On January 15, 2007 I resided in Morgantown WV while my family's official address of record was Quincy Michigan. Shortly before I was offered my position in the Department of Sociology & Anthropology at West Virginia University, my wife learned that she had been admitted into the RN training program at the community college near our Michigan home. She had been on a waiting list for more than a year to enter this program. After mulling the various options available to us, we decided it made the most sense that she and my daughter remain in Michigan where she could attend school and work (for a family business) and where we would have reliable childcare, while I would move to West Virginia.
As an employee of the State of West Virginia, I was given a range of insurance options to chose from. However, there was only one plan that provided any out of State coverage, the Public Employees Insurance Agency (hereafter PEIA). I have neither the time, nor energy, to chronicle my frustrating tales of getting PEIA to provide out-of-area coverage as in network (it involved several forms, validations, secret handshakes, and I think a telephone operator letting slip the secret national network name... but I can't prove any of that). Suffice it to say that we could receive in-network services at Beechstreet affiliated providers.
My coverage is actually quite generous, though not nearly as comprehensive and affordable as MCARE was while we were at Michigan. We $250 individual deductibles or a $500 family deductible, afterwhich the plan pays 80% of allowed costs (and the provider waives non-allowed costs). That's the coverage in theory at least....
Now, back to January 15, 2007. My wife, after consulting with a physician, scheduled an outpatient surgical procedure at W. A. Foote Hospital's Outpatient Surgery Center. Prior to scheduling this procedure, we dutifully confirmed that the physician, and the hospital were in-network providers. I confirmed with PEIA that, so long as we sought out the service at a Beechstreet provider, it would be treated as in network. The hospital and doctor's office likewise assured us that they participate in the network.
There were several billing problems with the surgery...specifically related to lazy claims adjusters at PEIA not bothering to confirm that that my family was authorized to seek beechstreet services outside the confines of West Virginia. But after many frustrating phonecalls with customer service reps of varying competence (there were some customer service reps who clearly went the extra mile, while there are some others, like the jackass I talked to this past Friday night, that deserve to be relegated to a special corner of hell).
Now fast forward to last Friday night. An envelope from my insurance company came in the mail. Puzzled (I haven't been to the doctor in months and my wife and daughter are now covered by wife's insurance plan... which, ironically enough, is different than mine, even though she is also an employee of WVU... except she works for the hospital which is run as a private corporation, partially I believe, so they can provide more competitive salaries and benefits... not that I can confirm any of that) I opened it. I find an explanation of benefits from my insurance company, rejecting a nearly $1,000 charge from the Anesthesiologist from my wife's procedure. Of course, because explanations of benefits don't explain anything, I had to call PEIA to find out, if you will, WTF?
The unempethetic voice at the other end of the line, gruffly said that this service was out-of-network and the claim came in after the allowed deadline for out-of-network coverage... "the patient is responsible." "But it was in network" I protested....I called everyone and confirmed this before the procedure. The operator, nearing the end of his shift, replied, "no, we called Beechstreet and confirmed this provider (the Anesthesiologist) is not in their network. He then condescendingly told me, "you should read your statement of coverage; this is clearly spelled out on page 57." Sensing an urge to tell him what he could do with his statement of coverage, I hung up.
Next, I called the Beechstreet customer service number. A helpful young lady searched for the Anesthesiologist's name, but could not find it. She did confirm that the surgeon and hospital were network providers. I asked, how can it be that a doctor providing an essential service for a surgery in a network facility for a network surgeon, is not also in the network. She said, "unfortunately, that's the way some hospitals do things."
So, I stew on this all weekend. My daughter asked me why I was so grumpy. (I didn't want to tell her that I was trying to decide if I should buy her Christmas presents, or make sure that I have money in the bank to pay for a year old medical bill that should have been covered). This morning when I got to the office, I called the hospital. I asked the billing office, to explain what happened. I was informed that:
* this hospital is indeed a network provider
* but, the hospital contracts with it's physicians.
Meaning that it has no say in what networks its practicing physicians are in, or are not in. While we had done the legwork on the surgeon, we didn't know that we also needed to inquire about the anesthesiologist, radiologist, pathologist, or any other potential expensive billing MD as to their participation.
I protested that we were not given a choice of anesthesiologists... we showed up at the surgery center and some dude in a funny hat came in and asked about loose teeth. That was it. Had I known that 20% of the billable services for the surgery were out of network, we would have found a different doctor in Kalamazoo, Lansing, or Ann Arbor. The hospital person was understanding, but told me that ultimately, this is not her problem. [As an aside, it's un-bothering-believable how often I've heard those three words in the past two years when sorting out medical billing. There are an awful lot of problems which don't belong to anyone but the patient/consumer].
The silver-lining in the story came when this woman at Foote hospital asked me why the claim came in so many months after the procedure. "How am I supposed to know?" I replied. "That's what has me ready to scream right now, we've done nothing wrong here and we seem to be the ones getting punished."
She told me, "well, we expect our contracting Physicans to bill in a timely and responsible manner. This looks like a billing problem, which was not your fault. If your insurer is refusing any payment for failure to file claim in a timely fashion, the billing folks usually write off the charge (e.g., PEIA could process the claim as out-of-network, force me to pay my $500 deductible, and then cover 60% of the remaining balance... but they're not even doing that because the claim was not filed within 6 months of the service.) Since this is the billing office's mistake, they will eat the claim. But they apparently, need to the insurance company to reject the claim first before they can adjust it. That's why I got the EOB, (because whenever the company takes an action on my behalf, they must explain it).
So, if at the end of the day, I owe nothing, why am I upset?
In what universe does any of this make sense? I spent too much time today on the internet googling "specialist out-of-network". This is a surprisingly common problem. Many medical specialists do not join managed care networks because they don't have to. Insurance companies take a hardline in establishing fee schedules that providers feel are too low. If all the specialists in the area decide to remain independent from networks, there is little the hospital can do to force them to participate. The hospitals compound this problem by not being transparent about the extent of network coverage. I'd argue that a reasonable person, upon hearing that a hospital is in-network, would assume that all services rendered in said hospital are likewise, in-network. (My google search confirms that this is a shared sentiment). This is especially true for services essential to the procedure being performed... it's kind of hard to have someone cut you open without an anesthesiologist on hand to keep you both asleep and alive.
In this bureaucratic journey, I've yet to find anyone who disagrees with me on the central point that I had done nothing wrong. Yet, the insurance companies calously point to their contract of service agreements generally, and the specific language such as the following:
Why is my anesthesiologist not in network when my hospital and surgeon are?
Your anesthesiologist is a separate entity from the hospital. Anesthesiologists’ contracts with hospitals do not require that they contract with the same insurance companies as the hospital. It is the patient’s responsibility to verify that all providers are in network.
Some lessons we learn the hard way. (I'm crossing my fingers that the biller actually does write this charge off. But I wouldn't be surprised to get a bill in the mail next month). God save us from the evil single-payer heath care system!