Basic Healthcare Reform and Bill of Rights, Part II
Here is a story- strange but true. Mr. Martin came to my office after he had a fracture of his thigh bone near a hip replacement that was previously put in.
As it turns out, I am not in Mr. Martin's Health Plan. Mr. Martin decided that even though I was not in his plan, he wanted me to reconstruct his femur and fix him.
He was pleased to know that the hospital I am affiliated accepts his health plan as does the Anesthesiology Department there. When he called his health plan here is what he learned (I am not making this crap up):
Since I was not in his health plan, the plan was now treating my hospital which is in his network and the Anesthesiology group (in Network) as out of Network providers and they would not pay their bill. Their reason was that it was "their policy."
When Mr. Martin told them that the reason he chose their plan was because of the fine hospital and he was willing to pay my fee separately- they say- no dice. If you choose an out of network doctor- all in-Network providers and hospitals are now not covered.
How in the world did the Department of Health allow this policy to happen? Did some just wake up in Albany and decide they were going to act like idiots and cower to the insurance company whims at the expense of patient's?
This interesting policy is NOWHERE to be found on any literature supplied by the company in enrollment materials and they could not even show me this in writing when asked. In general, I do not care to mention specific company names in this column because nearly all of them are guilty of this.
Why can't we have Health Plan nutritional information sheets mandatory? Is it so hard for someone to list the particulars of a health plan and the rules and regulations?
Here are some mind-boggling facts that may need to go on the box of your health plan enrollment kit:
1. Monthly fee
2. All co-pays
3. Exactly which tests are approved and which are not
4. Exactly which tests need precertification and which do not
5. Where is the published list of ALL the medications
I would be most interested in many more comments the readers have on what information health plans should provide.
Related Topics: Health Insurance Education Center
, Mental Health Insurance Pays
Technorati Tags: health insurance, insurance enrollment, policyholder rights
As it turns out, I am not in Mr. Martin's Health Plan. Mr. Martin decided that even though I was not in his plan, he wanted me to reconstruct his femur and fix him.
He was pleased to know that the hospital I am affiliated accepts his health plan as does the Anesthesiology Department there. When he called his health plan here is what he learned (I am not making this crap up):
Since I was not in his health plan, the plan was now treating my hospital which is in his network and the Anesthesiology group (in Network) as out of Network providers and they would not pay their bill. Their reason was that it was "their policy."
When Mr. Martin told them that the reason he chose their plan was because of the fine hospital and he was willing to pay my fee separately- they say- no dice. If you choose an out of network doctor- all in-Network providers and hospitals are now not covered.
How in the world did the Department of Health allow this policy to happen? Did some just wake up in Albany and decide they were going to act like idiots and cower to the insurance company whims at the expense of patient's?
This interesting policy is NOWHERE to be found on any literature supplied by the company in enrollment materials and they could not even show me this in writing when asked. In general, I do not care to mention specific company names in this column because nearly all of them are guilty of this.
Why can't we have Health Plan nutritional information sheets mandatory? Is it so hard for someone to list the particulars of a health plan and the rules and regulations?
Here are some mind-boggling facts that may need to go on the box of your health plan enrollment kit:
1. Monthly fee
2. All co-pays
3. Exactly which tests are approved and which are not
4. Exactly which tests need precertification and which do not
5. Where is the published list of ALL the medications
I would be most interested in many more comments the readers have on what information health plans should provide.
Related Topics: Health Insurance Education Center
, Mental Health Insurance Pays
Technorati Tags: health insurance, insurance enrollment, policyholder rights
18 Comments:
It sounds like Mr. Martin is in a plan that doesn't allow out-of-network benefits.
I'm in a similar type of HMO, but in the 2 page summary of benefits that came in the enrollment package, it states clearly that there is no coverage of specialist/hospital services if there was no written referral from a primary care doctor. In the 33 page plan contract that details all benefits and exclusions, it states the above again in 3 different places. It also says that if a patient gets care without a referral, then the plan won't pay, except in emergencies.
For Mr. Martin to figure out what his plan covers, he needs to get the plan contract, which he's legally entitled to. He has to request it himself, it won't come with the enrollment package. Either his employer will have the contract, or he can get it from the insurer.
Since you are now out-of-network, any care that you initiate, including surgery, will not be covered, since there can't be a referral from the family doctor.
Mr. Martin could contact his primary care doctor's office, and see if they know of any options in this type of situation (out of network surgeon and in network hospital). They've probably seen this problem already.
I've run into the same situation twice in the past year, but decided to look around for surgeons who accept my insurance. Luckily, I'm with the biggest Blue Cross in my region, so they have plenty of doctors signed up.
Perhaps it would be beneficial at this point, since it seems like Mr. Martin needs medical care soon, for you to give him names of several surgeons that you know are good; hopefully one of them will take his insurance. I know this isn't ideal or fair, but it's the reality of what we patients have to deal with.
That is a bunch of crap. I've never heard of a plan that doesn't allow out of network benefits! My husband's plan allows out of network benefits but pays them at 70% instead of 80% in network. That just shows how bad the insurance industry is and how crooked they are. I count myself pretty lucky as I have Medicare primary and my husband's secondary so most of my expenses are paid for and since I've had at least one surgery every year since I've been on disability I've always reached my out of pocket early in the year. But I'm one of the few and far between. And I go to doctors in Minnesota (out of network) I live in Iowa. I choose to do that because, well just because. I won't go into it. I agree with Dr. K. The insurance industry needs to be reformed at the very least or done away with at the very most. And I'm not sure that what MA is doing is the answer either. Even though everyone is required to have car insurance not everyone has it. So, just because everyone will be required to have health insurance, will they have it? Look what is happening in the south! The insurance made how many billions of profit even with the hurricanes last year? Of course they did! Because they aren't covering anything anymore just like health insurance isn't. What's the use of having health insurance if it won't cover anything? We may have pretty good health insurance but we pay good money for it too! It gets taken out of my husbands checks. We don't really have a choice since I have so much arthritis, fibromyalgia and heart valve regurgitation problems from the Phen-Fen drugs. My husband has spina bifida occulta, but also has a birth defect in his tail bone from that that causes a great deal of pain and now our daughter is having some foot and ankle pain that needs some attending to. So, you have to have insurance but it seems like you're damned if you do and you're damned if you don't.
To the first "anonymous":
You are correct that Mr. Martin does not have out of network benefits BUT the primary care physician did generate a referral for surgery to an in network provider who Mr. Martin felt was unqualified to handle his case. Based on that- care to get surgery was already initiated.
Mr. Martin just wished to change one of the providers and pay out of pocket.
Here is the punchline: I sent a complaint to the department of health and as soon as it went in the insurance carrier negotiated a fee with me. They DID NOT want this to go to a ruling.
Every poor decision by an insurer needs to be reported to the state.
Just my policy.
Dr. K.
Dr. K: Do you go to the Department of Health with your own insurance if they make a poor decision? It's an interesting concept. Just last week I went to my husband's company because I happened to see that they paid my OS out of network benefits but is supposed to be paid at in network benefits. So, I called and the gal I talked with had to get into it and call me back. This was after I had called my surgeons office to find out if he had signed the paperwork to still be in the network and found out he was then they called my insurance co. and they said he was in network after some other person in the in. co. said he wasn't. Suffice it to say the last gal I talked to called me back to tell me that some man had evidentally decided that last year my surgeon was out of network and reversed all the claims for a year and a half. The gal I talked to said he definately was IN NETWORK and she would go back over all the claims and repay those that needed to be repaid and put him back as an in network provider. I thanked her profusely and called back my OS office and gave them the good news. The sad part about this was the idiot that reversed all those claims took a supervisory position elsewhere. Can you beat that? But thanks for the tip because if I have to go through much more of that I will call the Department of Health. I don't think alot of people feel they have a choice. But, I know I'm going to spread the word. Insurance Company's use fancy language to confuse people also and half the time they don't even understand their own benefits or what they are entitled to or what their limits are. They count on that. It's time we fight back. Thanks Dr. K. Linda
I'm anonymous who made the first post. I'm glad that Mr. Martin was able to be treated by you, Dr. K. I suppose the fact that he was an existing patient of yours carried a lot of weight, when you made your complaint to the Dept. of Health.
I also have gotten an immediate response from my health insurer when they wouldn't give me a straight answer about an issue I had with them, by simply saying that I was considering contacting the State department of Banking and Insurance to have that agency look into the matter. Like any other business, the insurers don't like having regulatory agencies coming around.
For other patients - make certain you have the correct state agency name before you threaten your insurer with filing a complaint. In some states, it's the Insurance Commissioner's office that regulates health insurers; in other states, it the Dept. of Health. Your state government websites will have that information, as well as directions about how to go about filing a complaint. In one case, I called my state agency's office, just to find out what my legal rights were as a patient, and what the insurer's responsibilities were to me.
Thanks Dr K.
I was so pleased to run across your posts.
Reading the problems that Mr. Martin had and your response brought to mind an experience I had years ago with an HMO I had.
I had been disgnosed with TMJ Disease and it was decided by myself and two oral surgeons that it was important that the cartlidge in the TM's be replaced with an implant due to the fact that mine had disinigrated.
All set up to go, referrals sent in and approved. I was ready to go.
At the last minute my insurance company realized that my jaws were being operated on and the reason being TMJ disease. I recieve a phone call from the insurance company the morning of my surgery and was told that because of a little known exclusion to TMJ if I went ahead with the surgery I would be responsible for the costs incurred.
I was in horrific pain and had been for almost two years, it took that long to decide that the invasive treatments were not doing a thing to help me because I literally had bone rubbing on bone. I bring this point up only because I have to tell you that I had to wait another whole year for an open enrollment period so that I could change my insurance to one that did not exclude TMJ. The awful thing was that my dental insurance said it was medical, the medical insurance said it was dental. In my mind it was medical, but what does a layperson know even if it makes sense that the jaw joint has not alot to do with your teeth.
To the end of this story, I had the Arthoplasty bi-lateral finally in 1986, I had Vitek Proplast implants put in. I am sad to say that I remained symptomatic after the surgery and recovery time.
Come 1991 the FDA recalls these Vitek implants due to a high rate of failure.
No wonder I had remained symptomatic! Duh!
Thanks for listening~
For one thing they should make doctors provide better services to people in need. I've gone to the hospital 3 times in the last month with the same pain in my stomach and no one has done anything about it yet. All the doctor keeps saying is it's my appendix and it'll go away. Do appendixes not burst if not fixed and wouldn't that put me in harm.
Health Insurance is as bad as doctors are.....they don't care as long as they get paid that's all they're worried about. I'm so fed up about stupid doctors. If I didn't have to I wouldn't go to them at all.
........just one more thought. Some doctors are caring for their patients, but how to tell the good from the bad that gets me.
Excuse me to the last publisher. Can't you go to a different hospital? Or if not to a different hospital a different doctor? I certainly wouldn't accept an answer like that and wonder if my appendix were going to burst or not! I would demand an answer or demand some tests to make sure I was getting some help or some answers. I tell my doctor when I want X-Rays and C-T Scans but thats because I have so much arthritis that I know when I have changes and I want them checked and I have had 4 foot surgeries, all of them fusions and two of them have been non-unions so I don't trust X-rays anymore. I want C-T Scans. They are the best at telling me the truth at whether my fusions are healed or not although I know by the pain in my foot but my surgeon doesn't always believe me. So, I've learned to take it over to my PCP's office, also. When I think I need some X-Rays, or some type of tests I tell her and she usually orders them. Actually I usually know when I have yeast infections, throat infections and so on and lots of times I just call her on the phone and she gives me a prescription over the phone but I've been going to her for years and I have a long history with her. I found a lump on my left ankle which my OS thinks is a fatty tumor but said if I start to have pain in it I should have it removed. Well, of course knowing me I started having pain around the edges of the lump so I went to my PCP and she was not comfortable removing it so is sending me to a Podiatrist to remove it as it could involve my tendons. Sorry this is so long. Bottom line is: It is your body, You are the master over it. You must take good care of it and insist on whatever tests you need to make a correct diagnosis. If one doctor won't do it, go to another, and another and another until you find one who will. It is like getting a second and third opinion when you find out you have cancer or you need surgery. You don't always go with what the first doctor says. He may be right, he may not be. There are some bad doctors out there, but there are many more very good ones out there like Dr. K. I especially feel lucky that I have excellent Orthopaedic Surgeons but I chose them and I researched them and that's what you need to do with your doctors. Good luck. Linda.
Hooray for you, Dr K. We need more surgeons around like you that are willing to take on an insurance company for the sake of his patient. I have out-of-network benefits and I will be visiting you soon for consult. But I live in NJ and our OS's don't have the training and expertise that you have. I don't mind traveling if the results warrant. See ya soon.
I agree with everything you have said and the situation is getting worse.
Most of us know that premiums are increasing, less and less of patient's procedures are being covered, and our reimbursements are decreasing...so where is the money going and who is foolish enough to go into medicine? HMMMMM...we know!
I recently went to a book signing of a woman who hit the nail on the head with a book she came out with called "Healthcare for Less." I encourage everyone to give one to their patients and read it themselves because she picks up on the points that our patients should be asking insurance companies. She also gives some great insight and suggestions on saving money and how the patient may even be better off without insurance; and negotiating prices with me directly!
Yes, this is where the health industry is going....and unfortunately, doctors cannot unionize like other industries to get things done. The best and the brightest are not foolish enough to go into medicine and the patient will only begin to feel the effects in 10 years or even less.
Yes, I also, got that book, "Healthcare for Less" and found it fantastic! It taught me how to shop around and help my doctor help me! I even taught him a few things about saving money that I learned from the book, such as the 2-1-1 number that saved me hundreds of dollars on my diagnostic MRI! Check out my review on www.amazon.com under the book titled "Healthcare for Less." We must learn as patients that we are in charge of our own healthcare...why would we stick with a doctor we are not happy with or stick with an insurance plan that is not good for us? We live in a democracy and have choices...as patients we should shop around for the best choice for us!!!
I love your writing! You need a show on CNN, CNBC, or Fox. Better yet, how about a seat on the Senant? Why can't more people like you be making our laws? Simple, to the point and not full of legal crap! My Dr. recommended a hystorectomy 3 years ago. Medically neccessary of course and my insurance denied it! My Dr. was horrified and went to the mat with them. They won. Finally, they accepted, I had the surgery last Dec. Before the surgery, they told my Dr. he was not a "partisipating physician" and I had to pay up front 20%. After the surgery, they decided he WAS a participating physician and made him refund me $695. He really got screwed. Some system. I think I will move to Canada.
My husband works for the government in the state that we live in,and while most of the time our insurance is great about covering procedures,MD visits,and prescriptions;I was completely dumbfounded when four years ago I had to undergo a total abdominal hysterectomy due to stage IV endometriosis(after many,many other attempts and less invasive surgeries to remove tumors,lesions,etc.)because the insurance company would not cover a drug that would have put me in medical menopause(which would have had the almost exact same effect as the hysterectomy,only it would have been possible to reverse this medical menopause when and if I chose to. I was only 25 years old!!! My friend who also has severe endometiosis and is on Medicaid was able to get the medicine and didn't have to undergo the same surgery. Medicaid covered it, and my insurance company chose to pay way more for the surgery than they would have ever had to pay for the medicine. What kind of world do we live in, where hardworking people who try to live "right" and work and pay their own way through life don't get the same healthcare or as good as healthcare as indigent or Medicaid patients?!
I know what you are talking about, in a 3 year period I was out $45,000 for all the not covered or only pay this expense. After my ins went up to $850.00 a month and dropped my neurologist from the plan, I got pissed off and dropped everything and pay out of pocket for everything. I know this is dangerous but after all this I had to file bankruptcy, now I'm trying to get my disabilty, it has been two years wait for that, so some of the treatments I need are put on the back burner.
help Ineed imfomatin about the recall of tmj implants Istill have them and I'm wondering if there is a link to other illness I have , such as fibermyalgia please contact me at mamma_renee@yahoo.com
To mamma_renee above,
For answers to specific questions about your conditions, please visit our message boards.
My insurance is a PPO, my in-network physician performed an endoscopy and sent a specimen for testing to a physician who is out-of-network. Is this the right thing to do? When I received the bill, I called the Lab Dr's billing service and they said that happens quite often and I should call my insurance company to negotiate. I feel the surgeon is responsible for the difference since he knew my insurer was cigna and he constantly refers to this lab physician (who he knows is not in-network). Cigna will recalculate since I had no control over where the surgeon sent the specimen; however, they will still treat it as out of network. Who should be responsible for the difference I have to pay?
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