Out-of-network costs cripple many patients financially

Out-of-network costs cripple many patients financially

By Paul Raeburn | Kaiser Health News


WASHINGTON — On the evening of March 1, 2008, Gary Diego was relaxing with his wife, Ellen, when she abruptly lost her hearing, began repeating herself, and seemed to be losing her grip.

Alarmed, Diego rushed her to his insurance company's in-network hospital, near his home in Truckee, Calif. Unable to handle what was determined to be bleeding in the brain, the hospital quickly transferred her to Renown Regional Medical Center in Reno, Nev., where she spent 17 days in intensive care. While recovering, she caught pneumonia and died.

A few weeks later, a still-grieving Diego learned from his insurer, Health Net, that he owed the Reno hospital more than $75,000. The reason? The hospital wasn't in his approved network.

Diego's story is an extreme example of what can happen in medical emergencies. Consumers who are careful to choose in-network doctors and hospitals for their routine medical care often can't choose where or how they are treated in an emergency. In a practice known as balance billing, insurers pay a portion of the out-of-network charges, and the balance owed to hospitals and doctors is dumped on patients.

Until recently, the problems associated with out-of-network emergency care had received little attention. But now they're being attacked on multiple fronts, with insurers, hospitals and doctors pointing fingers at each other, and patients stranded in the middle.

more...

http://www.mcclatchydc.com/washington/story/74099.html

A friend of mine recently got sick while on vacation. Her insurance had ONE doctor nearby in their network. He wasn't accepting new patients.

'They'll tell you which doctor you can and cannot see and they'll ration your care.'

Anyone with any brains at all can figure out that every time the Republicans open their mouths, they are only admitting what is wrong with the present system that benefits the Insurance, Medical, and Pharmaceutical Industries.

either. It just means a facility that didn't contract with a particular insurance company. We have a hospital about a mile from us and one about 6 miles away. The one closest was out of network and the one farther was in network. The insurance company also will switch them from year to year so it's easy to go to the wrong one thinking it was still in network. It's a sneaky way to limit their liability for the health care they should be covering.

they'd do away with this network and out of network b.s. along with abolishing pre-existing conditions cop-out clauses industry wide. Then again pigs will start flying soon I'm told.


I seem to remember listening to an interview with a PR bimbo working for the insurance lobby around the time Hillary tried to get something done. There was this talk back then about how insurance companies were more than ready to do away with the pre-existing conditions stipulation in their policies and that they didn't need to have new legislation to accomplish that. :eyes:

One piece of reform I'd like to see is that providers of services at all levels be REQUIRED to calculate how much will be covered under your plan.

Case in point:
I'm sent to Physical Therapy for shoulder pain.
Staff at PT clinic can tell me what the cost is for uninsured, but have no clue what my plan will cover.
My plan is written in an incomprehensible way.
These details could easily be accessed electronically, how much deductible remains, copay, etc.
After 8 treatments I get a fat bill.
Had I known, I'd have only had two treatments.

Case two:
I've gone to the same lab for 12 years for routine blood and urine testing for cholesterol, etc.
Every Single Motherfucking Time I have to fill out the forms.
Every Fucking Time.
My old plan through same employer covered full cost.
New plan requires I pay $188.
Lab doesn't tell me, and doesn't send me a bill.
Go to get a FICO score to find it's gone from 851 to 695 because of a collection from an unpaid bill from the fucking lab.

:banghead:

In this electronic age, there's no reason (except in emergencies) that a provider, be it an ambulance, lab, therapist, or other, shouldn't be able to access your insurance records and tell you up front if there will be out of pocket costs and what they will be.

:nuke:

them to manage and interpret claims with various insurance companies.

Now whether it's the provider's job or the responsibility of the insurer to tell us is immaterial.

The fact remains that it's next to impossible to find out and it wouldn't be that hard to mandate clarity and transparency with respect to costs.

various providers that is the real problem.

:shrug:


Policies to address out-of-network charges

Posted by Don McCanne MD on Wednesday, Aug 19, 2009

http://pnhp.org/blog/2009/08/19/policies-to-address-out-of-network-charges/

"What are private insurers selling us? Their primary product is a network of health care providers that have contracted to accept the insurers’ rates. The benefit of that is that it has helped to slow the rate of increase in health insurance premiums. One major problem with that is individuals frequently obtain care from out-of-network providers – usually not by choice, but by medical circumstances not really under the control of the patient. Under most insurance plans, the individual then becomes responsible for payment of most or all of the out-of-network charges.

...It’s also the American way for Mr. Diego to receive a $75,000 out-of-network bill for his wife’s life-threatening and life-ending care. Haven’t we had enough of our uniquely American system?

There is another way of protecting patients from out-of-network charges. The government can require that out-of-network fees be close to insurer-authorized payments within networks. Yes, that would be the imposition of government fee controls, but fees that are designed to match fees already imposed by the private insurer bureaucracies. That would help, but it does bring up an important question. If the government is going to impose fee controls anyway, then why should we continue to pay the costs of the outrageous administrative waste of the private insurers?

Some might say that they do provide us with the function of pooling risk. But one of the goals of reform is to pool risk across insurers, relieving them of the burden of bearing risk. If we achieve risk equalization then it would be much more efficient and equitable to establish a single universal risk pool administered by the government. Again, the private insurers would be superfluous..."


AHIP explains why private insurance is a bad deal

http://www.pnhp.org/news/2009/august/ahip_explains_why_pr.php

Comment:
By Don McCanne, MD

"As we look at comprehensive health care reform, we really have to ask ourselves just what is it that the private insurance plans are providing us in exchange for their exorbitantly high administrative costs and the costly administrative burden they place on the health care delivery system?


...So what service are they providing us? They have instituted private sector price controls by establishing contracts with hospitals, laboratories, health care professionals and other sectors of the health care delivery system. Their report released this week confirms that this is an important function. Prices set by the health care industry are much higher than prices dictated by the health insurance industry. If you think health insurance premiums are high now, just think of what they would have been without the private sector price controls applied to the contracted networks of providers.

Of course, there are trade offs. It is very expensive to provide the administrative services of both the insurers and the providers that are necessary to establish and manage these contracts. More dollars are diverted from actual health care to pay for these administrative excesses. A more perverse trade off is that patients are denied their free choice of health care professionals, hospitals, and laboratories since they must choose from the limited in-network panels provided by the insurers. They are limiting our choices, and they are charging us more for these unwanted services. Who wants that? ...."

And I'm of above average intelligence.

Can you imagine how hard it is for my mom and dad in their 80's?

Even with their medicare, I have to be the primary contact with all of their providers.

Let me tell you, medicare will benefit from reform with respect to records--BIG TIME!

:thumbsup:

to read through all the garbage, they just want medical care without going broke.

but when you're having chest pains it's probably not a good idea to start calling around to find out who has the cheapest ambulance ride or which hospital charges less for cardiac care.

Jeez, people, is it really that difficult?

The closest 'in network' doctor is about the same distance away. There are doctors closer to home, but not 'in network'. When I am sick enough to go to the doctor, I am in NO condition to travel for an hour to see a doctor.

And, with a $ 5,000.00 deductible, I have to be DAMN sick before I go near medical help.

Death, I can afford. Health care, not so much.

So, 'in network' has been a problem for me for quite some time. It's not always about an emergency situation.

Well, at least it was that way before I got laid off, couldn't afford the COBRA and just let the insurance lapse.

"the system is fine the way it is" contingent.

but for out-of-network it's $25,000. :grr:

And yet we have wacko teabaggers screeching to maintain the status quo. WTF?????