By now every American citizen should be aware of changes mandated under ACA correct? So you have read your Benefits Booklet and well, you've been meaning to have a check up anyway and hey, it is 100% free now! So you visit your Primary Care Physician (depending on your plan) and because of your age, family history or life style, your beloved PCP advises you should have a "routine colnoscopy". He suggests a good gastorenterologist (who is also in your network) and offers to schedule an appointment. On your way out of the office you stop dutifully to pay your co pay only to be waved off by the beaming billing clerk who advises that "there is no co pay for wellness visits." Wrong.
Even though ACA excepts wellness, preventive and routine services from co pay, deductibles and co insurance by law, a vast majority of both comsumers and providers are either ignorant of this fact or fail to adhere to it. I am not suggestng it is intentionalin every case. Often the counter person at your doctor's office does not even know you're there for a routine physical and will NOT know until the bill is coded as such after you leave. This is best case scenario but unfortunately, many doctors offices do know and attempt to collect the co pay anyway. Why? Because more often than not, your $30.00 or $50.00 co pay represents a major portion of the total sum your provider will be paid after insurance pays its part. Rouglhy, about 30% of what the provider actually bills.
So first thing, go back in your files and if you have seen a physician in that physician's office for a routine or wellness visit and you DID pay a co pay, you have a refund coming. I do this at least 10 times every week.
After a visit with your friendly gastroenterologist, you decide to schedule a routine colonoscopy. And then you shake your head at how any procedure as invasive or uncomfortable as a colonoscopy could even BE routine, you pick up the two gallon orange container filled with some viscous material which will comprise the sum total of your caloric intake for the next 24-30 hours.
After you awaken from the anethesia your doctor advises "Everything looked good. I removed a few polyp-like pieces and just to be double sure, I've sent them to the Lab. You'll hear from my office in a few days as to the results but I wouldn't worry."
You feel good that you finally got this done. You feel blessed to live in a country where this can be done with no out of pocket expense right? Two weeks later you get an explanation of benfits from your insurance company. The first claim is from the gastroenterologist's office. The enitre medical procedure has been DENIED. All you have is a one or two line explanation and an invitation to call customer service "should you have any questions."
You are looking at a bill for around $1700.00 which will come later from the physician. (This figure is actually the contracted amount. The original bill was for around $4100.00, The gastro dude's billing peeps billed for a biopsy, a polyectomy, reading the results, etc, etc, etc). Next comes the bill from the anesthesiologist group who, incidentally contracts with the hospital and is NOTt in your network. The claim has been denied on that basis. Since this is the case, there is no contract rate with your insurance company and you are legally obligated for the full billed amount of $1300.00 Under normal conditions, this bill would be paid at around 30% or a little over $350.00 and the medical group would accept it as payment in full "IF" they were in your network. Because out of network services are not regulated like contractual rates, you owe the whole damn thing. Though we aren't quite done yet with all of this, let's review for a minute.
A colonoscopy is a SURGICAL procedure. You read correctly. Most forms of diagnostics can be performed by techicians but any procedure that might require some actual incision or excision, must be done by a SURGEON. Since your gatsro dude performed a small polypectomy, your routine colonoscopy is no longer rouitine and your policy's surgical benefits kick in. Yes he coded this on the paperwork because after all he gets paid extra for it and afterall, removing a polyp is standard in this kind of medical procedure. Your policy dictates a $2500.00 deductible for all in network procedures so the entire amount of his services was applied to your deuctible.
OK so best case sceanrio you have the surgeon AND the anesthesia people applied to your decutilbe so hey, at least you have MET it now right? Wrong. You dont have any benefits for out of network services at all and you have to eat the whole bill.
The hospital lab (which bills separately formn the actual facility OF the hospital) is billing you $850.00 to look at a very tiny silver of your colon. You have to eat this as well BECAUSE the ruling or primary diagnosis of a non routine surgical procedure causes subsequent services to be non routine: makes the PATHOLOGY non routine, This can however be applied towards your deductible since it was in network. Now you have duly "satisified" your $2500.00 annual decuctible between the pathologist and the gastro dude, which is a GOOD thing because you haven't even gotten the actual hospital facility claim yet. So far you are on the hook for an out of pocket total of $3250.00
Your policy says this: " after you meet your deductible, we will pay 80% of reasonable and customary charges as interpreted by us." Lucky for you, you only have to pay 20% of the contract amount for the hospital facility claim which was billed at $2100 and paid out at 80% of only $600 (contratced rate), so all you really owe them is $120.00 which at this point almost seems like it is something GOOD finally!
Now you can make all the phone calls you want. Your insurance company will tell you the exact things I relayed above and then they will painfully remind you of the provisions of your policy. You cannot refute this. It is in black and white. You call the gastronenterolgist and they will tell you they are sorry but this happens all the time, really. Just because something starts out routine doesn't mean it will end as routine. Same argument you will get from the hopsital who tells you they have NO control over who "is or isn't in your network".
Not one decision made in all of this was made with your full awareness but was made on your behalf. You signed up for it. Remember the intital forms you didn't really read but signed anyway? You gave your legal permission for the hospital and the doctors to act in your best medical interest while you were totally knocked out under anesthesia. Of course had you know in advance that ANY of this would happen you would do what most people would do and not even have the procedure done.
Absolutely you would NOT have knowingly used that anesthesia group, would NOT have consented to pathology, would aboslutely NOT have done any of it. But it is too late now and the best you can do is to hope you can negotiate a better rate wth the out of network aneshtesia group and ask everyone to put you "on a payment plan" until done..
If you think this scenario is extreme, think again. It happens thousands of times every day. Substitute bone density scan, mammogram or other related "wellness benefits" and you can see how much havoc is being visited upon conusmers a full TWO years after these federal mandates have been implemented......I deal with it every week. Eve routine blood samples drawn by your physician's attendant can be sent to an out of network lab an you're stuck pauing an out of network rate(full billed price)
By all means any medical procedure you are considering that cannot be done INSIDE the actual physician's closed office doors, do your homework. NEVER allow a healthcare provider to offer to call your insurance on your behalf to determine your benefits. Do it yourself. And NEVER pay a health care provider any post service money without FIRST calling your insurance company to see if they have signed off on what you owe.
Know your plan limits, exclusions and exceptions. In the battle of slaying the helath care monster, YOU are your best, and often only, advocate.
