it does, the member should always notify the insurer). Also if the doc is a non par doc with a par hospital (your case) you should contest this. Most insurers work very hard to ensure they contract with all independent contractors the hospital brings in, but it's hard to keep track of new arrangements/subcontracts. However most insurers (this should be universally true of POS arrangements, mostly true of PPO arrangements) will not put the member in the middle of the financial "discussion" that is going on. Just like the ER admit above, they will separately work with the provider to negotiate either a contract or an acceptable rate, but this is generally a game of politics where the provider wants to drag the member in the middle and the insurer wants to drag the Large National Employer into the fray. You shouldn't pay anything that your EOB does not specifically say you are responsible, and if you get pressure from the provider, take it right back to the insurer. Chances are the insurer isn't trying to screw you, it's working towards striking a deal that saves you the most money.

    Bottom line is you really need to pick your insurer based on how much you like the in network providers, because very few of us have the discretionary income to afford OON services. It makes no difference if it is under an HMO or insured (PPO) license. It's all about in network.
    Definition of "Horse": a 4 legged mammal looking for an inconvenient place and expensive way to die. Any day they choose not to execute the Master Plan is just more time to perfect it. Be Very Afraid.



  3. #3
    Join Date
    May. 6, 2003
    Posts
    1,888

    Default

    When I had my c-section, one of the surgeons was out of the network and would have cost me $$$. I never got a bill after seeing that cost on my EOB and called the surgeon's office. The billing person told me that they would work it out with the insurance company and I didn't need to worry about it and they would not be billing me.
    According to the Mayan calendar, the world will not end this week. Please plan your life accordingly.



  4. #4
    Join Date
    Apr. 28, 2008
    Posts
    6,878

    Default

    I don't see anything else the OP could have done, she tried to confirm that the surgeons were in-network.

    That's ridiculous. We've had problems recently too -- DH had a procedure and in-network hospital sent the labs off-site to an OON lab we knew nothing about. I hate this kind of "gotcha" from health care providers -- what could we possibly have done? We TRIED to stay in-network, they are the ones that chose to send it to an OON facility without informing us. Infuriating. Hospitals and providers need to consider/disclose this stuff before you get a crazy bill way outside the estimates they give you beforehand. We are still fighting ours, not sure what will happen.



  5. #5
    Join Date
    Aug. 12, 2010
    Location
    Westford, Massachusetts
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    Default

    It's been that way for a while. Watch labs too...I've run into an in-network doctor sending stuff to an out of network (non-contracted) lab and I get stuck with it. I've taken to asking exactly who will be involved in my care and trying to determine whether they are in and out of network in advance, it doesn't always work out. Fortunately, here in Mass, nearly everyone is contracted with BCBS, I got dinged when they sent it to a lab out of state. I use a different PCP now, in a hospital satellite with their own lab, radiology, day surgery...the whole thing is under contract, so it hasn't been an issue.



  6. #6
    Join Date
    Apr. 23, 1999
    Location
    Rosehill, TX
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    Default

    I did my best

    at hospital pre-admissions paperwork, etc I asked about anesthesologist, they weren't sure, tried to call, didn't get through so gave me the phone #, I got through later and confirmed in-network

    in pre-op (all dressed out in gown and stockings, i.v. line in, etc) woman came in speaking of monitoring nerve funtions during surgery - I stopped her and quizzed her about being with UHC -- affirmative

    but by the time I was in operating theatre I was knocked out so no opportunity to quiz any and all persons present ;-)
    Nothing says "I love you" like a tractor. (Clydejumper)

    The reports states, “Elizabeth reported that she accidently put down this pony, ........, at the show.”



  7. #7
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    May. 17, 2000
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    Default

    like I said, sgrey, take that story to the insurer. And if that doesn't work contact the Texas Consumer Health Assistance Program

    www.texashealthoptions.com
    855-839-2427 (855-TEX-CHAP)

    But it is important you attempt to resolve it with your insurer first, usually the CHAP type programs won't get involved until members at least bring the issue to the insurer's attention.

    If you have a COMPLETED EOB telling you that you are on the hook for the non par charges in excess of the negotiated fee, then I would act (or if the provider is sending you to collections). But your first step needs to be to tell UHC that you did everything right in confirming it was a par provider/facility, and you are potentially being financially punished and may have your credit ruined through no fault of your own, and it is their responsibility to resolve this issue with the provider promptly. Like I said, they are probably on top of it, but you need to have a record of your attempt to make them aware and resolve it ASAP.
    Definition of "Horse": a 4 legged mammal looking for an inconvenient place and expensive way to die. Any day they choose not to execute the Master Plan is just more time to perfect it. Be Very Afraid.



  8. #8
    Join Date
    Mar. 30, 2009
    Posts
    786

    Default

    I went off my company's insurance and onto Tri-Care (via my DH) for that very reason.

    We changed providers and I was told by what would have been my new company that, even for in-network doctors, because I have a chronic illness my treatments would likely not count towards my out of pocket maximum. This would have left me paying upwards of $20,000 per year just for my basic treatment.

    Thankfully I had the tri-care option where my out of pocket max is completely straightforward. Definitely read fine print carefully and ask questions when you are enrolling in health insurance and when you are going for a procedure (though sounds like the OP tried to make sure everything would be covered and still got a giant bill...that is just awful)
    My blog:

    RAWR



  9. #9
    Join Date
    Apr. 23, 1999
    Location
    Rosehill, TX
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    Default

    thanks dmk

    issues are in dispute with uhc -- have the response letters from them acknowledging that

    just wanted to make sure others are aware (I have gone from department to department within my company - no one other than my hr head had any idea that this is the way these things are handled -- I have been a one-person educcational program here at the office)
    Nothing says "I love you" like a tractor. (Clydejumper)

    The reports states, “Elizabeth reported that she accidently put down this pony, ........, at the show.”



  10. #10
    Join Date
    Jul. 19, 2007
    Location
    Michigan
    Posts
    10,075

    Default

    I'm kind of glad I buy my own (Blue Cross.) My deductible is what it is, and it's HIGH, though it's getting to the point where it's not worth it as the premiums keep creeping up as they have to add in coverages for upcoming federal law (I wanted to cry--it's all the useless garbage like pediatrics that I deliberately opted not to buy in the first place) and Michigan law (autism testing? SERIOUSLY?)

    I'm at the point I'd rather just pay the doctor out of pocket.



  11. #11
    Join Date
    Feb. 25, 2012
    Location
    Montana
    Posts
    1,960

    Default

    United health care is absolutely the worst for this. As someone suggested, call the state insurance commissioner's office (whatever they are called) for sure with this! you should NOT be in the middle,although I am not surprised it was UHC. I would think the State could help you , but perhaps you can join one of the ongoing law suits against them. Tricare is also becoming UHC, so be warned. BTW,their Medicare "supplementals" are just as bad. Nothing like having to worry about quizzing docs while you are going under, or trying to recover! Glad your surgery went well!!



  12. #12
    Join Date
    Nov. 13, 2002
    Location
    Maryland
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    Default

    For my surgeries last year, I ended up going out of network for the surgeon only (only surgeon who did the surgery I needed and was not so far away I would have to fly get there) and I ended up owing well into the 5 figures between him and all the co-pays and exclusions for the in-network stuff (even with a neogtiated minimum payment to the surgeon- would have been 3 times as much without that)
    My HR told me the out of network benefit worked the same way you thought it did SGray (and I thought it did) but they were wrong.
    Not only does only the approved amount covered count towards your deductible but the difference between the insurance company's approved amount and what the doctor actually charges are your responsibility even after you hit your out of pocket maximum.
    In addition, BCBS (and I am told nearly everyone else) has fun other "rules" that they pull out of thin air and use to cut their payment that are nowhere in any literature available to individual subscribers. For example, if there are 2 surgeons, they automatically cut the 2nd surgeon's fee in half (even if it is a surgery that requires 2 surgeons). If more than 1 procedure is performed in one surgery, even if they are all medically necessary and the additional procedures add to the time and cost of the surgery, they will only pay for one (because, yes, lets encourage doctors to put people under anesthesia additonal times if they want to be paid for their work). These are only 2 of the fun-filled "rules" that BCBS came up with after my surgeries and that the health insurance advocate I worked with said would be upheld if I challenged in the state administrative proceedings because "almost everyone does it"
    No wonder something like 80% of personal bankruptcies are caused by medical bills.
    There is something about the outside of a horse that is good for the inside of a man.(Churchill)



  13. #13
    Join Date
    Apr. 23, 1999
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    Rosehill, TX
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    Default

    another dispute I'm having with uhc in this instance involves an in-network doctor

    apparently he is not providing the documentation that uhc has requested from him -- so they put his disputed charges in the "Amount You (that's me) Owe" column

    I was on the phone with them and they tell me about the documentation problem and my question is "What are you doing putting $3+k owed in my column!?!?" "Isn't that between you and the doctor that is in your network!?!?"


    rest assured, I will not be paying that 3k but it irks me to no end that this is the way their system is set up
    Nothing says "I love you" like a tractor. (Clydejumper)

    The reports states, “Elizabeth reported that she accidently put down this pony, ........, at the show.”



  14. #14
    Join Date
    Aug. 14, 2000
    Location
    Clarksdale, MS--the golden buckle on the cotton belt
    Posts
    17,658

    Default

    I'm disgusted with most private health insurance across the board. I have regular medicare and am very happy with it, but my prescription drug plans have been a bitch from the beginning. My only regular medication is for my thyroid, and I can get it from the Kroger pharmacy private pay for $10 for a three month supply. If I try to get through my plan, the cost is about three times more expensive per month. And since I use so little medication, I'll never meet my deductible, especially since the plan doesn't cover muscle relaxants and pain medication. They aren't on the formulary or if they are they require pre-approval. My doctor doesn't do Pre-Approvals. So now I have to look for another doctor who is willing to work with the insurance companies.

    I know people abuse muscle relaxer and pain medications, but if it's the only time that I present a prescription in a year, abuse is highly improbable.

    So not only looking for a new doctor but a new plan. PITA!
    "I'm a lumberjack, and I'm okay."
    Thread killer Extraordinaire



  15. #15
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    May. 17, 2000
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    Default

    Quote Originally Posted by lilitiger2 View Post
    United health care is absolutely the worst for this.
    I wasn't going to say it, but yes I think they are.

    Everyone has that fee schedule for elective non par admissions, but the issue of payment to nonpar subcontractors at par hospitals seems to be more of a problem with some and not others.

    But for those who are blaming the insurance company or the providers, it is a difficult issue on both sides. In general, insurers try to contract with the par hospital's known contractors/subcontractors, but sometimes they legitimately do not know about them until the claim comes in. If the contractor (let's say it is a new radiology group) has not signed a contract with the insurer and the claim comes in as non par, the insurer has a few choices:

    1. Pay whatever is asked, no matter how in or out of line it is with prevailing costs. The pro of this is it makes the member happy. The con of this is it undermines any ability to negotiate with the provider group to get them par for a reasonable (prevailing) fee. By default this group will see unwitting patients like sgrey who are directed to a par hospital in all good faith. Gold Mine! It also means sgrey's portion of said fees (coinsurance) will be considerably higher. It also means that everyone's premiums are going up since if you think word doesn't travel in the medical community and other negotiations are not undermined, you'd be wrong. This version of the game is called "Do you have any vaseline before I bend over?"

    2. Just ignore them and pay them non par fee structure and stick it to the member. The con is obviously the member is screwed through no fault of their own. The pro is eventually the provider might come around or might not. This version of the game is called hardball.

    3. Negotiate with provider by trying to sign a deal that works for members, groups, the hospital, the provider and the insurer. As a means to this end the insurer uses the hospital and large national employers as leverage to further negotiations, while provider uses members who have received services as their own leverage. Really, this is the game everyone plays. It's going on behind the scenes and it may have been going on for a while. It sucks for everyone involved, but it's the way things work as long as hospitals have independent contractors. The good (or bad news) depending on your view is it is expected that most provider groups will work for hospitals in the next 10 years or so, so everything old is new again.

    On the provider side, they are just (reasonably) looking for the best deal possible. Insurers are too. It's like every two party negotiation ever. And sometimes one or more of the parties is more of an asshole than the situation warrants, but usually not.
    Definition of "Horse": a 4 legged mammal looking for an inconvenient place and expensive way to die. Any day they choose not to execute the Master Plan is just more time to perfect it. Be Very Afraid.



  16. #16
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    Sep. 7, 2009
    Location
    Lexington, KY
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    Default

    Quote Originally Posted by danceronice View Post
    I'm kind of glad I buy my own (Blue Cross.) My deductible is what it is, and it's HIGH, though it's getting to the point where it's not worth it as the premiums keep creeping up as they have to add in coverages for upcoming federal law (I wanted to cry--it's all the useless garbage like pediatrics that I deliberately opted not to buy in the first place) and Michigan law (autism testing? SERIOUSLY?)

    I'm at the point I'd rather just pay the doctor out of pocket.
    Well, good luck with that. Better hope you're not diagnosed with cancer, have a heart attack or end up as a victim of street crime.
    "We can judge the heart of a man by his treatment of animals." ~Immanuel Kant



  17. #17
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    Apr. 23, 1999
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    Rosehill, TX
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    Default

    any hints on avoiding this kind of situation in the future?

    or on figuring out what the ACTUAL annual out of pocket amount might be?

    do I may all providers sign a note promising that all involved in my care will be in-network?
    Nothing says "I love you" like a tractor. (Clydejumper)

    The reports states, “Elizabeth reported that she accidently put down this pony, ........, at the show.”



  18. #18
    Join Date
    Sep. 5, 1999
    Location
    Central FL
    Posts
    4,347

    Angry

    For surgeries, etc. NOT in an emergency

    Not sure if it would help in your case, but I called the insurance company (pre surgery, the day the appt was made) MYSELF the last time, made a point of getting the name, title, and phone extension of the person I spoke with.

    She was quite helpful and patient, and I showed up at the hospital with check in hand for the amount she quoted, and was not billed for anything above that amount.

    (The total bill was over $67,000 and no, I didnt pay anywhere near what they are asking you to pay)

    and it was United Health Care. So of course we don't have them anymore, because that would be too easy!

    So sorry this is happening to you



  19. #19
    Join Date
    Nov. 13, 2002
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    Maryland
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    Default

    The most important thing, you actually did- ask. I would however call the hospital ahead of time to find out who all your providers will be and ensure that they all participate because, as in your case, you may not be able to ask everyone yourself at the time of surgery (and frankly if someone had walked into the OR and told you they were not participating, what are you going to do at that point?). I called ahead for my recent elbow surgery and frankly, if after calling and confirming I only wanted participating providers, if anyone who was not participating tried to bill me as out of network, I would tell them to go fish.
    For the arbitrary rules I knew nothing about, while the literature given to individuals did not include any of them, most (not all) were in the contract that my employer had. If you know you have a big medical expense coming up, ask your employer for a copy of the full policy. I would have been more prepared if I had done this.
    For emergencies where you cannot call ahead, many companies have a policy (including BCBS) that if you go to a participating hospital, everyone who treats you for the emergency visit gets treated like an in network provider. That does not mean the insurer will do it unless you call and question it (ask me how I know this)
    The next thing I would suggest is callling the insurer and questioning every single EOB afterwards. I finally resorted to that after the huge bills I had last year and for responses, I got a mix of "here is the illogical rule we are unilaterally imposing so that we don't have to pay more and can screw you" and "oh yeah, you are right, we should have paid more- ooops, our bad, we will re-process").

    Danceronice- good luck with the no insurance approach. While I was out of pocket a lot for my surgeons and co-pays for all the people involved in my care, my hospital bill alone (no doctor or post-release expenses- just hospital stay) was more than $200,000. That at least was entirely covered minus a $250 co-pay. And that bill is nothing compared to the cost of cancer treatment.
    There is something about the outside of a horse that is good for the inside of a man.(Churchill)



  20. #20
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    May. 17, 2000
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    Default

    Quote Originally Posted by bambam View Post
    For emergencies where you cannot call ahead, many companies have a policy (including BCBS) that if you go to a participating hospital, everyone who treats you for the emergency visit gets treated like an in network provider.
    Actually that would be less like a company policy and a lot more like a federal law (reasonably prudent layperson definition of an emergency). "Emergency" treatment and admission is not treated as an "out of network" claim and not subject to those OON cost sharing requirements. But that doesn't mean the same scenario of negotiating fees between insurer and a non par provider doesn't play out all. the. time. (there are entire businesses dedicated to handling said negotiations). It just means you are not responsible for anything other than your defined cost sharing for that admission (assuming it really was an emergency and you didn't go into the ER to get a flu shot or something else that in no way could be considered an emergency).
    Definition of "Horse": a 4 legged mammal looking for an inconvenient place and expensive way to die. Any day they choose not to execute the Master Plan is just more time to perfect it. Be Very Afraid.



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