Boob is a Weekend Word

Getting Well is Only Half the Battle

June 27th, 2011

Sure, you have enough to deal with, what with the Cancer diagnosis, the surgeries, the chemotherapy and/or radiation, the follow up medications and screenings….the losing of body parts, hair, putting on or losing weight, memory loss, and general confusion, right?

It’s quite distressing that it doesn’t end there.

INSURANCE CHALLENGES

Then begins the costs…and if you are very lucky you have insurance of some type. If you don’t I sincerely feel for you because it has to be so monumentally stressful, scary and frustrating.

I do have insurance, albeit a pretty high deductible. My insurance is with Coventry One. Its a 5k individual, 10k family deductible. I chose this plan because the premiums were reasonable, and I was prepared to cover a 5k deductible should anything critical happen. I am very thankful to the doctors I have seen that take this insurance despite their, at least what I consider to be, unreasonably low contractual payments. I’m really very happy these doctors take as much care of you as they would their patients with the really high end high paying insurance policies.

But strangely, it doesn’t end there.

My plan year started April 1, 2011 and by April 26, 2011 I had met my 5K deductible. Arguably, any other charge I incurred would be paid by insurance alone. I have no copays on any service….As long as I stay “In-network.”

“In-Network” isn’t very cut and dry and this is the problem.

Having a serious health issue such as breast cancer requires the care of many different physicians and specialists. In my case, I started the process with my “In-Network” gynecologist. I was referred to the Athens Regional Breast Health Center, which is an “In-network” hospital, for a mammogram, and whatever other procedures they felt were necessary to handle my case. This included a mammogram, an ultrasound, and biopsies, and the readings of each of those diagnostic procedures.

Imagine my surprise when I received a bill from the Pathologist showing I owed $1255.67 instead of what my insurance EOB showed I owed which was $442.62 based on the negotiated rate for the pathology reading. I assumed this was a mistake so I called Athens Regional Pathology Associates LLP (notice the reference to Athens Regional in their name). I was then informed that they (an Athens Regional affiliated practice) is not “In-network” provider with Coventry One and I was being balanced billed for the full amount.

Now wait a minute….I was referred to the Athens Regional Breast Health Center for all of these tests by my “In-network” gynecologist, to an “In-network” hospital. I literally showed up and was shuffled around from room to room, was never introduced to all the health care professionals that would be involved in my case, and honestly I had no idea how many people were involved behind the scenes – I only saw the radiologist and the mammogram tech. I didn’t even know who my radiologist would be until she walked into the room. They don’t tell you at the check in desks which doctors you will be seeing. You are just shuffled through their system and are made to sign a form saying you are responsible for paying for services if insurance doesn’t cover it – which seems strange in and of itself when you are at an “In-Network” hospital and you got pre-authorization to go in for these procedures.

Well ARMC, and i’m sure hundreds of other hospitals, don’t always keep all their physicians on staff. They use a great deal of contract physicians and specialists. These are referred to by the insurance companies as “hidden providers” or “phantom providers.” This means that you don’t know who they are, and probably never even interact with them. You, as a patient, have no way to know this is happening.

I don’t know what the Georgia law is on this, but it only seems fair, if you agree to be on contract with a hospital, you should be within all of their insurance networks to prevent this sort of problem for patients. I am fortunate to be a bulldog about this kind of thing and I inquire and dispute all of these cases but there are some sicker or older individuals who may not even understand what is happening, and they just end up going into medical debt, damaging their credit histories, or filing bankruptcies because their don’t know how to dispute these incidents.

Possible Solutions

I have found the way to go about it is to call your insurance company first. Explain you were at a covered facility, were sent around to different doctors and specialists in that facility and that you received what is called a “balance bill.” They will file a dispute with the provider and request removal of the balance bill on the account. I asked my insurance company if the provider is forced to accept the contractual amount only and was told that not in the state of Georgia. The balance billing law only prevents “In-network” providers from balance billing.

I’m not sure how to head this off besides when you show up for an appointment, force the intake desk to look up which physicians and specialists you will be seeing (including pathologists) and then call your insurance company to find out if they are covered. Do this right on the spot. If they are not covered, your only option is to call the practice where they work, and ask if they balance bill. If they do, you might refuse treatment through that practice and ask to be seen by an “In-network” specialist or doctor. This will probably result in a delay of your procedure or test, but it will save you heartache and time at the end.

Unless Georgia gets this under control, patients will always be the victims in the insurance bureaucracy. Its not a good place to be when you are trying to heal.

I’m in contact with the Finance VP at ARMC to find out if there is a way to prevent this in the future but I haven’t yet received a possible resolution. I will update this as I get responses.