Fw: NYTimes.com: How Not to Get Blindsided by Out-of-Network Fees

February 18, 2009

I thought this was a great article and wanted to share it with the group. I'm

always looking for tips on navigating the insurance companies.

Charlotte

mom to , severe apraxia and 3 1/2 years old

February 14, 2009

Patient Money

How Not to Get Blindsided by Out-of-Network Fees

By WALECIA KONRAD

How much, if anything, does your health insurance company reimburse you when you

receive out-of-network care? The question has never been more scrutinized than

now.

An investigation led by the New York attorney general, M. Cuomo, recently

uncovered that the database the nation’s insurers use to calculate

out-of-network charges consistently shortchanges patients. And because the

database is owned by the giant insurer UnitedHealth Group, Mr. Cuomo’s office

found that it was fraught with conflicts of interest.

Typically, patients go outside their insurer’s network of preferred doctors and

hospitals for two reasons. A medical emergency may demand immediate treatment

from whatever doctor or hospital is nearby. Or the patient may need to see a

specialist who is not part of the insurer’s network.

Plaintiffs’ lawyers throughout the country have filed several class action suits

on behalf of patients who feel they have been overcharged or unfairly denied

reimbursement for getting out-of-network care. And this past Tuesday the

American Medical Association, joining several state medical associations,

announced it was suing health insurers Aetna and Cigna, saying they used the

flawed database to underpay doctors for more than a decade.

This magnifying glass is good for consumers. Seventy percent of insured working

Americans are enrolled in plans that let them choose their own doctors — and

typically pay a higher premium for that privilege — which means that most

insured people would potentially benefit from reforms to the system. If

out-of-network reimbursements were more in line with reality, the average

payment on the insurer’s part could increase by 10 to 28 percent, Mr. Cuomo’s

office estimated.

But change won’t happen overnight. Until a new database can be set up by an

independent operator — a process that could take 6 to 18 months — the flawed

database will continue to be used to calculate out-of-network charges

industrywide. And even with reforms, consumer health care advocates don’t expect

an end to out-of-network disputes with insurers.

“There will still be cases where emergency room visits to out-of-network

hospitals get denied or an insurer turns down a request for an out-of-network

specialist,” predicted Candy Butcher, president of Medical Billing Advocates of

America, a clearinghouse for firms that help consumers when they have a dispute

over a medical bill.

So, the next time you need out-of-network care, here’s what you need to do.

Find out exactly what your plan covers. The recent headlines have sent plenty of

employees scurrying to their health plan handbooks to check up on out-of network

policies. You should too. Taking the surprise out of the equation can help you

decide whether to go out of network, when you have a choice, and can help you

plan for your share of the bill.

Most plans offer out-of-network emergency coverage, although the burden may be

on you to explain why the situation was an emergency and why you went to an

out-of-network facility. H.M.O.’s and other similarly restrictive plans may pay

a portion of out-of-network care only in an emergency or when you can prove that

the network does not include a specialist you need. So-called preferred provider

organizations, known as P.P.O.’s, offer more generous out-of-network coverage,

usually 70 to 80 percent of “reasonable and customary” charges.

But there’s the rub. The insurance industry uses that Cuomo-maligned database to

calculate what’s reasonable and customary in a local market.

Even if the insurer’s calculations can be trusted, often people forget about or

don’t understand the reasonable and customary part, says Tom Billet, a senior

executive with the benefits consulting firm Wyatt. “They figure if they

have a $100 doctor’s bill, they’ll get a check for $80,” Mr. Billet said.

But the insurer will reimburse you only 80 percent of what are considered

reasonable and customary charges in your area. If that number turns out to be

$80, your insurer will only reimburse you $64 (80 percent of $80). Your share of

the bill now goes from $20 to $36.

The new database should help increase the amount your insurer considers

reasonable and customary, but in the meantime you’re on the hook for the extra

payment. And even under the new system, 80 percent won’t necessarily mean 80

percent of the doctor’s actual bill.

Find out what your insurer’s reasonable and customary fee is for specific

treatments. Unfortunately this isn’t something you can do with one phone call.

First ask your doctor, or better yet, the person in your doctor’s office who

handles billing, for the “C.P.T. code” — the current procedural terminology —

for the test, treatment or consultation you’ll be receiving out-of-network. Get

it in writing to avoid errors.

Then, call your insurance company asking for prices. If the rep balks at giving

you this information, don’t be afraid to remind him or her of a little-followed

but important advisory by the Department of Labor that says usual and customary

charges should be disclosed to patients, said Cheryl Fish-Parcham, the deputy

director of health policy at Families USA, a consumer advocacy group. For more

information on the Labor Department advisory click here.

Negotiate with your doctor. If you find out your reimbursement for a specific

treatment will be lower than you expected, tell your doctor exactly what the

insurance company is going to pay and ask if he or she can lower the fee to that

amount. “When they join a network, doctors routinely discount their bills by 35

percent or so, “Ms. Butcher explained. “You should ask for the same, lower

rate.”

Prepare carefully for a hospital visit. If you receive care at an in-network

hospital you might assume that all the doctors you see will also be in your

network. Warning: That isn’t necessarily true.

Your surgeon may be on your network, but the hospital’s anesthesiologist or

other practitioner that treats you may not be. Some hospitals have contract

practitioners that are not staffers and thus not part of your network either. Be

sure to ask your doctor and someone in the hospital admissions office what

doctors you’ll be seeing and whether or not they are part of your network. If

they are not, find out if an in-network doctor is available.

Even with careful planning you may still end up being seen — and billed — by an

out-of-network provider. In that case, Ms. Butcher said, you need to tell the

hospital and the doctor that because you were not made aware of the specific

extra charges, the out-of-network provider should accept the fee your insurer is

willing to cover. There are no rules or regulations on this, but Ms. Butcher

said that in her experience most practitioners agree to the reduced rate when

patients complain.

If you think you were overcharged — fight back. You have the right to appeal any

denial of payment by your insurance company. First step, follow the appeal

procedures on your explanation of benefits. Also, contact your doctor’s billing

manager and your employee benefits manager for help in filing the appeal. Your

state’s attorney general and department of insurance may be able to help you.

Finally, a health care advocate can negotiate with the insurer on your behalf,

for a fee. To find one near you click

http://www.billadvocates.com/FINDANADVOCATE/tabid/69/Default.aspx

http://www.nytimes.com/2009/02/14/health/13patient.html

February 21, 2009

hi charlotte ,, daniel from kuala lumpur malaysia

________________________________

From: Charlotte McLaughlin <mckidsthree@...>

Sent: Thursday, February 19, 2009 4:14:40 AM

Subject: [ ] Fw: NYTimes.com: How Not to Get Blindsided by

Out-of-Network Fees