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ObamaCare Clusterfuck: Warning from Colorado: "[I]t is the responsibility of the patient (not the doctor) to check on the network status of their provider"

Just what you want to think about in an emergency, right? Whether your provider is in- or out-of-network! And yet your decision, sick in the back of an ambulance, could bankrupt you! There's a good deal of controlled but justified anger in this LTE from Judee Cathrall, in Dillon, Colorado:

Obamacare is a good thing — but not for all Summit County residents. Those lucky enough to have a grandfathered health plan and those on Medicare and Medicaid are in excellent shape. But those whose employers switched into an HMO plan, and those seeking insurance on the Colorado exchange or directly from an insurance company, are at a disadvantage.

The large deductible and out-of-pocket expense may or may not be a deterrent for those who consider themselves healthy. However, the fact that St. Anthony Summit Medical Center (Summit County’s only hospital) is not a provider on any of Anthem HMO policies, including the most expensive Gold plans, is a major concern. All Colorado Exchange policies and all new Anthem Colorado offerings outside the exchange are now HMO policies.

In an emergency, an ambulance, the ER and subsequent admission would be covered [but could be balance billed!] since under the new law ambulance service is required to deliver a patient to the nearest ER. The plans work if the ambulance/ER is considered an emergency and not just a “convenience.”

However, if your hospital stay is not an emergency, all bets are off. While most Summit County primary care providers have signed up for the HMOs, their admitting privileges would likely be to St. Anthony Summit. That non-emergency stay (for whatever reason) would not be covered in our non-network hospital.

Also, if you are going to have a baby, your local hospital of choice is not in the network. Want to have your baby in Vail (so that you will be covered)? Make sure your obstetrician has admitting privileges there.

If you need tests — MRI, CT, x-ray, lab work or out-patient surgery — expect to travel to Vail as St. Anthony Summit is, once again, out of network.

Why should a Summit County resident need to use a hospital in Vail, Kremmling or Leadville when our taxes subsidized the Summit medical center? Our county contributed free land and waived and reduced fees to bring the hospital here. Now, the hospital chooses not to provide services to all who live and work here. All other hospitals in the Centura system are in the network, but St. Anthony Summit is not. A non-emergency use of its services means that you will pay 100 percent of the cost — but that cost does not even count against your deductible or your out-of-pocket.

I bet there are county- and state-subsidized hospitals all over the country; perhaps even (say) in Chicago. It would be interesting to know how many taxpayers stumped up to keep hospitals in their counties, and then don't get to have the benefit of having the hospital they paid for in their network.

The situations I have presented — and the potential consequences — have been checked out with representatives from both the Colorado Exchange and Anthem. Both also advise that it is the responsibility of the patient (not the doctor) to check on the network status of their provider. [1]

More insanity from ObamaCare's model of "mandatory shopping." It's always good to shop! Even when you're giving birth in the back of an ambulance!

UPDATE [1] A Dromaius points out in comments, this is not new. Here again, my weakness as a poster is that I have virtually no experience either with the health care system or with purchasing insurance! However, it does seem to me that ObamaCare has added an additional layer of complexity, and also, by narrowing the networks, increased the risks for the patient, so that, at least, is new. In fact, the networks are now so borked that even the doctor might now, so if you hold on to your decision until you get unloaded from the back of the ambulance, you might not get the right answer anyhow.

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quixote's picture
Submitted by quixote on

This crapola is what Dromaius has been warning about, but no matter how many times I read it my first reflex reaction is still, "No! Can't be. They would never do that!"

The stuff about patients sorting out who's in their network is new to me though.

Unbelievable. Michael Moore will be able to do a whole new film about pulling out their own teeth because their only alternative was Ocare.

Submitted by Dromaius on

In an emergency, an ambulance, the ER and subsequent admission would be covered since under the new law ambulance service is required to deliver a patient to the nearest ER. The plans work if the ambulance/ER is considered an emergency and not just a “convenience.”

And of course, this is the lie that keeps propagating around.

Even these "covered" ER visits are subject to balance billing. The feds have established that the insure-co's have to reimburse ER visits at a certain rate. The point of mandating the reimbursement rate is in the hope that if the reimbursement is at a certain rate, the hospital won't come after the patient for the balance. However, there is no law preventing them from doing so (except in certain states. Colorado is not one of those states.).

To back myself up:
From the Families USA Affordable Care Act brochure (brochure page 6, which is Adobe Acrobat page 10)

“Although the new law does not completely solve this problem [balance billing], it does make some changes that are designed to minimize your bills for emergency care: It sets some standards for what health plans must pay out-of-network emergency providers, and when providers are paid adequately, they are less likely to balance bill.

Your plan must pay the emergency providers the greatest of these three amounts:

1. The amount it pays in-network providers;

2. A payment based on the same methods the plan uses to pay for other out-of-network
services (for example, a percentage of usual and customary fees charged by other
providers in your area); or

3. The amount Medicare would pay for that service. “ [Doctors typically hate this reimbursement rate.]

Rainbow Girl's picture
Submitted by Rainbow Girl on

From personal experience that is exactly what "U&C" is. Without much fanfare (cough) many private insurers who offer alleged out of network coverage have downgraded to using Medicare-Minus or Medicaid schedules as the benchmarks for reimbursing OON out of pocket expenses. Bwa Ha Ha Ha. And usually the "U&C" system of reimbursing OON expenses is "80% of" whatever the benchmark is. So the InsCo's would be reimbursing at 80% of Medicaid or some mutant version of Medicare rates.

It's possible that they are all doing that (logical business move if they're maximizing premium-collection and minimizing payouts, which is their fiduciary duty to the C suite and shareholders), but the Insurance Commissioners sure aren't forming a National Taskforce to look into the issue. Nor have they in the past 20 years. This has been one of the great looting frauds in the insurance "space" that has received practically zero attention except for a blip during Spiter's AG years, but that's another pitiful story for another day. I may do a post on it, except now it's all becoming moot because OON coverage seems to be becoming extinct as every policy being issued seems increasingly to be finding its lowest common denominator as a de facto Medicaid (skeleton coverage) policy.

Submitted by cg.eye on

Even though Vail is a resort town, the folks who live there long enough to qualify for in-state health insurance are in service jobs, with not a lot of cash to go out-of-pocket for anything even when the tips and paychecks are coming in..

And I'd betcha St. Anthony Summit has positioned itself as the hospital of choice for any ski bunny with massive disposable income, just in case Binky or Chad bite it on the slopes. That means that the county's residents not only subsidized the building of the hospital, but also the luring-in of those high-wealth patients, literally at their own expense. Tell me how this makes sense, the next time there's an infectious disease outbreak among hotel staff too stressed or broke to research how they could take time off, for treatment....

Submitted by lambert on

Bet the taxpayers didn't think they were funding health care for others!

Check out their nauseating values statement. Because (naturally) they're faith-based:

At St. Anthony Summit Medical Center, health care is not merely a business. It's a calling. We celebrate the value of each person's life and consider it a worthy cause to lift the burdens of other by lovingly offering care to people regardless of who they are, what they believe or where they're from. We seek to combine finely honed medical skills with compassionate touch to care for the whole person-body, mind and spirit. In this manner, we strive to create healing sanctuaries that carry on the ministry of Jesus Christ. -

Except for the taxpayers who funded them, of course.

Alexa's picture
Submitted by Alexa on

to convert Medicare to "managed care."

Just think--soon, millions of Medicare beneficiaries may find themselves in the same boat as Cathrall.

As much as I detest the ACA, for my entire adult life it has been the responsibility of the health insurance beneficiary--NOT the employer, government health plan, etc.--to verify that a health care provider (facility, physician, etc.) is "in-network" in the employer-sponsored group health plans that Mr A and I have participated in.

We have received care through employer-sponsored insurance through both private and government service, and military (active duty) facilities. Neither of us have ever been enrolled in a public health program.

And the onus has "always" been on us (not applicable to military medical services) to determine which provider is, and is not, an "in-network" provider.

I "feel for" Cathrall (and anyone in a HMO or MCO) if they are as poor coverage as I've often seen described.

For all of our group health plan's shortcomings--it is STILL, for now, a PPO network--NO physician referrals are necessary, or as Dromaius would put it--"no gatekeepers!"

Thank goodness!

But, our plan puts a lot more of the ER costs on us than they did a couple of years ago.

We have a co-pay--several hundred dollars--UNLESS the ER visit results in a hospital admittance. Of course, our deductible must be met (thousands of dollars), the aforementioned "co-pay" met, and THEN, if a ER visit if not deemed "necessary" by the plan administrator--80% of the "Usual and Customer" Charges will be paid will be paid by the group health plan.

Any charge charges in excess of U&C, will be the responsibility of the group plan beneficiary (employee).

(And if I understand it correctly, this amount will NOT be applied toward the out-of-network out-of-pocket "maximum.")

Now, both of these "features" existed prior to the ACA.

But the ACA magnifies or exacerbates greatly some of the more negative aspects of the typical health insurance plan in the US.

Oh, Cathrall might want to at least see if she can qualify for a "Out Of Area" exception. Some insurers allow this, if say there is not an "in-network" hospital within so many miles--30, 40, 50--of one's resident home. Certainly many PPO's provide this exception. (Although I suspect that by the very nature of "managed care," this may not be a possibility.)

Just wait until Democrats usher in "Medicare Managed Care" for all. (Assuming that they will. Certainly, many test pilots are adopted.)

We may just have another "Dan Rostenkowski" moment.


quixote's picture
Submitted by quixote on

Alexa, I get that the insured normally has to check for the in-networkness (in-networkticality?) of a doctor or a procedure, but that's for appointments made in cold blood, so to speak. I was under the impression that in an emergency, your care was covered as if it was in-network because you couldn't have much say in the matter.

It worked that way for me the one time I needed it, but that could easily be because the university insurance was better than average. The bills freaked me out even without balance billing!

I'm boggled at the notion that a patient in dire straits should be carefully shopping in between surgeries.

Alexa's picture
Submitted by Alexa on

regarding paying any amount over U&C if one goes "out-of-network."

Our benefits manual allows says that the amount one pays providers due to balance billing do not count toward a beneficiary's annual OOP max--just checked it.

And our plan now has several categories of claims processing. You can be denied coverage if you do not appropriately process a claim according to their "rules."

Alexa's picture
Submitted by Alexa on

"The situations I have presented — and the potential consequences — have been checked out with representatives from both the Colorado Exchange and Anthem. Both also advise that it is the responsibility of the patient (not the doctor) to check on the network status of their provider."

I'm sorry, quixote, that I didn't make this clear. (I started to go on and ad that quote, but it was late and I was pretty tired, so I skipped it. Next time I'll try to be more precise.)


Submitted by Dromaius on

It's always been on the insuree to figure out if the doctor was in-network, but the way you could figure that out was by calling the doctor.

With these fingerling networks, sometimes the doctor doesn't even know if he/she is in- or out-of-network.

Alexa's picture
Submitted by Alexa on

plans that we've participated in--that physician office information was to be relied upon.

As a matter of fact, we've also been warned NOT to go by what the physician's office says. That's because "the last say" rests with the insurer--not the physician.

But, we've been insured by group plans which were either under the Federal CS System, a State University System (basically a "state" employee plan), or a group health plan in the private sector.

IOW, Mr A and I have not been insured in the individual private market.

For example, we have been advised that we should call our Group Health Plan Administrator THE MORNING OF each medical, dental or vision care appointment, each time that we see a so-called "in-network" provider.

(And even then, they admit that there is a small window for error regarding provider contracts. Asked what you can do if told someone's in, and then told the aren't--we can "repeal.")