Insurance and Out of Network Care

Is this ridiculous? Or Am I misreading something?

Let me get this straight. These patients voluntarily sought out of network care, knowing that insurer didn’t pay those providers.

Then they got pissed off?! Insurer was dumb enough to send the checks to patients, who often times didn’t pay the various providers for services with that money, then got pissed when collectors came calling?

Is this a new welfare scam? One individual lamented she didn’t get near what a family member got for surgery. Let me know so far if I’ve misunderstood anything.

And while I’m at it, can anyone tell me what sort of relationship ‘fiancée’s daughter’ is for purposes of insurance coverage? Unless he adopted her, of course, then that’s a relation eligible as a dependent.

Schemes and scams like this that most likely drive up health care costs are one of many reasons I prefer concierge providers, and now have two. No insurance, or insurance doesn’t cover a service, they offer a discounted fee.

This wouldnt be an issue under single payer…

Go america for being stupid!

I did not read that at all…

  • The providers are the ones who are “angry” since they may not get paid.

  • The patients just seem confused… they did not do anything except get healthcare, and were sent checks. Yes, it looks like at least one person from Washington took that money.

  • The insurer is the entity driving this, purposefully, to get providers to change their policy… that is the whole point of the article.

Why are you blaming this on the patients? The only “scheme” here is by the insurers to pressure providers…

Why exactly did they think they were getting thousands and hundreds of thousands of dollars from their insurance companies?

The article plainly states the patients are supposed to send those checks to providers.

And who exactly if making them seek out of network care?

The real scheme is providers refusing to contract with insurers and charging 10x’s what it cost them to provide the care.

Our system is jacked up.

Healthcare is one of the only industry where consumers dont shop based on price.

Again, this is driven by the insurer. Answers:

  • They were surprised, like you would be.

  • It appears they did send them except for one instance noted.

  • The referring doctor, most likely, to see a specialist.

Your anger at the patients is misplaced and bizarre.

“Health care is the only industry where consumers don’t shop based on price.”

Actually there are various online resources available for comparative price shopping in health care.

Why should someone go for, let’s say, a $1,000 MRI if another facility charges half for the same exam.”

“Your anger at patients is misplaced and bizarre.”

What’s misplaced and bizarre is expecting that check in the mail is for other than a provider of health care services.

Also choosing a health insurance policy without understanding its terms—like what are the consequences of choosing out of network care—fits that decription.

Having worked full time close to 30 years, policies are pretty clearly stated before plan is chosen. This HMO doesn’t cover at all for out of network care. This PPO reimburses out of network 10% less than in network. This vision plan reimburses patients for glasses or contacts purchased out of network a paltry amount.

What is also misplaced & bizarre is an insurance company sending payment to patients rather than having a more straight forward policy with regards to out of network coverage. Yet another reason I prefer concierge providers—no middle man, just cash, check or charge.

If a provider doesn’t accept ones insurance, the insurance company will not pay the reimbursement to the provider. They pay it to the enrollee.

I use an out of network dentist. My insurance only reimburses me for 30% of the total cost. I pay my dentist the full amount billed at the time of service. My dentist then submits the paperwork to my insurer and a few weeks later I get a check from the insurance - made out to me.

I tried to read the article but I got a “this page doesn’t exist,” so I cannot comment on the situation outlined in the article.

I work for a pretty large health insurance company and for out of network claims that are above a certain dollar threshold we will send these “for negotiation”. This is where we contact the out of network provider and ask if they will accept a reduced amount compared to the billed charge. If they agree we then make payment directly to them bypassing the member plus they do not balance bill the customer.

A few years ago I was working with a customer who was expecting a check for about $70,000 for out of network services. We had issues with medical records etc which resulted in the inquiry being escalated to me. I got everything resolved including successful negotiation with the provider. When I told her she went ballistic, telling me she had already made a payment arrangement with the provider. Obviously my explanations that the payment arrangement was no longer necessary and she was saving a substantial amount of money fell on deaf ears because she was expecting a pay day. In her anger she even admitted that she had already earmarked the money for something else!!!

However, she was the exception and not the norm. Sure some people try to game the system but the vast majority of people go to out of network providers out of ignorance of their own benefits or network.

My advice to anyone is even if you have checked with the insurance company if the doctor is in-network, when you go to have services rendered just ask them if they still participate with your insurance company as an in-network doctor. It never hurts to double check.

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A few weeks ago I was sent to the ER by my doctor. I was there less than 3 hours and received a bill for $8,000. I had a CT scan and a shot of morphine. The single shot of morphine alone was $400!

After insurance my responsibility was $2,000 which was only the facility. I received a seperate bill from the ER doctor, tech who took the CT scan and for reading the results.

The crazy thing is that even at $2,000 it would have been cheaper for me to jump on a plane to the UK and get an uber from the airport to the nearest ER where as a UK citizen who has kept up to date with National Insurance contributions I am still entitled to healthcare free at point of service. Obviously that is not practical but you see what I am getting at.

I hope you’re doing well.

My limited understanding of medical pricing is—and this may not be explained by insurers—that E R docs are largely considered out of network providers, and this is why so much of the financial burden falls on patients.

I can only comment on my employers network and we find most ER doctors are in-network. We do have some that are out of network and even some ER facilities that elect to be out of network.

ER costs are outrageous which is why there is so much focus on helping customers find alternatives such as immediate care centers or even tele-medicine. We offer a 24-7 access to a video consultation with a doctor. The doctor can even prescribe medicine and send it to your pharmacy. There is a flat fee of $49 for the consultation and if the doctors determines you need a face to face visit with a doctor or need to go to the ER there is no charge.

Really? If I am directed to a doctor, the first thing I want to know is if he is part of my insurance company’s network. If not, I would request another doctor.
I realize this might not always happen, if say youre in network surgeon used an anesthesiologist who was not in the network. Mostly it is easy enough to do.
And if they are in network, they can’t just charge whatever they want.

Most anesthesiologists are not in network but they are covered by RAP protocols - these are rules which govern hospital based radiologists, anesthesiologists and physicians. These are services where the customer has no say therefore procedures are in place to ensure they are not held responsible.

You take the time to determine if a doctor is in network and good on you for doing that but many people do not especially if its their primary doctors that refers them to another doctor. A lot of people feel intimidated by their doctor and dont feel comfortable asking all those questions. Which is why health insurance companies have protocols for that. My employer allows the customer service teams to determine when situations like what you describe have occurred and can make the immediate adjustment to the claim.

Morphine is a helluva drug.

The lawyers and pols have made this so complicated it’s almost guaranteed we’ll screw it up.

And on that point we can both agree. ACA had a lot of good parts to it but it no way did it address the underlying causes of increasing health insurance costs, it was at its core health insurance reform not health care reform. There was nothing in the ACA that prompted health care providers to address their increasing costs. Same with lawyers, medical malpractice suits are out of control and the damages that are awarded are crazy.

Exactly right.

Making sure your provider is in network is only one part of value shopping.

Most folks have no idea what provider A charges vs what provider B charges.

Well, here is some information to change that: