Experience with out-of-network?

[TargaDave]

Curious what people’s experience has been with out-of-network coverage, especially as it relates to “customary and allowable” expenses, and going to one of the big name clinics (Mayo, Cleveland, Johns-Hopkins, etc)?

Short story: DW goes for post cancer surgery checkups at Mayo 1-2 times per year, about $7k/visit. Our PPO plan (Health Assurance) advertised 70% out-of-network coverage but the typical “allowables” are way below what Mayo charges (i.e., something like $300 for a cat-scan versus Mayo’s $1200 fee and so on). So far this year we have $12k out-of-pocket med expense excluding deductibles. I know she could get certain tests done in-network but she feels far more confident in Mayo’s overall competency (uncommon condition).

Insurance agent told us to try and “negotiate” with Mayo ahead of time for her next visit. Can’t believe that’s gonna do much good. Anyone ever do that?

T-Dave

[mykidslovedogs]

Quote:

Originally Posted by TargaDave Curious what people’s experience has been with out-of-network coverage, especially as it relates to “customary and allowable” expenses, and going to one of the big name clinics (Mayo, Cleveland, Johns-Hopkins, etc)? Short story: DW goes for post cancer surgery checkups at Mayo 1-2 times per year, about $7k/visit. Our PPO plan (Health Assurance) advertised 70% out-of-network coverage but the typical “allowables” are way below what Mayo charges (i.e., something like $300 for a cat-scan versus Mayo’s $1200 fee and so on). So far this year we have $12k out-of-pocket med expense excluding deductibles. I know she could get certain tests done in-network but she feels far more confident in Mayo’s overall competency (uncommon condition). Insurance agent told us to try and “negotiate” with Mayo ahead of time for her next visit. Can’t believe that’s gonna do much good. Anyone ever do that? T-Dave

Out of network benefits usually have a separate deductible, and then the insurance company only pays a percentage of what they would have allowed for in-network benefits. The out-of-network providers are then allowed to "balance bill" or charge you for the difference between the billed amount and the "allowed amount" The "allowed amount" is actually what your carrier has already negotiated with their in-network providers. If I were you, and if you have the time to, I would explain to the Mayo providers about your situation to see if they willn negotiate with you about the balance billing. Some providers are willing to do this. It all depends on what their negotiated rates are with other insurance carriers. You might be able to at least talk them down to what their negotiated rates are with the insurance carriers that they work with.

It can't hurt to try....

MKLD

[FinanceDude]

I agree, particularly with Mayo. Of the clinics you mentioned, I believe Mayo would negotiate the easiest.

[crazy connie]

Mayo does negotiate a bit. A friend of mine lost his wife to kidney failure almost 2 years ago. She had many diagnostic tests thru Mayo in Scottsdale and passed away in hospice care. Her chemo was administered by Mayo and co-pay was over $300 a week. The Mayo bill that was not covered was in excess of 200K. His plan is to pay $50 a month for the rest of his life. Mayo was not on the Approved Provider list of a United Healthcare Plan. Because he is making payments they are not after him so to speak. My guess is they will file as a debtor when he passes away and collect from the residual estate.

Not a real heartening thought I know.

[youbet]

Quote:

Originally Posted by crazy connie Mayo does negotiate a bit. A friend of mine lost his wife to kidney failure almost 2 years ago. She had many diagnostic tests thru Mayo in Scottsdale and passed away in hospice care. Her chemo was administered by Mayo and co-pay was over $300 a week. The Mayo bill that was not covered was in excess of 200K. His plan is to pay $50 a month for the rest of his life. Mayo was not on the Approved Provider list of a United Healthcare Plan. Because he is making payments they are not after him so to speak. My guess is they will file as a debtor when he passes away and collect from the residual estate. Not a real heartening thought I know.

Unless there is a typo here, Mayo is really being generous! If your friend lives 30 years, he'll pay only $18K (9%) of the $200K debt. And most of that with inflation devalued dollars over the 30 year period. For all practical purposes, your friend is paying almost nothing at all on the debt in real terms. For Mayo to not go after him (by selling the debt to a collection agaency) and crush his credit rating, etc., is really an act of charity. I guess not all big businesses are the meanies we assume them to be!
[/quote]

[TargaDave]

Quote:

Originally Posted by mykidslovedogs Out of network benefits usually have a separate deductible, and then the insurance company only pays a percentage of what they would have allowed for in-network benefits. The out-of-network providers are then allowed to "balance bill" or charge you for the difference between the billed amount and the "allowed amount" The "allowed amount" is actually what your carrier has already negotiated with their in-network providers. If I were you, and if you have the time to, I would explain to the Mayo providers about your situation to see if they willn negotiate with you about the balance billing. Some providers are willing to do this. It all depends on what their negotiated rates are with other insurance carriers. You might be able to at least talk them down to what their negotiated rates are with the insurance carriers that they work with. It can't hurt to try.... MKLD

Seems reasonable, and we'll certainly try. I'd be curious to know which insurance carriers Mayo (or any of the major clinics) has negotiated rates with? I get the impression that best clinics are not under much pressure to negotiate significantly lower fees with any carrier (supply and demand). Maybe I'm mistaken.

[lets-retire]

My SIL had a similar experience of charity with a hospital, so I'm told. I guess she went in for some type of emergency procedure she couldn't afford. When everything was finished and the bills started to come in she basically called the hospital and told them she could afford to pay the bill. The hospital worked out an arrangement where she paid some ridiculous amount, IIRC $20.00, every month over many years. The hospital also told her that as long as she paid as agreed the account wouldn't go into collections. She agreed and paid it. After paying for so many years she was able to get on her feet and paid the bill off.

I guess the hospital figured being paid back even a small amount was better than putting someone through the ringer and probably not ever receiving any back.

[crazy connie]

Quote:

Originally Posted by youbet Unless there is a typo here, Mayo is really being generous! If your friend lives 30 years, he'll pay only $18K (9%) of the $200K debt. And most of that with inflation devalued dollars over the 30 year period. For all practical purposes, your friend is paying almost nothing at all on the debt in real terms. For Mayo to not go after him (by selling the debt to a collection agaency) and crush his credit rating, etc., is really an act of charity. I guess not all big businesses are the meanies we assume them to be!

On one hand, yes they are being generous. On the other... They collected over 700K in benefits for out-patient diagnosis and care they oversaw. That is a lot of money for testing and oversight of care. Treatment including a limb amputation and 3 months in Hospice was covered in excess of 95% by Banner Health which is In-Network with UHC Plan. As the Mayo Accounting Team explained they do not turn over to collections to force bankruptcy when you continue to make payments... So, it appears they are waiting instead of forcing a write off. Good business decision.

[crazy connie]

Quote:

Originally Posted by TargaDave Seems reasonable, and we'll certainly try. I'd be curious to know which insurance carriers Mayo (or any of the major clinics) has negotiated rates with? I get the impression that best clinics are not under much pressure to negotiate significantly lower fees with any carrier (supply and demand). Maybe I'm mistaken.

Many most carriers have rates with Mayo. Most employer group health plans do not authorize at that level. Major corps carry dual plans. 1 plan which is decent basic and 2nd plan for execs with gold plating. Most folks with group health have decent basic with choices which are tough. Reasonable & Customary apply to the worker bees. Those who can afford better and are willing to pay for it can get it. No one ever said life was fair.

[Martha]

Not surprisingly, our Minnesota BCBS plan covers care at Mayo.

You might want to read these links about Mayo:

http://www.mayoclinic.org/billing-rst/

http://www.kaisernetwork.org/daily_r...fm?DR_ID=30220

[Nords]

Quote:

Originally Posted by TargaDave Insurance agent told us to try and “negotiate” with Mayo ahead of time for her next visit.

How naive of me-- I assumed that's what insurance agents are paid to do when they collect our premiums...

[Rich_by_the_Bay]

If your care at an out-of-network facility is readily available in-plan, you are probably not going to receive much support from your carrier.

If I were you, I would look for some aspect of what was provided which could not be reasonably provided within the network. That is your strongest argument. Most plans allow out-of-plan coverage in that scenario but insist that you get preauthorization.

If the care is available in-network, consider receiving it there. Usually it will be comparable barring an esoteric disease or procedure being present.

[mykidslovedogs]

Quote:

Originally Posted by Nords How naive of me-- I assumed that's what insurance agents are paid to do when they collect our premiums...

Due to Federal HIPAA privacy laws (what I call anti-customer service laws), hospitals no longer allow agents to act on behalf of clients without a myriad of pain in the neck medical release authorization forms that require processing before we can even begin to help.

[Nords]

Quote:

Originally Posted by mykidslovedogs Due to Federal HIPAA privacy laws (what I call anti-customer service laws), hospitals no longer allow agents to act on behalf of clients without a myriad of pain in the neck medical release authorization forms that require processing before we can even begin to help.

Thanks for that timely factoid on HIPAA's legal intricacies, MKLD, but your insurance-agent lecture just demonstrates why I think that other agent doesn't (and you don't) understand.

My point is that a customer who's paying the money should be reasonably expectant of a level of service that could include processing a medical release or otherwise trying to take care of the problem...

Perhaps an insurance agent could say something like "That's outside our insurance allowables, but we have an agreed rate with the Mayo of $xx and we can ask them to give that rate to you." Maybe Mayo will do that, maybe not, but at least the agent actually put forth the effort that a customer could appreciate... instead of educating the customer on why that couldn't be done. I don't pay an insurance agent to educate me on all the latest processes & complexities of the whole freakin' industry, I pay an insurance agent to help find solutions. Instead of saying "It doesn't work that way", try "How could we make that work?"

Whether or not it's "allowed" or "approved", that's the kind of service that keeps the customers coming back at renewal time. Perhaps if we all pulled our heads out of the rulebooks and looked at the situation from a service perspective then good results would be a bit more achievable.

[mykidslovedogs]

Quote:

Originally Posted by Nords Thanks for that timely factoid on HIPAA's legal intricacies, MKLD, but your insurance-agent lecture just demonstrates why I think that other agent doesn't (and you don't) understand. My point is that a customer who's paying the money should be reasonably expectant of a level of service that could include processing a medical release or otherwise trying to take care of the problem... Perhaps an insurance agent could say something like "That's outside our insurance allowables, but we have an agreed rate with the Mayo of $xx and we can ask them to give that rate to you." Maybe Mayo will do that, maybe not, but at least the agent actually put forth the effort that a customer could appreciate... instead of educating the customer on why that couldn't be done. I don't pay an insurance agent to educate me on all the latest processes & complexities of the whole freakin' industry, I pay an insurance agent to help find solutions. Instead of saying "It doesn't work that way", try "How could we make that work?" Whether or not it's "allowed" or "approved", that's the kind of service that keeps the customers coming back at renewal time. Perhaps if we all pulled our heads out of the rulebooks and looked at the situation from a service perspective then good results would be a bit more achievable.

Actually, that's exactly what we do, but thanks to the regulation, it now takes 1-3 months to help a customer instead of just a few hours. I was just pointing that out, so that you could be aware why insurance agents sometimes have limitations to our level of service that we can provide.

Your comment made it seem like all we do is sit back and collect our paychecks without putting forth any level of service at all. A lot of times, it's not feasible for people to wait that long for help on certain things. In the case of negotiation, we would have to have a form filled out for each provider that person works with. Then, if we were lucky, the form would be processed when we contacted billing to help out. 5 times out of ten, the billers will claim they never got the release form. Then, we have to get another one...and so on and so on... In this case, it would be much easier for the patient to go directly to the different doctors and explain the situation. It would take much too long for an insurance agent to get involved with the billing negotiation at a place like Mayo.

But, if they client is willing to wait, and willing to fill out all of the forms and willing to turn in each of the the release forms to every doctor, then, we are happy to help out.

[Nords]

Quote:

Originally Posted by mykidslovedogs But, if they client is willing to wait, and willing to fill out all of the forms and willing to turn in each of the the release forms to every doctor, then, we are happy to help out.

Like I said, customer service...

[mykidslovedogs]

Quote:

Originally Posted by Nords Like I said, customer service...

HIPAA privacy laws prevent us from being able to provide timely service, filling out release forms, or contacting the client's provider in any way, shape or form. The client must follow all of those steps before a provider will even say "Hi" to us. (Ask Rich in Tampa - I'm sure he can vouch for me on this).

Also, the doctor's offices won't even send us the forms. The forms have to go directly to the client, they can't be faxed in, and they have to be sent back in the client's handwriting in the original format. No faxes allowed. Snail mail...all the way.

[Rich_by_the_Bay]

Quote:

Originally Posted by mykidslovedogs thanks to the regulation, it now takes 1-3 months to help a customer instead of just a few hours. I was just pointing that out, so that you could be aware why insurance agents sometimes have limitations to our level of service that we can provide. ... In the case of negotiation, we would have to have a form filled out for each provider that person works with. Then, if we were lucky, the form would be processed when we contacted billing to help out. 5 times out of ten, the billers will claim they never got the release form. Then, we have to get another one...and so on and so on... In this case, it would be much easier for the patient to go directly to the different doctors and explain the situation. It would take much too long for an insurance agent to get involved with the billing negotiation at a place like Mayo.

And this is the system you think is so great?

[mykidslovedogs]

Quote:

Originally Posted by Rich_in_Tampa And this is the system you think is so great?

Nope, I am TOTALLY opposed to the Privacy Act (when it comes to regulation in the financial industry.) It goes too far. I guess that's one area where I disagree with conservatives.

In general, I am opposed to "too much" government regulation. I'm not saying it's never necessary. I just don't like any form of "nannyism".

[Nords]

Quote:

Originally Posted by mykidslovedogs HIPAA privacy laws prevent us from being able to provide timely service, filling out release forms, or contacting the client's provider in any way, shape or form. The client must follow all of those steps before a provider will even say "Hi" to us. (Ask Rich in Tampa - I'm sure he can vouch for me on this). Also, the doctor's offices won't even send us the forms. The forms have to go directly to the client, they can't be faxed in, and they have to be sent back in the client's handwriting in the original format. No faxes allowed. Snail mail...all the way.

See, this is where I'd refer you back to the part where I said:

Quote:

Originally Posted by Nords but at least the agent actually put forth the effort that a customer could appreciate... instead of educating the customer on why that couldn't be done. I don't pay an insurance agent to educate me on all the latest processes & complexities of the whole freakin' industry, I pay an insurance agent to help find solutions.