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Posts Tagged ‘in-network’


Yep.  That’s me. Are you being screwed, too? 

I cannot think of another way to summarize the health care system besides using this term. When you live in a small, rural community that is isolated from the rest of the world, I really do think that the health care systems feels you are supposed to feel indebted to them while being screwed. And if you don’t?  Well, they don’t give a rip.

You may recall my earlier post about 2010 and the struggles I’ve been dealing with regarding medical billing. Yes, they continue. I spent nearly 6 hours non-stop today scanning, copying and summarizing the one situation in my complaint to my state’s Public Regulation Commission (PRC). 

Do I feel better? No. Why not? I’m expecting to be screwed yet again for reasons that are presently unknown to me.

The health care system is not just screwed up, it’s totally broken.  I have *zero* hope that it will ever get fixed.  Socialist health care won’t fix it. Goodness knows having insurance doesn’t contribute in any way past lowing the dollar amount owed by those with good insurance by which the consumer gets screwed.  It’s like having a bullseye on you when you have insurance.

Seriously.  One test now in dispute was billed at over $220.  Insurance says “reasonable and customary” for that procedure is around $40.  Insurance paid at 90% even though the PPO provider sent the labs to a non-PPO lab.  Which means…… I am “responsible” for paying the difference.  See -that’s getting screwed. 

Insurance says the contracted amount should only be around $40 and will pay over $35. My portion, if the lab had been under contract with my insurance group, would have been around $3.95.  But I, the consumer playing by the rules, is going to be billed the remainder of that $220 plus amount, and will be screwed if I don’t pay.  And, I’ll be charged tax on the whole amount because, since the provider is not in network, neither is lab testing, which means they can charge me gross receipts tax for any non-covered procedure.

I can’t tell you how darn tired I am of getting screwed. The consumer, as far as I know, has no recourse, except to file a complaint and ask for an investigation. It feels like everyone is out to take advantage of people who do have insurance, especially those in poor, rural locations where options for care are not abundant. 

In my opinion, if I go to a PPO (in-network) provider for a ser vice that is contracted and covered by my insurance, it should be the responsibility of the provider to perform and likewise send labs to other PPO providers. I was never given a warning that this would not be the case, nor the option to specifically chose who labs get sent to. Rest assured, I would have travelled 200 miles in any direction to ensure that things would go to ONLY PPO providers had I known the alternative. Traveling would mean ultimately paying more out-of-pocket, but to not have the battle afterwards would justify the expense, in my opinion.

I’ve also recently been told that no one cares about pursuing this because of the low dollar amount.  Excuse me? For me, it’s not so much the dollar amount as much as it is the principle of the thing.  I’m not one who says, “Oh, gee, because this one only costs “x” amount, I will pay it.” It doesn’t matter.  The point is that they could charge you *ANY* amount.  Dollar amount does not make something right. The could charge $2,000 for the labs or the procedure – they could only charge you $2. Some might say that the lower dollar amount isn’t worth their time to fight.

Who is going to pay me for the 6 hours I spent today to speak up? If they charged everyone $2 and no one complained, it wouldn’t take long for it to add up. They can screw up my credit rating over $2 if I don’t pay it, yet I have no recourse for unethical and fraudulent billing?

Here’s another problem with the medical community where I live.  In order to get into a doctor, it takes as a new patient nearly 3 months to be seen. Most doctors here are already overwhelmed and aren’t accepting new patients.  Until I got sick 3 years ago, the only medical person I saw in the last 15 years was my midwife. That’s right, I don’t use doctors unless I have to.

Now imagine you don’t have a family doctor and you or your child gets really sick with a respiratory something. Is it reasonable for you to wait 3 months to be seen – or even 2 weeks if someone is willing to try to squeeze you in -when you are very ill and having difficulty breathing *now*?  No, it’s not.  So, what to are your choices?  In the last year, we have finally gotten a single non-emergency after hours clinic that is open on Saturdays and until 9 pm. Before that? Nada.

It was no wonder people went to the emergency room for non-life threatening problems! Initially, my company’s health insurance plan responded by changing the deductible for emergency room visits.  At first, it was $300 out-of-pocket, which did not go towards meeting the deductible, and then it was contracted plan amounts after the deductible was paid. Then, it went up to $500 out-of-pocket etc. This extra amount was waived in the event you were admitted to the hospital. 

I don’t know what it is now, but our family motto is that unless death is imminent, we’re not using the ER (which only works unless stitches are needed). And, even though you go to an in-network/PPO provider like both of our local hospitals, the ER doctors are provided by a company/service which was not contracted with my PPO, which meant that we got charged all the excessive charges because they weren’t bound to a contract.

Both hospitals used this same service because since we are in a rural town, they weren’t able to ever get enough people on staff to cover the ER. So now you get totally screwed again. And charged tax because the doctors are providing the in-network provider with out-of-network services.

Yes, I know the world isn’t fair. Yes, I know I have no real impact over anyone doing (or not doing) the right thing. But I am TIRED OF GETTING SCREWED.  If that means I have to waste my time to complain and go public, then I will. Until you and I, the consumer, keep at it until someone gets tired enough of hearing from us to address the issue, unethical and fraudulent medical practices will continue.

But darn, I am tired of the fight. I’m tired of the hassle, the headache, the stress and chasing things down trying not to get screwed. If you have answers, please share!

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Yes and I don’t know.   I had 9 major items on my to-do list today, most of which involved using the telephone.  I am not a phone phobe, but I admit that I *much* prefer email and other online communication. Calling is rarely something I look forward to doing.

Calling to struggle with medical insurance and billing is never something I look forward to doing. Today was no exception. I always anticipate a solid, uphill battle; rarely actually seeing the results that were supposed to come from the first round of calling.

The result today is a mixed bag. I did get the one bill issue resolved, I think.  She said she deleted the one account addressed to Hunny Me; hopefully it really IS resolved.  On the upside, two bills – both to labs with the same name but different locations – were sent for review when I called a few weeks ago, even though I hadn’t gotten the second bill.  BOTH of these bills were from last April.  Are you kidding me?  It takes 8 months to finally bill insurance?? 

 

While insurance did pay the in-network amount for “reasonable” charges on both bills, there was a substantial amount of the most recent bill that was not deemed “reasonable” by insurance.  *This* part of the billed amount is what the other providers (out-of-network providers practicing at in-network facilities from my post here: 2010) like to use to try to screw over consumers with, in my experience. 

Even though my insurance has graciously paid at the in-network price on the reasonable charge, because the provider is out-of-network, they justify charging you the whole amount because they are not bound to any kind of contract with your insurance.  See how this works?  They could charge you a million and $1 dollars for a Tylenol, and expect you pay the million dollars your insurance has deemed to be not “reasonable and customary.”

Now I get to sit and wait. When it comes to this kind of stuff, that usually means worrying, too.

Was the day a total loss?  I don’t think so.  I think it was a victory to get the one account cleared up, and hopefully that solution sticks.  I made numerous phone calls over several hours; calls that I had been dreading.  I feel better knowing those are off my mental plate.

I also got some work stuff accomplished, which is also nice to get off my mental plate.  I missed my opportunity for a nap today, and my head is pounding. I am hopeful it will not become a migraine.

I haven’t gotten anywhere with the dealing with the stuff issue, as we didn’t get the cubes (see my Stuff  post to know what these are).  We looked at the cubes, but the sale was over, so we’ll wait until they come around on sale again. That might actually give us time to sort through the stuff and get some of it sorted!  😆

I feel good about what I got done today.  It’s a tight time-line, and I need to stay on track. I am a list-maker on days when I have a lot to do.  It’s a good feeling to cross things off that list and know you won’t have to do those again today. Tomorrow, I’ll make a new list, unless I do that tonight so I don’t forget something.  😆 

For now, I am going to drink my pot of chamomile tea, and think about what to make for dinner.   🙂

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Was a pretty rotten year. While I hope 2011 will be markedly better, I am not holding my breath.  I see so many with enthusiasm for the new year; happy celebrations and looking forward to a “clean slate.”  A clean slate? How does one get such a thing?  Where do I sign up?

On the last day of the year, I woke up well past 9 am, which is a rare occurrence for me.  In a busy house, there are usually children arguing or dogs barking or any combination of noxious, sleep-prohibitive noises. But this morning, after getting up to see what the dog was barking at in the girls’ room at 4 o’clock in the morning, I actually managed to fall back asleep and stay that way, well past getting a jump-start on productivity.

“Aaaahhhhhh, ” I thought, “Maybe today I’ll write on the healing properties of restful sleep that gives one’s soul respite.”  Drinking my morning tea, I thought of any other number of topics, and came to realize that the laundry was piling up in my room, and in the room as well. And that being in such a state was counter-productive in getting a handle on the stuff (from yesterday’s post), so it would make more sense to put off the writing and get to doing something with tangible results.

I had great plans for yesterday, but alas, as typical of my life, it didn’t quite go as planned.  I didn’t get into the pile of “unseen” movies.  And the packing up of the Christmas stuff didn’t get totally done.  Today didn’t go as planned, either.  I didn’t get the stuff out to storage, although I did brave the crowds at Wal-Mart and had plenty of time to think about writing my reviews on the relatively new do-it-yourself-checkouts that were causing mayhem and terribly long lines. Tonight, though, I am going to kick back and watch the movie I was going to watch yesterday.

Unlike so many others that I know, I don’t have a lot of excitement for the new year.  We haven’t managed to stay up for the last several years to watch the ball come down, and going somewhere to drive home with all the drunks has never appealed to us.  So home we stay and to bed we go.

When I look back on 2010, it was a year of frustrations, most of which come from being chronically ill. As I look forward to 2011, I can’t help but anticipate more of the same, if today’s mail is any indication. Medical billing is broken, and is a source of deep frustration and never-ending stress for me. It still amazes me how much they can bill you for things like blood work.  They can bill to draw your blood; to send your blood somewhere else; then to test the blood at the other place; to read the results of the blood work tests, and then bill yet again to give *you* the results of those tests.

Have a surgery or procedure done that is bi-lateral?  But then they only do one side? Or only part of the <larger> procedure?  Nevermind that – don’t be thinking you get any kind of discount because you won’t.  Nope, they are going to stick it to you just the same. Here again, is another amazement at all the little pieces parts they can charge you – charge separate for the anesthesia, for the anesthesiologist services, which are not included in the thousands of dollars you already paid for the surgery; charge for materials/supplies, etc.  And then don’t forget the lab work from the surgery – this is more pathology that qualifies for the charge-for-every-step-we-can-think-of.

I have insurance.  Which I am immensely grateful for, because otherwise, I sometimes feel like a bullet in the head would make far more sense. I have learned that no matter how hard you try to play by the rules and follow your insurance’s guidelines, there is going to be someone doing something regarding your medical care that is not “in-network” which then requires you to pay more.  A LOT more.  Let me share a few examples.

Say you have a single hospital in town and for a reason, like a child requiring stitches after regular doctor hours, and that hospital is “in-network.”  Because you don’t want your child’s wound to bleed uncontrolled all night and risk infection, etc, you take the child to the emergency room, to this hospital, which is the only one available to you for 200 miles in any direction.  To this hospital, which is IN NETWORK. 

You get billed for all kinds of the things, like the privilege of walking in the doors (this from insurance, which doesn’t apply to the deductible and is only waived if you are admitted).  You pay for hospital services, which include being seen by someone on staff and medical supplies.  Then you get another bill, from the service that provides the ER doc.  Are you as confused as I am?  Didn’t I already pay for the doctor? 

Nope.  Because you are in a town that doesn’t have ER doctors on staff (except for the idiot who runs the department, but is also employed by the doctor supply agency), the agency provides the doctor services for a fee, to be paid by *you*, the unsuspecting fool who has no choice but to go to the ER. The kicker is  – THEY ARE “OUT-OF-NETWORK.” So, you play by the rules and go to an in-network hospital, who provides, as your ONLY option – doctors who work for an out-of-network service.  And the insurance, of course, pays them the out-of-network price.

How do I, as a conscientious consumer, do any better to keep costs down and follow the rules when stuff like that is going on???

Now, if that visit includes x-rays, you’ll be charged for the x-rays, of course.  Then, the x-rays will be read by another doctor there, who then tells the ER doctor the results.  That’s another bill from that doctor, too.  You hope they are in-network.

When this happens, you can usually call and talk with your insurance company, and I have never, to this point, not had them pay the in-network fee.  I have also written numerous letters of complaint to the charging doctor’s service (the one who is out-of-network but providing doctors to the in-network facility); and expressed that not joining the same networks as the facilites their doctors are working in and then expecting the unsuspecting consumer going to the emergency room to pick up the slack in cost is fraudulent and unethical.  If your doctors work at XYZ which is an in-network provider for company A, company B and company C, YOUR COMPANY should be a participating provider and also in-network with companies A, B and C. 

I mean, really.  What am I supposed to do?  Go to the only emergency room available to me and ask the ER doctor his network status while blood is running all over? Puh-leeze.  “By the way, don’t restart my heart if you aren’t in-network.  I’ll wait the 3 plus hours to get to the next nearest hospital, because those doctors should be in-network.” 🙄

I have called and written letters to the hospital, sharing the situation and sharing my perpective that *their*providing practices should not screw over the consumer making use of the only available IN-NETWORK services who then use OUT-OF-NETWORK providers!  Seems the hospital is over a barrel, because they are small and “need the doctor service.”

I had great hope that this kind of stuff would end once we got a second, physician owned hospital. It is in-network, and most of my in-network doctors use this facility for procedures and surgeries. For certain, it’s a MUCH nicer facility.  And not just because it’s new. The people are nice, in every department. They treat you like a real person with a brain, which I greatly appreciate.  In talking with my insurance company, as it turns out, they too, use the same doctor service for the ER.  You know, the out-of-network doctor service. ❓ ❓

What I have also learned, to my great annoyance, is that when you have unplanned surgery there and they send your stuff out to the lab, the lab isn’t in-network!!  Here again, I ask:

How do I, as a conscientious consumer, do any better to keep costs down and follow the rules when stuff like that is going on???

*sigh*

The first work day of the new year – the one that so many feel is a “clean slate” – is primarily going to consist of me calling insurance again. After I get done with insurance, I have the thrilling task of calling another hospital conglomerate (one that is 200 plus miles away; one direction) that has my one set of my specialists there.  I need to find out if a new charge is for the doctor calling me on the phone to give me my lab results, or if they are totally messed up, given that this bill came to my husbands first name with my first name as his last name. While I am getting used to be calling Mr. ______, this one with Hunny Me as the billed name is a new one for me.

That is another thing I find frustrating. It’s a reminder of the mess when I was there the first time, where the one part of the conglomerate -the one that took all my information initially – billed me just fine, but the other part of the conglomerate couldn’t find me listed with my insurance at all and therefore billed me the entire mutiple-thousand dollar(s) amount.

I am tired of the stress and frustration that comes from these things which are out of my control. I am tired of playing the game the right way, only to continue to have issues and trouble that ultimately would cost me mega bucks to ignore. It’s not healthy to have this kind of constant stress and the feeling of being completely overwhelmed that comes with it.

I would *love* to have a clean slate.  I would *love* to have a shred of optimism that so many others have with a new year, or a new month. I’d settle for a new week, even!

As this year come to a close, I can look back and wish to be able to close the cover, never to revisit. There are some things, though, that keep on “giving,” even when we don’t want to accept the “gift.” I know this is my struggle; one I didn’t wish or ask for; one I can’t control or really even impact much.  I don’t fall prey much to asking “why me” and having pity parties, but sometimes, I reach my breaking point where I cannot take any more. I think I am there.

I am not one who can walk away and decompress and just not think about things like this. I don’t relish the fact that I have a battle that I can’t wage for 2 more days. I’m going to have to think about this all weekend, and know that I have to deal with it on Monday. I’m a “deal with it and move on already” kind of person. I don’t generally tend to think that there is anything to be gained by sitting and waiting to address something. Do it and be done with it already!

It is hard to have “hope” for a new year, when you have left-over stuff from the last year to have to deal with.

Lest you think that I am depressed and need that shrink, this is my reality.  These are the kinds of things I deal with on a regular basis. This kind of stuff is the dirty diaper of life.

Overall, I still feel blessed. I know that in many regards, I am very lucky. I have a roof over my head. We have steady income. I have a loving family. My family is generally pretty healthy. I have insurance. Most of the time, I can function reasonably well. I recognize that many including those that I count as my friends – don’t have some of these things. My heart breaks for them, and my prayers go to them. ♥♥♥

In my effort of trying to keep on keepin’ on and staying on track, I am now going to do more laundry. And then I am seriously going to try to watch the movie I didn’t get to yesterday. My goal this year, as in years past, is to try to manage the stuff. 😀 I’ll keep you posted and let you know how that goes. 😆

May you all have a blessed new year, filled with good news, good health, and good relationships!

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