Tuesday, June 30, 2015

"out of network"

Seems my little boo boo has accumulated a little over $15,000 in "out of network" bills.  That is a clever insurance term for "we don't cover this even though you doctor ordered it".  Over 2/3rds of it was for my emergency surgery - like I had any choice in the matter with a bone sticking out of my leg and doped up on morphine.  I am already out of pocket for about 9 grand.  I have always paid for my own health insurance and have better coverage than most will choose from the exchanges.  If you think Obamacare means a free ride - go break you leg like I did and you will see that subsidized health insurance does not equal affordable healthcare.  Next steps:  1.  Resubmit the charges to my insurance company.  2.  File a claim for mediation with the Texas Department of Insurance.  3.  Click on this email I got today.  83,91,71,0,B


Margery Bills said...

My Ohio friend died here in Texas-much to my shock. Obama care did not cover him. They took him off of life support, put him in a room and after about 2 days he died at around age 50. He was new to Texas and without a job.

Margery Bills said...

Have you ever at your local private neighborhood pool been hit in the face with a ball and then have all the young people giggle. My first time. Now that is something to look forward to when you become a worthless dispensable older person. I was just leaving anyway.

Rob said...

We have a health care industry, not a system.

On the bright side you had enough insurance to get you in the door.
The last numbers I was able to find said that 40,000 Americans die every year because they cannot afford the product that the American health industry sells.

ßeulah ßee said...

Our health care system is pure corruption and shaft (just ask anyone who's had a major illness) and it's even worse for seniors who are forced into Medicare which adds another layer of shit to the mix. And how about US citizens paying up to 80% more for drugs than anywhere else in the world? Did you see the 60 Minutes expose June 21? Few have the tenacity to fight the gross errors that are made (medically and mathematically) and they make it hard by design so most give up and give in. But I know from personal experience it can be done and wish you good luck with your appeal. What you learn this time around will prove invaluable should it ever happen again.

Jeff Crosby said...
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Margery Bills said...

:-) yes, yes of course. You know i had decided not to blog so I missed a day online and then I saw you had not blogged a day. So i called the sheriff out there to check on you but fortunately you had helped yourself to live and everything turned out o.k. We had met at the mailboxes by accident and you were so nice that I took a special interest. That's why I called about your well-being but I had to apologize because I did not want to meddle.

Margery Bills said...

(I was the one with all the dogs and the Weimaraner). Everytime I opened a door of the silver suv there was another dog in a cage-the crazy dog lady. :-) So I got a sweet baby boy Weim from a ranch near Laredo where I used to work for the government. My regal female lady Weim approved of him. He is so very sweet and gentle and whoops weighs 114 lbs. and is a giant Weim.

pw said...

Margery Bills, Texas has a gap in coverage thanks to Perry. Your friend's lack of coverage was NOT because of the ACA.
Let's at least be factual

Larry G said...

Sorry this happened to John.

When you are treated by a team of doctors in an emergency - you may or may not be covered depending on the kind of insurance you have.

This was actually one of the issues with market insurance (as opposed to employer-provided) in the Affordable Care Act. In general, the less network restrictions - the more expensive the insurance and there are no real standards... it's buyer beware.

It also illustrates how little most of us actually know about our own insurance.. until we need it and often under urgent or emergency conditions. Most of us probably have never read our policies.. we just "assume".

It also shows how vulnerable we all are - financially - even WITH some kinds of insurance and especially so if it does not cover everything 100% and almost none do - not even Medicare.

Finally - even though TODAY, we blame govt left and right for every real or imagined ill - WHO do we go to when something like this happens? - the govt, naturally... right?

Imagine what insurance might be like if there was NO government regulation and no govt to go running to when we get ripped off?

Insurance is one of those things that sets us apart from 3rd world countries - but it takes
govt to provide some level of protection for people who buy it - i.e. who makes the insurance company pay off when you have a claim? In 3rd world countries - the govt often
has no role in that - you're TRULY on your own.

Best to John in his recovery, physical and fiscal! ;-) and in his great adventure!

Ronald Mahan said...

I agree with the writers that suggest our current health care system is a bloody mess - full of corruption and rip offs! Since I am not getting any younger, I plan to stay off my brother's 4 wheeler and use my big 4x4 truck more - because it protects me better & is more difficult to turn over!

Larry G said...

well yeah but you can break a leg just trying to get out of those high-rise 4x4s ! ;-)

Grandmama Sarah said...

John, I have coordinated insurance benefits like this for my family (including my mother and dad in the years before they died) since the 1980's. That out-of-network clause in an emergency situation can usually be contested and brought back to in-network levels. But, in my experience, it takes a whole lot of calling, work and documentation. It's not an activity for people who are suffering with long term debilitating illnesses.

Glad that you are recovered enough to be a squeaky wheel, because that's what it takes. On a number of occasions, there was no record of my previous call. Document!!! with names!! Don't let a week go by without a response.

Many times, I have explained the situation to four or five different folks on the same call. Now, I cut to the chase and ask for a supervisor at the second person response. Sometimes, an insurance company will have a special problems resolution unit. You might try for that.

rj said...
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rj said...
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Larry G said...

there is actually "Platinum" plans also.. so 4 levels and each level is a tradeoff between what is covered vs out of pocket co-pay and deductions but all of them have a catastrophic threshold .

the thing about the Exchanges is that they not only tell you about the coverage and limitations, out-of-pocket, deductibles - etc AND you can compare and make informed choices whereas when you buy outside of the exchanges - all that info is up to you to develop.

Buying from the exchanges is more like looking at Consumer Reports first - before you decide.

you can even use the Exchanges to develop the info and then use that to go out and shop for non-exchange insurance if that is what you want.. because then you know what the key things are to look for to compare...

rj said...
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rj said...

Those with Affordable Care Act (ACA - Obamacare) - DON'T get the lowest cost Bronze plans. Way too much copay and way too high "Maximum Out of Pocket". You need at least the Silver if you can't afford a Gold plan.

For everyone out there that believes you are healthy and can "afford" the cheap plan (even many employers are offering the low cost "high deductible" plans now), be sure you know what the "maximum out of pocket" is for both "in network" and for "out of network". Don't buy anything that has no "maximum out of pocket". Once you have that feature and know the limit, the bills don't get any higher. By the way, straight Medicare has no maximum out of pocket, but a Medicare Supplement or PPO does have it.

And yes, Rick Perry would not allow the expansion of Medicaid (the low or no premium coverage for the poor) in Texas. Even those with Medicaid in Texas are controlled by the state, not the Federal Government. Finally some states have laws that require hospitals and doctors to disclose when they are out of network or you don't pay. Not Texas.

Ronald Mahan said...

----Larry G. --- I always stop my truck before jumping out - and have so far - avoided any leg breaking accidents. Getting out of my truck when stopped - is not hazardous because my F-150 is not lifted at all. However, a more probable health hazard is getting it stuck - because getting it unstuck is a serious physical chore! However, I once buried my diesel Ford F-250 so deep - it took 2 commercial wreckers (and much money) to pull it out. Since then, I have followed John Wells sound advice about driving on these muddy roads! "Just don't do it!"

Larry G said...

@Ronald Mahan Many years ago I "buried" a Chevy Blazer in similar circumstances and came away with one morsel of thinking - that wherever you go with a 4-wheel is just further and more money away from extraction!

but I do know a number of people who "stepped wrong" and ended up like John... it happens.

John Wells said...

Jeff Crosby...my bad - why didn't I think of spending a couple hours on the phone with my insurance company and various hospitals BEFORE calling 911. FYI - it was the EMT's that made the decision to fly me to the hospital in Odessa...the best/fastest option due to the severity of my injury. Risk of complications and infection skyrocket the longer it takes to repair a compound fracture. Really, the point of this blog post is that "affordable healthcare" is an illusion bought hook, line, and sinker by idiots that think Obamacare is a lifesaver. Sure, having insurance might get you in the door easier but the cover charge is still there. If you can barely afford paying even subsidized insurance premiums, what makes you think you can cover your deductible and all the hidden costs from a complicated/out of control system.

Rev.jimmyleebob said...

My man servant Rupert is always kind enough to get on his hands and knees and allow me to use him
as a step getting in & out of my truck. I employ him less than 30 hrs. a week,

Steve said...


Did you buy insurance through the ACA marketplace? If so, are you receiving government subsidies?

Jeff Crosby said...

@John Wells, well that makes sense. Based on what I had read, I was under the impression that 1. you picked the hospital and 2. You had selected that hospital before you had the accident (as part of the contact with the heli company). Your charges stem from the initial hospital, not the hospital you were later flown to. Got it.

John Wells said...

Jeff Crosby...I was flown directly to Odessa - there was no "initial hospital". Steve...I have always manned up and purchased my own health insurance. Fortunately I did not loose my existing coverage as did over a million people when the law came into effect. I do not receive any subsidies - in fact, my premiums have doubled since ACA.

Larry G said...

The reason your premiums went up is that the ACA law no longer lets companies dump you if you have an expensive injury than can also become a "pre-existing" condition - downstream that they use to deny you.

what folks were doing prior to the ACA were signing up for cheaper insurance - which was fine as long as you stayed healthy and you did not get an expensive broken leg. Once that happened to you - they would cancel you and none of the others would insure you - either at all or not without substantially higher premiums.

This is how we ended up with so many uninsured.

The ACA won't fix it all but basically what they did was require that people - even sick or injured - be offered insurance - and yes the costs went up.

and before anyone goes high order about paying for others - we already do - 3 ways:

1. - all employer-provided already works this way - you are entitled to insurance no matter your pre-existing - and yes it does affect the premiums of the others on the same plan as you. been that way for decades. Employer-provided costs the US Treasury 300 billion a year because of the tax exemptions (exemptions other folks who work and pay taxes - don't get if they do not have employer-provided and have to purchase market insurance like John).

2. - Medicare - all people 65 or over are Guaranteed insurance - no matter their health and they get it for about 105.00 a month - up to 85K in annual income. This costs the US Treasury more than 500 billion a year.

3. - we pay for people who go to hospitals with broken legs that have no insurance. we all do. It's part of the taxes you already pay and it's why when you go - and are "covered" you pay $10 for aspirins and bandaids.. and such.

Margery Bills said...

That's right pw-forgot the details and thought it was known. Sorry.

Margery Bills said...

Funny John about calling hospitals ahead of time. :-)

rondeb said...

Every working person pays a Medicare Tax their entire working career. That tax is going toward the Medicare Insurance they will receive upon retiring. Then they pay a monthly premium. Copays are high even for Medicare. $300 for the most minor outpatient procedure. Costs have gone up 5x in the last 5 years. Most procedures now are under scrutiny and are being denied left and right. Trust me, Seniors are paying a very high price for all the money that was taken from Medicare in the Obamacare Bill. People, even with the "NEW Affordable care act" (what a JOKE) are not going to the Doctor because they are having to pay the first thousands of dollars out of pocket before anything is covered and they can't afford it even with hundreds of dollars per month premiums. Everyone has been put on a "catastrophic" insurance plan but are paying for what used to be a NO COST insurance plan. In reality Obamacare has just created a Country of people that virtually have NO insurance

Larry G said...

They're paying for Medicare Part A not Medicare Part B. No one pre-paid for Part B and if you did not pay enough into Part A in your work life, -you'll have to pay a penalty to get it when you get to 65.

Part A is hospitalization and Part B is for doctors and providers and there is no "out of network" issue because it is single-payer/universal.

Part B is entirely voluntary - you have to sign up and you do get it for 105.00 a month even if you have up to 85K in income.

Yes.. it does not pay for everything - original Medicare has a 20% co-pay but if you get Medicare Advantage it usually covers that as well as optical, dental and hearing.

But Medicare takes everyone regardless of their health - and for the same price 105.00

Medicare costs the Government 500 billion and it is rising fast because of the influx of boomer retirees and because many more are signing up for Advantage to avoid the 20% co-pay.

Here's the reality. You cannot get all the health care you want . much less for one low price. You can look high and low - but you won't get a better deal than Medicare.

but it will not cover everything - for sure.. but it would have largely covered John's leg.

and you're wrong - NO INSURANCE means NO INSURANCE - it means if you are John - you owe the whole bill ... and your savings evaporate.

Portraying high co-pays and deductibles as virtually "no insurance" is just wrong. If you got a choice between no insurance and Obamacare it's a no-brainer.

Simple reality is - that without govt - no insurance company wants you if you are sick , injured or old. THat's the reality. Premiums are kept low because they get rid of the costly ones.

pamit said...

John, consider how the "over a million" that lost their health coverage compares to the several million uninsured that now have insurance, thanks to ACA. Furthermore, those prior policies were cancelled because they no longer met the standards of coverage set by ACA. Those "over a million" that lost coverage now most likely have far, far better coverage.

And those are the principal reasons why some...SOME...premiums went up: more people covered, and more reliable coverage due to the ACA-mandated standards.

I do indeed think that the ACA is a "lifesaver" for many folks. You label me an "idiot"...goodness, how judgmental for a Christian man. But I forgive you :-)

rondeb said...

Medicare Advantage does not remove the 20% co-insurance requirement of Medicare and to have a Medicare Advantage plan you will pay anywhere from $100 to $200 a month extra and for that money, you get a gym membership and an annual eye exam LOL. My point on the ACA is that the copays are so high that insurance coverage does not start until you have a catastrophic claim. Catastrophic Insurance policies prior to ACA were extremely cheap. Making people pay for coverage they don't need or want is criminal. A catastrophic policy offered to the masses could have been a much better approach. The only thing ACA has done is increase the Medicaid rolls, (increased our national debt) and THOSE individuals have NO copays or out of pocket expenses plus they get dental, eyeglasses etc. None of that is covered in Medicare unless you are paying for an extra policy which is limited to an annual benefit not much more than the premiums. If someone wants a better policy they can go for a supplement plan which in most cases runs $300 to $400 a month.

Larry G said...

Many, if not most Medicare Advantage plans DO cover the 20% and some of them charge no extra.


" My point on the ACA is that the copays are so high that insurance coverage does not start until you have a catastrophic claim. "

that's simply not the truth for many.. it might be for some. It depends on whether you get the bronze plan or the silver or higher level plans.

but it does exactly what Conservatives have argued for years - that insurance is not supposed to be for everything - just the things that would ruin you financially.

don't tell me that folks with pre-existing conditions would not benefit from catastrophic.

yes alternatives have been possible since way before the ACA and has been possible in the 50+ repeals that had no replaces.

how do you increase the Medicaid rolls if more people are insured?

and how do you increase the deficit when ACA is not funded from general revenues?

there are a wide range of plants in the exchanges - your choice - and none of them can deny you for pre-existing or dump you if you get sick or injured - UNLIKE what was available before.

the thing is - before , during and after there were opportunities to do something different but the critics have maintained that govt did not need to do it.

and it's a myth - only the govt can protect people from being denied insurance for pre-existing conditions.

no matter how you cut it - that's the reality.

I'd be 100% fine with a different approach - that works - but I have yet to see one from the critics - that they would support as legislation. They all have "ideas" - none with agree with each other.

sorry -you got the ACA because you failed to deliver anything better.

rondeb said...

We got the ACA because it was an Illegal Bill that starting in the Senate (was required to be started in the House as it has increased taxes), passed in the middle of the night by changing the laws of the senate to allow a simple majority vote on something that would impact the American People so drastically and passed without one Republican Vote. That is how we got the ACA.

rondeb said...

You are providing information on Medicare that is from 2013. Trust me I am on Medicare and there is no Advantage plan that pays your 20% coinsurance and Only a few Supplemental Medicare plans that do at a cost that is truly out reach of all but a very few individuals. Also, if you believe the ACA is not costing the American People Billions of dollars you are not paying attention. All Medicaid expansion is being paid for by the American People. It has been already presented that the costs to the Government for ACA far exceeds the expected costs by a huge amount. The enrollment wasn't anywhere close to what it had to have to make it pay for itself. I can't wait until 2017 when it will be repealed.

rondeb said...

If you want some examples of what the ACA has done to Medicare here are a few examples. A drug that cost the insurance company $100 a month now costs the insurance company $1000 a month. The drug benefit of Medicare for most individuals is used up in the first few months of the year and then the patients have to foot the bill for those exorbitant drug costs themselves the rest of the year. Many Drugs that were covered before are no longer covered and if it is something you must have it is out of your pocket. Procedures that have been covered for years (spinal injections to reduce pain after 7 back surgeries) are now denied for seniors. I could go on and on what the ACA has done to Medicare by taking away almost a billion dollars a year to pay for insurance to others , but I am too angry. Many doctors no longer accept Medicare patience as they are paid virtually nothing to see them. So you say that the ACA has made insurance companies accept anyone, but they are denying the treatments.

Larry G said...

@Rondeb - I'm on Medicare also and I DO KNOW. but this is foolish. You're actually blaming the govt who is providing you with taxpayer-funded insurance because it's not enough for you? You pay 105.00 a month for original Medicare. The govt pays the rest. How many people do you know that have guaranteed insurance for 105.00 even if they had to pay 20%?

comeon...what would you do without Medicare? what do you want instead?

Medicare IS funded from General Revenues. The ACA is not. Medicare actually DOES affect the deficit and the ACA is not.

I don't get it. You depend on the govt for your insurance and blame the govt cuz you don't like the benefits and blame the govt because the ACA does not provide enough benefits either?

good lord!

pamit said...

@rondeb I believe Medicare began limiting reimbursement of spinal injections for pain, because there is limited evidence that these are efficacious. This is indeed one of the cost-control provisions of the ACA. I can certainly understand how you would be upset, if this procedure helped your pain.

Most of us do form opinions based on our own datapoints. It's hard to have an objective view when you personally have been negatively affected. But I think we all have to try and look at the big picture here, as Larry G is illustrating.

Unknown said...

Texas does not comply with the affordable care act- if it did you would have better choices

Larry G said...

Texas did not do the MedicAid Expansion - but Texans can go to the Federal Exchanges

here's an example: https://goo.gl/fE8Ymp

I had put in a single guy, age 50 with 50,000 annual income and the max out of pocket deductibles were 4000-6000 ... Premiums 300-400 ...

Larry G said...

oops the out of pocket was about 6500, sorry

James Price said...
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Larry G said...

Medicare Part A (hospitalization) is

but not Medicare Part B (doctors and other service providers).

it' a common misconception that demonstrates that a whole lot of folks don't
know the simple facts...


James Price said...

How is Medicare funded?
The Centers for Medicare & Medicaid Services (CMS), a branch of the Department of Health and Human Services (HHS), is the federal agency that runs the Medicare Program and monitors Medicaid programs offered by each state.

In 2011, Medicare covered 48.7 million people. Total expenditures in 2011 were $549.1 billion. This money comes from the Medicare Trust Funds.

Medicare Trust Funds

Medicare is paid for through 2 trust fund accounts held by the U.S. Treasury. These funds can only be used for Medicare.

Hospital Insurance (HI) Trust Fund

How is it funded?

Payroll taxes paid by most employees, employers, and people who are self-employed
Other sources, like income taxes paid on Social Security benefits, interest earned on the trust fund investments, and Medicare Part A premiums from people who aren't eligible for premium-free Part A
What does it pay for?

Medicare Part A (Hospital Insurance) benefits, like inpatient hospital care, skilled nursing facility care, home health care, and hospice care
Medicare Program administration, like costs for paying benefits, collecting Medicare taxes, and combating fraud and abuse
Supplementary Medical Insurance (SMI) Trust Fund

How is it funded?

Funds authorized by Congress
Premiums from people enrolled in Medicare Part B (Medical Insurance) and Medicare prescription drug coverage (Part D)
Other sources, like interest earned on the trust fund investments
What does it pay for?

Part B benefits
Part D
Medicare Program administration, like costs for paying benefits and for combating fraud and abuse
Related Resources

Tips to prevent fraud
Find someone to talk to

Find someone to talk to in your state
Is your test, item, or service covered?

Search Medicare.gov for covered items

Larry G said...

not totally clear - here is some more:

The SMI Trust Fund consists of two separate accounts — one for Part B, which pays for physician and other outpatient health services, and one for Part D, which pays for outpatient prescription drugs. Premiums for Part B and Part D are set each year at levels that cover about 25 percent of costs; general revenues pay the remaining 75 percent of costs.


but here it clearly says that it's paid for with premiums (about 104.90) and general fund subsidies (75%)

this is fixed by law by the way. No matter how many new retirees there are - the law says the govt must cover 75%... which means every year more retirees are added and every year the amount of subsidy required - goes up.

This is the Medicare that Conservatives are talking about going "broke"... Part A - funded from FICA taxes will always be around as long as folks pay FICA taxes.

Larry G said...

again - I'm not necessarily advocating for or against.. what I'm advocating for - is getting the facts upon which to base one's opinion.