Are there Gaps in Your Healthcare Coverage?

When Robert and Cindy (not their real names) learned that they were going to become parents, they tried to cover all of the bases.  The couple contacted their insurance, Blue Cross Blue Shield, to make certain it would pay for both the hospital stay and Cindy’s doctors.  Reassured that they were covered, they settled back to await that special day.

 But it didn’t work out quite that way.  The baby went into fetal distress during labor and Cindy needed an emergency cesarean section, after which her newborn daughter, Jennifer was born.  Lisa spent eight days in the neonatal intensive care unit at the local hospital, and made a quick recovery.  But the complications were not over yet.  The neonatalogists weren’t in the Blue Cross Blue Shield network, so Robert and Cindy were billed $6,000 for Morgan’s care.  Cindy had no idea that it was even possible that a doctor can be out of network when the hospital was an in-network hospital.

 If your hospital care goes beyond your primary physician or surgeon to include anesthesiologists, pathologists, radiologists, or even an assistant surgeon or doctors in the emergency room, your insurance may not cover the cost.  The out-of-network charge for a pathologist who analyzes your lab work may be only a couple of hundred dollars.  But if your baby ends up staying in the neonatal intensive care for a few weeks, the cost could easily exceed $20,000.

 When the hospital stay isn’t an emergency, you have time to plan.  For example, if you are having surgery, it isn’t enough to know that your surgeon is a member of your insurance network.  Ask the surgeon who will provide your anesthesia, and make sure that the doctor or nurse-practitioner also participates in your plan.  It is fairly routine to hear patients say that they do not even know who the doctor is that is listed on their bill.

 Check to see if the pathologist is covered too.  If you have a choice, tell your primary doctor you’d prefer a physician in your network.  But you won’t necessarily get your wish.  If the neonatalogists on a hospital’s staff are members of the same practice, it is likely that all or none of them will accept your insurance.  Or, an in-network specialist may not be available.   

What more could have been done?

 Well, without a crystal ball, there is not much more that anyone in a similar circumstance can do.  Considering the following: 

• Given the state of the medical system in this country, is there any more due diligence that Cindy could have performed?
• Is it realistic for the average person to know all of the in and outs with doctors and hospitals, billing codes, and participating plan members, etc?
• Does it seem like the odds are stacked against you?
   

What we did to help Robert and Cindy out

 Well, first of all, the baby is taking up almost all of Cindy and Robert’s time.  So time seems to be a premium at this point in their eyes. 

 We intervened on their behalf and worked out an arrangement with the out of  network doctors' (to which there were three).  Concurrently, we worked with the hospital and the patient advocates that assisted in our cause.  We then filed an appeal through the insurance companies appeal process.  The first one proved unsuccessful, so a second one was filed, after contacting the New York State Insurance Department.

 Finally, 13 months after Lisa’s birth, the claims have been settled.  The insurance company picked up over $28,000 in costs associated with the birth, of which only 16,000 was in-network costs. 

Conclusion

 So, to go back to the initial question posed, are there gaps in your healthcare coverage, the answer is YES!  All plans have gaps between in-network and out of network coverage, and no matter how much up front work you do to prepare, it may never be enough.  Certainly no one will argue that you shouldn't do your homework first, as educated consumers.  However, things did not go according to plan, as in the case of Robert and Cindy, which is how this all started.