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"I'm mad as Hell and I'm not going to take this anymore!" - Blather. Rants. Repeat.
A Møøse once bit my sister ...
"I'm mad as Hell and I'm not going to take this anymore!"
Actually, I'm not. Not at the moment, at least. But the quote is significant to the story, in terms of the movie that it's from.

Recognize it?


Presciently, the network in that film was called UBS. And U are about to read about the BS we've been exposed to in the past day.

Eleanor has what we call "the good insurance," provided by Wegmans through its hometown Blue Cross carrier known as Excellus. She pays the first $500 of covered expenses, then 20 percent thereafter until hitting a maximum annual out-of-pocket of $750, and then, except for prescription co-pays and some odd-and-unlikelies, she's done. Last year, she hit the $750 by early spring due to her shoulder problems. This year, we expected, and budgeted for, the $750 to be eaten up by the two cataract surgeries in late February and early March.

Now. Not everything in the world is covered under her plan. For instance, the eye doctors explained that laser procedures would not be covered (at least not the $1,500 that they exceeded the traditional kind), but that standard surgery (which she opted for) would be. They were painstaking in providing her with lists of requirements and options and pre-surgery and post-surgery instructions.  And it was made quite clear that there would be three bills for each of the two procedures: one from the doc, one from the surgery place, and one for the gas-passer.

It's the latter which is currently causing the flatulence.


Previously, we paid something in the upper $600s toward Eleanor's pre-surgery clearance from her GP, and for the first of the two ambulatory center bills. So when our share of Doc Bill Number One came in at just over $150, it seemed about a Benjamin too high.  Eleanor spent a good couple of hours yesterday trying to sort receipts and other statements, but it took the actual explanation of benefit forms from Excellus to solve the mystery.

They're pretty good, once you actually access them (they don't mail them, and they need to be downloaded and then converted to pdfs to print them), but hers look like this:

So you get who did what, how much they charged (the "rack rate" you'd pay if you had no insurance), how much they reduced the bill by (because you do have insurance), and how much they and you pay of that "covered expenses" amount based on where your deductible and annual maximum amounts are.  Oh, and one other thing: "NETWORK PARTICIPATION  YES." This will be important later.

Because, it turned out, the anaesthesiologist fell into NETWORK PARTICIPATION NO" category.  And while we did get the benefit of a 50 percent reduction in that provider's charge on account of having insurance, we would be billed the full amount of each $480 remaining balance for each of the two facemaskings. None of it paid by Excellus, no deduction from deductible or annual maximum. Too bad, so sad.

And we would know this, how?  The doc didn't tell us. The surgery center made clear we would get separate bills from the three providers each time; it did not make clear that those providers might be out-of-network. What is the patient supposed to do- demand insurance identification from the gas-passer before the mask goes on?

So as of now, the thing has cost us that extra $100 or so of the bills to the covered provider, plus most if not all of the anaesthesiologist's charges. Having said that, I must also note that the gas-practice has not yet actually billed us for anything; maybe they have some deal with the doc, or somebody realized there was a screwup.

Also, it would have been far FAR worse if either of the other two providers had been out-of-network. We could have been out more like 10-12 grand if those bills hadn't been reduced by the Excellus fee schedule and then covered by the plan.

There will be calls, and letters, and maybe litigation, coming from this, unless it's just the 100 or so we're already out.  But the lesson has been learned. ALWAYS check EVERYTHING in advance when dealing with this behemoth of a beast.
4 comments or Leave a comment
glenmarshall From: glenmarshall Date: April 23rd, 2014 04:02 am (UTC) (Link)
Yours is a small sample of the manure heap that anti-Obama[care] folks will cite when bashing the ACA. Why? It's hard to understand and, once your have grasped the essentials, difficult to rectify. Most people will blame the powers-that-be or whoever else they're inclined to be mad at.

The actual problems are (1) there is no price tag attached to any health care service, (2) it's all billed per-service, and (3) the people preparing those detailed bills are error-prone. Worse, depending on your insurance, the payment is often on a per-case basis and cross-footing to per-service is a PITA. And, of course, insurance often pays late. The result is that consumers get bills they cannot understand, often months after the service is rendered.

Edited at 2014-04-23 12:16 pm (UTC)
symian From: symian Date: April 23rd, 2014 04:55 am (UTC) (Link)
How much would it cost if there was no such thing as health insurance? I've had people tell me that if we got rid of health insurance rates would drop because individuals do not have the deep pockets that insurance companies have. Perhaps, but one procedure could still bankrupt the average Joe. People are so foolish.
drbear From: drbear Date: April 23rd, 2014 03:13 pm (UTC) (Link)
Check with your insurance to see if it has a thing called RAPL - this means Radiology, anesthesia, (I've forgotten P) and Laboratory. Basically, it's a clause that says that in a hospital setting in a network hospital, any out of network specialist in the above category is treated as in-network for charges. Now, I was working at United Healthcare, so BCBS may have different rules.
greenquotebook From: greenquotebook Date: April 23rd, 2014 05:08 pm (UTC) (Link)
Not that you don't already know all of this, but...

Truth, this is quite usual. Anesthesiologists, radiologists, pathologists and other 'invisible' docs (and labs!) are frequently NOT providers because they don't have to be. You just learned the same expensive lesson that I tell all of my insurance 'clients' (hard to call them that with a straight face since I don't charge for my services!) It falls to you to make sure that all of the doctors, facilities, and labs that are providing your services are on your PP list. Often, your doctor's office will do that for you if you ask, but generally, they have favorite providers that they use unless a preference is expressed by the patient (and sometimes even though that preference is expressed). Every time you need lab work, you get an order and go to a lab that you know is on your list rather than trust your doc to draw your blood and send it to the right place, yes? Same thing. You need to verify this with the doc *and* the insurance company before a procedure, since docs drop on and off the list constantly. The fact that you are a lawyer might make a difference because that lends a certain power to your words and calls. If you are successful in getting this adjusted off, let me know how you managed it. I could use the guidance for future appeals.
4 comments or Leave a comment