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Another reason to hate our healthcare system
Posted by: Ombligo
Date: November 29, 2020 05:04AM
We make a point of using medical providers who are in our insurance network. When my wife went to the ER at a network hospital, due to a bed shortage she was admitted to a sister facility (also in our network).

Now the surprises start - While it is a network hospital, most of the doctors are not on ANY insurance plans. If she had been admitted to the hospital we went to, she would have been attended to by her local physician who is in the network.

Now we are finding out that the ER doctor (who we had no choice in as he was the only doctor there) is not part of any network. Then the attending physician assigned to her (again no choice) also is not in the hospital network.

End result, I'm looking at more than $10,000 of out-of-network medical bills that insurance will not cover despite being at a network facility. The doctors figured out they have a captive audience and don't need to deal with insurance. They charge full rates and will not negotiate.

Why even bother anymore.



“No persons are more frequently wrong, than those who will not admit they are wrong.”
-- François de La Rochefoucauld

Growing older is mandatory. Growing up is optional.
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Re: Another reason to hate our healthcare system
Posted by: Speedy
Date: November 29, 2020 05:09AM
Ouch. I have no advice but I wish you good luck fighting it. I hope your SO is recovering swiftly.



Saint Cloud, Minnesota, where the weather is wonderful even when it isn't.



Edited 1 time(s). Last edit at 11/29/2020 05:10AM by Speedy.
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Re: Another reason to hate our healthcare system
Posted by: Buzz
Date: November 29, 2020 05:49AM
You didn’t authorize any out of network treatment, so don’t make any out-of-network payment for it.
Thank them for your care, then tell them to pound sand for any and all above network charges.

Odds are there’s something in the bill that shouldn’t be there; find it and use it to stop any harassment they give or try with you.
PM me for the full 411 and pep talk.
==
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Re: Another reason to hate our healthcare system
Posted by: S. Pupp
Date: November 29, 2020 06:03AM
That seems to be an example of a complication of the healthcare industry considering itself a "business." It's not a business, it's healthcare.

I can understand not wanting being under the thumb of insurance companies, with their ethically sketchy contracts ("if we make a decision that your treatment plan is unnecessary and will not be paid for, you will inform the patient that we are correct, or your contract with us will be terminated," etc) and dangerous delays in treatment. However, to have such a "captive audience," as you so rightly put it, strikes me as just as unethical.

There is so much wrong with our healthcare system in this country. It's no wonder that 60+% of physicians are burned out. You'd think that the efforts of healthcare administrators to identify such physicians would be a sign that they want to change their behavior in order to reduce burnout of their fellow human beings, but no: "It is vital to discover physicians suffering from burnout, so we can weed them out of our healthcare system." (I forget where I read this, so can't offer a reference)

It used to bug me to no end when in practice.
Now I'm a patient, well, at least I knew what to expect.
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Re: Another reason to hate our healthcare system
Posted by: space-time
Date: November 29, 2020 07:27AM
I would not pay those bills.

That being said, I am not sure what happens if they send the accounts to collection agencies. I am not sure if that ends up on the credit report, it shouldn't since this was not a loan or a line or credit.

I never give them my SSN, just insurance card. If they ask for SSN, I say I don't have any. If they ask how I get by, and how I get paid, I say that is none of their business. (of course I have SSN and I pay taxes).
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Re: Another reason to hate our healthcare system
Posted by: Ombligo
Date: November 29, 2020 08:06AM
In my fast research, this is becoming common in Florida as the state law sides with the physicians. If it was New York, they must accept the fee arranged by the hospital and Insurance company.

The other fun thing I discovered is he ordered a plasma transfusion that may still be considered experimental. No idea the cost, but will bet that insurance will say no coverage. We really can't complain about it as we would have authorized it regardless. It did make a difference.



“No persons are more frequently wrong, than those who will not admit they are wrong.”
-- François de La Rochefoucauld

Growing older is mandatory. Growing up is optional.
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Re: Another reason to hate our healthcare system
Posted by: Janit
Date: November 29, 2020 08:19AM
Quote
Buzz
You didn’t authorize any out of network treatment, so don’t make any out-of-network payment for it.
Thank them for your care, then tell them to pound sand for any and all above network charges.

Odds are there’s something in the bill that shouldn’t be there; find it and use it to stop any harassment they give or try with you.
PM me for the full 411 and pep talk.
==

Chances are that some kind of document was signed on or after admission authorizing treatment. Find this document and read it carefully. If you don't have a copy of such a document, ask the hospital for a copy.

Look carefully at the provisions for emergency care in your insurance documents. I would expect that ALL emergency treatments should be covered, and that your insurance provider is trying to argue that somewhere along the line your wife's care morphed from "emergency" into "non-emergency." They may be playing fast and loose with definitions to argue this. Look carefully at the status under which your wife was admitted, and see if her status was changed by the hospital at any point. Hospitals work these categories to their own benefit, and the insurers work the categories to THEIR benefit. Sometimes this benefits the patient, but often it does not. You may need to get the hospital to correct your wife's admission status.

First get the insurance provider to agree that the ARE responsible under the emergency provisions, and get them to pay the doctors their customary rates. THEN take on the out-of-network doctors for the balance-billing.

I am not a lawyer, of course, but these are the things I would investigate.

NPR and Kaiser Health News do a "Bill Of The Month" feature. It might be worth contacting them for help.

[www.npr.org]
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Re: Another reason to hate our healthcare system
Posted by: DeusxMac
Date: November 29, 2020 08:29AM
In a similar matter for those making Medicare decisions; Medicare “Advantage” plans have significant restrictions on doctors AND facilities they will cover!

When the need arose to get my elderly father into a rehabilitation facility, many in the area would simply NOT accept any patients with Advantage plans, but would accept those with regular Medicare. This extremely limited his choices.
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Re: Another reason to hate our healthcare system
Posted by: Acer
Date: November 29, 2020 08:33AM
OK, so, which provision in the Republicans' health care plan solve this? Price lists so you can shop around? Selling insurance across state lines? Limiting tort? High deductibles and co-pays so you have skin in the game and don't use health care just because it's free--oh, wait, we have that one.
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Re: Another reason to hate our healthcare system
Posted by: voodoopenguin
Date: November 29, 2020 09:06AM
Ombligo you have my greatest sympathies. I just cannot understand how what was the greatest country in the world and that very soon will regain that title has allowed such a health care system to develop over the years.

Paul



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Re: Another reason to hate our healthcare system
Posted by: Lux Interior
Date: November 29, 2020 09:10AM
Quote
Acer
OK, so, which provision in the Republicans' health care plan solve this? Price lists so you can shop around? Selling insurance across state lines? Limiting tort? High deductibles and co-pays so you have skin in the game and don't use health care just because it's free--oh, wait, we have that one.

What we have learned since March, is that our role is to be cannon fodder to serve the economy. There are plenty of us so 250,000 (and counting) extra dead is a minor sacrifice to keep the stores/bars/restaurants open.

So, you can pretty much tell how important our health is to republican lawmakers.
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Re: Another reason to hate our healthcare system
Posted by: rgG
Date: November 29, 2020 09:44AM
I am so sorry.
I think one of the worst things about our system, or rather the lack of a system, is that things like this come at you at the worst possible time, when you or someone you love is sick.
It is truly cruel to do this to people.
I think you have been given some good advice here.
The only thing I would add is that most hospitals have patient advocates, so maybe this person could help you.





Roswell, GA (Atlanta suburb)
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Re: Another reason to hate our healthcare system
Posted by: Spock
Date: November 29, 2020 10:20AM
Quote
voodoopenguin
Ombligo you have my greatest sympathies. I just cannot understand how what was the greatest country in the world and that very soon will regain that title has allowed such a health care system to develop over the years.

Paul

Rapacious monopolistic capitalism at its worse.

MAGA - morons are governing america.



Comedy Central: Best news channel that isn't a news channel.

Fox News: Best comedy channel that isn't a comedy channel.
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Re: Another reason to hate our healthcare system
Posted by: wurm
Date: November 29, 2020 10:20AM
I don't recall where you are, but I would certainly contact your state Attorney General's office. No harm in trying.
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Re: Another reason to hate our healthcare system
Posted by: Spock
Date: November 29, 2020 10:26AM
Quote
wurm
I don't recall where you are, but I would certainly contact your state Attorney General's office. No harm in trying.

Florida !!!

With a governor and majority of his cabinet cabbage brained, he'd be better off contacting the Agriculture Commissioner.



Comedy Central: Best news channel that isn't a news channel.

Fox News: Best comedy channel that isn't a comedy channel.
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Re: Another reason to hate our healthcare system
Posted by: sekker
Date: November 29, 2020 11:07AM
Quote
Spock
Quote
voodoopenguin
Ombligo you have my greatest sympathies. I just cannot understand how what was the greatest country in the world and that very soon will regain that title has allowed such a health care system to develop over the years.

Paul

Rapacious monopolistic capitalism at its worse.

MAGA - morons are governing america.

Sorry to say it, but AMA likes the current system... it’s not MAGA, was started long ago. We are just at the inevitable crossroads.
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Re: Another reason to hate our healthcare system
Posted by: space-time
Date: November 29, 2020 11:08AM
Meanwhile, how is your wife? IIRC she had Covid (unless I mistake you with someone else).
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Re: Another reason to hate our healthcare system
Posted by: davester
Date: November 29, 2020 11:18AM
Healthcare system? The US has no healthcare system. We have a loosely connected, poorly regulated network of for-profit insurance and medical treatment corporations



"In science it often happens that scientists say, 'You know that's a really good argument; my position is mistaken,' and then they would actually change their minds and you never hear that old view from them again. They really do it. It doesn't happen as often as it should, because scientists are human and change is sometimes painful. But it happens every day. I cannot recall the last time something like that happened in politics or religion." (1987) -- Carl Sagan
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Re: Another reason to hate our healthcare system
Posted by: SteveO
Date: November 29, 2020 11:25AM
Sorry to hear, positive vibes for quick healing for your wife, and a quick, good resolution to your issue.

No offense to my fellow lefties, but to blame all this on Rs, while it may feel good, is unfair and just wrong. The Ds also take a LOT LOT LOT of money from health ins cos and other related lobbyists to keep our shitastic system in place. We can start by demanding a real public option from our Dem "leaders." Once the MAGAs get a hold of what a real and fair health care system feels like, they will have to pry it out of everyone's cold, dead hands....and that is the industry's worst fear...that we actually GET A GOOD PUBLIC OPTION. Congress has a great health care plan, and my understanding is once you're in it, you get it for life. Why aren't they subject to the same bs plans we are? Another demand to make.

Example: I believe it was early this year, or last year, that the CA house voted on a public option bill. The Speaker of the House, a DEM, shut it down. Wonder why, hmm? Follow the money. It always comes from and leads to the same places.

Until we rise up and actually CLAIM fairness that is due to us, the rest of us remain fscked.
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Re: Another reason to hate our healthcare system
Posted by: Ombligo
Date: November 29, 2020 11:35AM
Quote
space-time
Meanwhile, how is your wife? IIRC she had Covid (unless I mistake you with someone else).

She is doing much better, there is hope that she will be home in a day or two. She will likely still be on oxygen, but rest is the key. Sixteen days in isolation is a long time. A covid test was done this morning with results due Tuesday. However that was just for records, she gets sent home even if she is positive. That is now the norm nationwide apparently. The beds are needed and patients are told to isolate at home with everyone else wearing a mask and distancing.



“No persons are more frequently wrong, than those who will not admit they are wrong.”
-- François de La Rochefoucauld

Growing older is mandatory. Growing up is optional.
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Re: Another reason to hate our healthcare system
Posted by: August West
Date: November 29, 2020 12:15PM
Wishing you the best, with a full recovery for the Mrs.; it's unbelievable that others will happily put you through such hell.



Apologies to the anonymous forum member affected by my previous sig pic. It was my personal pic of a country expressing great grief as their leader, one of the most recognized people in the world, lay on his deathbed 8 years ago, days before he died. Like a naif, I did not realize it was offensively political, I considered it an expression of deep emotion and a reminder of the mortal coil's nature; that we all, great and small, can only hope to make a difference in our short time here, no matter the personal cost.

I'll post another pic from my work in South Africa that is, hopefully, apolitical.

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Re: Another reason to hate our healthcare system
Posted by: GGD
Date: November 29, 2020 12:18PM
Wishing your wife a speedy recovery.

Have you checked the terms of your insurance carefully? Each type (HMO, EPO, PPO, etc) has different rules, I always go for the PPO so that I can see any doctor. My main medical center and doctors are in-network, but out of network is covered with separate deductibles, a lower % paid by insurance, and separate out-of-pocket maximum.

The out-of-pocket maximum is the important one to limit your liability, it may be high, but it's a cap on cost. See if you have one that these bills are counting against.

I'm going to be transitioning to Medicare next year and as others have said, that too has lots of plans and the Advantage plans that seem to be popular (or heavily advertised) come with networks. The medical center I use will only accept one Advantage plan, and it's one that they run, but they will take any "regular" Medicare. So I'm looking at Medigap plans instead that will be accepted by any place that takes Medicare, no separate networks, and will have an out-of-pocket maximum.

Now drug plans are another can of worms, to compare them you need to predict what drugs you will need in the next year, easy for daily drugs for things like blood pressure or cholesterol, but impossible for drugs that may be needed if you get sick.
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Re: Another reason to hate our healthcare system
Posted by: mattkime
Date: November 29, 2020 01:29PM
I'm sorry to hear what you've been through.

Fight tooth and nail.

About a year ago I can a bike accident. Low speed, hit a patch of ice, just fell on my hip wrong. I was outraged to discover that ambulance companies (in this case, the city I live in) don't negotiate with insurance companies. Insurance pays a set amount, the rest is billed to the patient.

I did find a loophole - they'll let me pay a dollar a month basically forever. No interest. This will take longer to pay off than my mortgage.



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Re: Another reason to hate our healthcare system
Posted by: Buzz
Date: November 29, 2020 01:45PM
Had a non-major surgery awhile back at the very famous, in-network, major teaching hospital, w/ my in-network surgeon. Assistant surgeon was a student probee from the affiliated med school, that I had agreed to before the procedure. The anesthesiologist was a doc I knew, and that was good friends w/ my old golf buddy docs, who had agreed to take in-network rates, also prior to the procedure.

After the surgery, when the bills started rolling in, I got a bill from an out-of-network assistant surgeon that wasn't even there! The assistant surgeon's office got pretty aggressive about collection, until I informed them that while I was sedated, I was still awake, and aware of what was going on. That included talking w/ the med school probee before, during, and after my surgery. The fake assistant surgeon's office had tried to claim that since I was unconscious, I probably wouldn't known about his presence in the OR.... fail. Then they tried to claim that he was dressed and ready, and on standby outside the OR, and therefore should still be paid...... also fail.

My insurance company paid about 8% of the assistant surgeon's billed fees, and I told the fake assistant surgeon's office where they could go, and what they could do about the clearly fraudulent fees they were trying to collect, especially the 92% they were coming after me for. About a week later I got a message on my answering machine that "they would settle for the in-network stipend/fee" paid by my insurance company. I called them back, and asked for confirmation in writing, and reminded them that they were actively and willfully engaging in insurance fraud. Didn't get the requested confirmation letter, and never heard from 'em again.

Another bill came from the anesthesiologist's office for some out-of-network services.... not fraudulent per se, but not agreed to, and that took just a couple of friendly calls to resolve; my insurance company and the gas-passer's office had to re-jigger the billing to conform to the in-network rate schedule.

That's only one instance. Unfortunately, we have several more that involve all sides/aspects of healthcare. CIGNA didn't/wouldn't sign off/approve my back surgery until the week after it was performed.... my surgeon had to guaranty it after CIGNA dragged their heels for over 6 months...., which was at least 4 months too long. All kinds of grief resulted thereafter. Next, an out-of-network surgicenter and an in-network surgeon's office tried to rip us, and UHC off to the tune of >$250K in conjunction w/ Baby Buzz's sinus surgery. That was worse than the Nightmare on Elm Street. Then there's Mrs. Buzz's droopy eyelid resection surgery, and the surgical removal of the steel plate from her shattered leg after her nasty skiing accident in the Alps a couple of years earlier.... a couple of more episodes from Healthcare Hell.

There are plenty more, but the moral of the stories is, that Hellthcare Hell exists for damn near everyone, and the peeps in the loop all will try to pass the buck, and buck the responsibility every chance they get. It's a struggle to get stuff straightened out, and sometimes it doesn't get straightened out properly.
Better moral: Stay Healthy!
==
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Re: Another reason to hate our healthcare system
Posted by: Spock
Date: November 29, 2020 02:15PM
Quote
sekker
Quote
Spock

MAGA - morons are governing america.

Sorry to say it, but AMA likes the current system... it’s not MAGA, was started long ago. We are just at the inevitable crossroads.

Perhaps I should have added "MAGA - morons are governing america and as far as healthcare is concerned this won't change on the Jan 20th 2021."

The need for change is obvious but the political will is sadly missing.



Comedy Central: Best news channel that isn't a news channel.

Fox News: Best comedy channel that isn't a comedy channel.
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Re: Another reason to hate our healthcare system
Posted by: sekker
Date: November 29, 2020 02:16PM
I hope your wife recovers soon, and that you can find ways to address all of this extra unnecessary stress in your lives (not counting the legitimate extra costs you are having to incur).
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Re: Another reason to hate our healthcare system
Posted by: Janit
Date: November 29, 2020 03:33PM
I had forgotten that it was Covid. I would also look into what special provisions may be in place for Covid treatment. You do need to fight this tooth and nail, and it may well be that every other word in the conversation should be Covid.
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Re: Another reason to hate our healthcare system
Posted by: rjmacs
Date: November 29, 2020 03:37PM
I'm sorry, Ombligo. This is the thresher we put people through in this country, and that's just people who have insurance.

The very existence of the profit motive in the provision of healthcare (not efficiency, profit) undermines the legitimacy of the industry. Some things should not need to generate excess revenue.



rj
AKA
Vreemac, Moth of the Future
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Re: Another reason to hate our healthcare system
Posted by: AllGold
Date: November 29, 2020 07:51PM
I'm with Buzz on this one -- don't pay it.

Emergencies should be covered at in-network rates, period. If not, then the billing got coded incorrectly. (Or you have the worst insurance ever because I've never heard of an insurance plan where emergency services get billed at out-of-network rates.)

It sounds like there are other billing/coding errors, too.



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Re: Another reason to hate our healthcare system
Posted by: abevilac
Date: November 29, 2020 08:31PM
I’m very sad to hear this; it’s so maddening — good luck. I hope your wife gets the rest she needs and heals quickly.
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Re: Another reason to hate our healthcare system
Posted by: mrbigstuff
Date: November 29, 2020 08:32PM
All great advice, I'm of no help except to offer some encouragement to fight it with the advice given.

The most infuriating part of this whole debacle came when ads by hospitals began to air on television to drum up business. Your healthcare dollars at work.
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Re: Another reason to hate our healthcare system
Posted by: RgrF
Date: November 29, 2020 08:48PM
I ran into this sort of billing shenanigans after one of my emergency surgeries. I at first ignored the bills but eventually mounted a full scale counter attack alleging "uninformed consent", in the end they all backed down.

Seems that for them it's a no lose situation. If the bill gets even partially paid they come out ahead and if no one objects and the fraudulent bills goes unpaid it creates a tax write-off for the medical PC and in some cases a credit ding for the patient. So the only loser is the patient.
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Re: Another reason to hate our healthcare system
Posted by: vision63
Date: November 29, 2020 09:06PM
Quote
DeusxMac
In a similar matter for those making Medicare decisions; Medicare “Advantage” plans have significant restrictions on doctors AND facilities they will cover!

When the need arose to get my elderly father into a rehabilitation facility, many in the area would simply NOT accept any patients with Advantage plans, but would accept those with regular Medicare. This extremely limited his choices.

Broadway Joe is helping with the Advantage plan and Magnum PI with the mortgage.
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Re: Another reason to hate our healthcare system
Posted by: vision63
Date: November 29, 2020 09:16PM
Quote
Ombligo
We make a point of using medical providers who are in our insurance network. When my wife went to the ER at a network hospital, due to a bed shortage she was admitted to a sister facility (also in our network).

Now the surprises start - While it is a network hospital, most of the doctors are not on ANY insurance plans. If she had been admitted to the hospital we went to, she would have been attended to by her local physician who is in the network.

Now we are finding out that the ER doctor (who we had no choice in as he was the only doctor there) is not part of any network. Then the attending physician assigned to her (again no choice) also is not in the hospital network.

End result, I'm looking at more than $10,000 of out-of-network medical bills that insurance will not cover despite being at a network facility. The doctors figured out they have a captive audience and don't need to deal with insurance. They charge full rates and will not negotiate.

Why even bother anymore.

What a nightmare. Think it all through. That's a lot of money.
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Re: Another reason to hate our healthcare system
Posted by: PeterB
Date: November 29, 2020 09:59PM
Ombligo, so sorry to hear of all of this, and the best wishes towards a speedy recovery for your wife and a return to normalcy (or at least as close to normal as possible under the circumstances).

In addition to the great advice above, do not be afraid -- should it come down to it -- to use your local politicians, social media, and the news networks to your advantage. (Janit makes reference to the latter above.) Sometimes the only way to get people/organizations to do the right thing is to shame them into it by shining a spotlight on their shady business practices, and just like cockroaches, suddenly you'll see them scurrying away. If that fails to work, seek legal satisfaction.




Freya says, 'Hello from NOLA, baby!' (Laissez bon temps rouler!)
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Re: Another reason to hate our healthcare system
Posted by: Bill in NC
Date: November 30, 2020 10:26AM
Pound the h*** out of the internal appeals process then go to local TV news if that doesn't work.

Plenty of doctors magically agree to accept in-network fees after being contacted by the "on-your-side" reporter from the local TV station in lieu of being personally identified on-air.



Edited 1 time(s). Last edit at 11/30/2020 10:27AM by Bill in NC.
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Re: Another reason to hate our healthcare system
Posted by: Michael
Date: November 30, 2020 08:43PM
A couple of people have mentioned Medicare Advantage programs and that they can be a problem with out-of-network care. I can't speak to all of them, of course, but our United Health Care will pay for out-of-network care, but sometimes at different rates.

Here's a quote from the Evidence of Coverage document:

Why do you need to know which providers are part of our network?
As a member of our plan, you can choose to receive care from out-of-network providers. Our plan will cover services from either in-network or out-of-network providers, as long as the services are covered benefits and medically necessary. However, if you use an out-of-network provider, your share of the costs for your covered services may be higher. See Chapter 3 (Using the plan’s coverage for your medical services) for more specific information.


Looking at the document in-network and out-of-network columns, most things are the same cost for co-pays. There are some things that are substantially more out-of-network co-pays, such as opiod treatment ($0 in and $395 out). Skilled nursing facilities are very different; $0 for days 1-20 and $160 daily for days 21-62 and $0 thereafter to 100 days when in-network. Out-of-network it's $195 for days 1- 35 and $0 for days 36-100. For the most common thing that we do, it's $5 to see an in-network primary care physician and $20 out of network. But, a bunch of things are the same co-pay in and out: specialist visits are $45 for either; urgent care visits are $0 for either; routine physicals are $0 for either; ER visits are $90 for either and that's waived if you're admitted; and it's $395 per day for days 1-4 for hospital admission for either (and $0 for either for additional days).

When we signed up for Medicare Advantage we used a service that our university system provided that looked at our medical needs and recommended particular Medicare and Medicare Advantage options. I didn't read any of the ones that were low-rated so I don't know if they just don't pay out-of-network, but I do know that a couple of them do pay out-of-network and we just chose the one that was highest rated for our needs. I'd suggest that those who are considering Medicare Advantage use one of the services that compares different options.
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Re: Another reason to hate our healthcare system
Posted by: DeusxMac
Date: November 30, 2020 08:59PM
Quote
Michael
A couple of people have mentioned Medicare Advantage programs and that they can be a problem with out-of-network care. I can't speak to all of them, of course, but our United Health Care will pay for out-of-network care, but sometimes at different rates.

Here's a quote from the Evidence of Coverage document:

Why do you need to know which providers are part of our network?
As a member of our plan, you can choose to receive care from out-of-network providers. Our plan will cover services from either in-network or out-of-network providers, as long as the services are covered benefits and medically necessary. However, if you use an out-of-network provider, your share of the costs for your covered services may be higher. See Chapter 3 (Using the plan’s coverage for your medical services) for more specific information.


Looking at the document in-network and out-of-network columns, most things are the same cost for co-pays. There are some things that are substantially more out-of-network co-pays, such as opiod treatment ($0 in and $395 out). Skilled nursing facilities are very different; $0 for days 1-20 and $160 daily for days 21-62 and $0 thereafter to 100 days when in-network. Out-of-network it's $195 for days 1- 35 and $0 for days 36-100. For the most common thing that we do, it's $5 to see an in-network primary care physician and $20 out of network. But, a bunch of things are the same co-pay in and out: specialist visits are $45 for either; urgent care visits are $0 for either; routine physicals are $0 for either; ER visits are $90 for either and that's waived if you're admitted; and it's $395 per day for days 1-4 for hospital admission for either (and $0 for either for additional days).

When we signed up for Medicare Advantage we used a service that our university system provided that looked at our medical needs and recommended particular Medicare and Medicare Advantage options. I didn't read any of the ones that were low-rated so I don't know if they just don't pay out-of-network, but I do know that a couple of them do pay out-of-network and we just chose the one that was highest rated for our needs. I'd suggest that those who are considering Medicare Advantage use one of the services that compares different options.

Note that there is a critical difference between an Advantage Plan willing to pay out-of-network, and an out-of-network provider willing to accept Advantage payments; they don’t all.
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Re: Another reason to hate our healthcare system
Posted by: AllGold
Date: November 30, 2020 10:20PM
I don't think Medicare Advantage is relevant in this case. The rules for non-Medicare coverage are entirely different.



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Re: Another reason to hate our healthcare system
Posted by: Janit
Date: December 02, 2020 07:44AM
I am enrolled in a Medicare Advantage Plan, but some of the issues I encounter may relate to other coverage as well.

Prominent in the new Braven Medicare Advantage plans being rolled out in NJ is this notice:

Quote

Benefits During Disaster or Emergency

You’ll have access to your benefits during a public health emergency or disaster. When one of these events is declared, and until it ends, we’ll:

Cover out-of-network services and benefits at network rates
Waive referral requirements, where applicable
Make changes that benefit you effective immediately, without the required 30-day notice

This appears to apply to both their PPO plan AND their HMO plan (which ordinarily does not cover any out-of-network services).

I encourage you to investigate anything in your plan or in your state that may relate to such circumstances. Your wife's situation was doubly affected by the COVID pandemic, as this was her illness, and your preferred providers were unavailable to treat her because they were already full to capacity.
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