A friend's insurance hassle. Check it out

[Orrex]

I know a woman who, while on vacation, took a bad step and wound up with her lower left leg and foot under what I'll call a pile of debris. The accident occurred at a campground, so she was carted away to the nearest ER where they gave her basic treatment and diagnosis. In short, she broke her leg above the ankle.

However, she lives about 200 miles away, and no local hospitals accept her insurance, so they stabilized her and put her in some kind of splint (or maybe a temporary cast) and urged her to consult an orthopedist as soon as possible. This part of her tale wrapped up on Sunday night.

Monday morning she called an orthopedist in her network and described her injury. "We can take you right now," they told her. Well, that's no good, because she was 3 1/2 hours away. "We can see you at noon," they said. This was at 10:30, so it was still no help. The earliest that they could accommodate her, given her uncertainty of travel time etc. was Wednesday morning.

Two friends with whom she was camping drove her home on Monday afternoon.

She saw the orthopedist on Wednesday, and in addition to her broken leg, she broke most of the bones in her foot. She'll require extensive reconstruction and a lot of pins. Her dreams of becoming a flamenco dancer are likely over.

Now, admittedly, I got the detals of this story on Friday night, so it had all transpired before I even knew it had occurred, and I can't really check the details. Still, it sounds close enough to the horror stories I've heard that I don't have much reason to question it.

I can see why insurance plans might only be available for purchase in certain regions, but why the hell shouldn't all legitimate insurance plans be accepted at all public hospitals? It's not as though she was injured in a bar fight in Nepal; she broke her leg in her state of residence! Is there any serious justification for this non-acceptance of an insurance plan? And by "serious justification" I mean some reason that doesn't pertain directly to the bottom line for shareholders in the insurance company.

[TZ]

1. Hmm.

I thought that most insurance companies would let you go out of network for a larger deductible, (say paying 20% instead of 10%).
But thats pretty crappy. What if it was a life threatening condition?
I wish this kind of nonsense would happen to the "no right to health care" crowd on Capitol Hill..they might change their tune quick enough.
Wow. This is the second time today I've said this. Yeah. There's no need for universal health care...:sarcasm:

[NV Whino]

2. That is a bit strange

I would think that any health care plan has coverage for emergencies.

I used to be with Kaiser but they covered about three emergency visits to the local hospital. Their hospital was over an hour away, their local doctors' offices were closed on the weekend and the local (non-Kaiser) hospital was only 5 minutes from me. There was a little bit of a hassle the last time, but a reminder that they had told me they had cleared the coverage took care of it.

[littlebit]

3. That's odd

I have BCBS of NC. About a month ago I thought I might have broken my foot when I was in NY. I went to the ER in Middletown NY and used my insurance with no problem. I got a bill for what my insurance didn't cover. Which wasn't a whole lot more than it would have been in NC.

[yellowdogintexas]

13. BCBS has a zillion different plans, depending on the group. If the national network

is what your plan offers, the national network is what you get. So your incident was relatively hassle free. UnitedHealthCare is much the same way..their network is huge, and national.

BCBS probably has a negotiated rate for ER that is pretty standard nationally, and your plan may have some additional stuff built into it as to how much the out of pocket expenses are.

[OmahaBlueDog]

4. Not an uncommon story

First, I'm sorry for your friend if this has really ended a dance career, and I'd urge her to see other orthopedists for additional opinions-- especially those specializing in sports injuries.

Second, insurance companies, even national ones, tend to put their health care (both PPO and HMO) into pools. So, when I worked in Florida, I was not merely with <<name of company>>, I was with <<name of company>> Select of South Florida, whereas now I am with <<name of same company>> of the Midwest. Sometimes, if you're lucky, they will let you use a specialist doctor in an out of area network, but often that takes weeks of arguing.

Third, someone made the point about emergencies. You're right -- they will cover emergencies, but often that only means any care in the ER, and resulting hospitalization. Follow-up specialty care outside the ER has to take place in-network.

Fourth, someone mentioned higher copays. This is true if you have a PPO or POS plan; these plans usually have in-network, as well as 80/20 and 60/40 tiers of coverage. But, if you have an HMO, it's generally in-network or pay full retail.

As an aside, this is where the conservative argument about "a national plan=rationing health care" falls down. It's not that they're flat out-wrong, but it's that rationing is exactly what HMOs do now; you're forced to stick with a group of doctors who'll take what your plan pays, and everything goes through a PCP, who is given pretty much every incentive on earth not to let you see a specialist unless absolutely necessary (in their judgment).

[Orrex]

6. I have to confess that I was kidding about the flamenco dancing, but

She's reasonably athletic, and this will certainly crimp her exercise regimen.

I think that you described the situation correctly in your Third point; the ER visit and care were covered, but specialist treatment has to be in-network.

I don't see this woman often, but I have other friends who do; if I hear of any further developments, I'll post.


Thanks for your input!

[yellowdogintexas]

8. or if you have an EPO which is an Exclusive Provider Network. Not quite the same

as an HMO because all the physicians don't work exclusively for the same outfit, and truthfully an EPO usually contracts with the biggest network they can find, so you don't get caught w/o services.

If she had actually been admitted to the initial ER her plan might have been more lenient but not haveing read her contract I could not say.

EPO is also better than HMO because you don't usually have to parade through the Primary Care office to get your specialty care paid for. Now I will see my PCP to get her opinion on a specialist, but she doesn't have to write a referral for me.

[OmahaBlueDog]

11. The EPO may eventually become the preferred alternative to the HMO

The old-style, traditional HMO with capitation, has some good ideas, but eventually succumbs to the greed factor; the PCPloses money every time you see a specialist. Even most HMOs have lots of exceptions to the PCP (e.g. well woman OB/GYN, Dermatologist in many states).

The EPO, as you state, allows you to see anyone in a network (which a lot of people live), but there's generally no out of network provision.It's a great option for folks with allergies, for example, who really need to deal with an allergist, but who (in a traditional HMO) will get a lot of prescriptions for albuterol and flonase before they see the inside of an allergist.

I see these replacing many PPOs in the next few years.

[yellowdogintexas]

12. so do I. I have not been offered a capitated PPO by any employer in a very long

time, and have chosen the EPO because it is less expensive and the network it used was HUGE, and national in scope.

We recently had to change to a different plan which is PPO with out of network rates for non net providers. Fortunately my doctor is willing to file all the claims all the way back to the July 1 effective date as soon as we get the cards, and refund any thing back to us, and I can just get a prescription printout from Walgreens to submit on the RX. Our family MD is not in this network any longer but will still file claims and will send us to the in net labs, radiology, facility etc. Those are the real expensive things anyway. If all I had to deal with was HER office costs, I wouldn't care if I had coverage at all. We have the coverage in case a hospitalization or major lab/xray/or other outpatient procedure is required.

having processed claims for years, in many different formats, I KNOW it is a nightmare. Lucky people who work for large companies, or government entities w/ many participants simply get better coverage. Small group and individual plans can be total nightmares.

[LeftyFingerPop]

5. Ahhhh...Health care and "insurance"

Insurance "Ensures" nothing (typo intentional).

I am living the insurance and specialist nightmare now...AND IT IS MAKING ME FEEL THE WORST I HAVE EVER FELT IN MY FUCKING LIFE.

Fuck this country, fuck our health care system.

We treat our citizens like fucking wild animals.

[ET Awful]

7. Once, while snowboarding, I broke my collarbone. The clinic on the mountain took NO insurance.

They insisted that the injured person pay for the care, then submit the bill to their insurance company.

[yellowdogintexas]

9. I used to process those claims all the time. Those mountaintop clinics are

of the captive audience variety. You are there, you need them, you do the paperwork. They don't bother with all that staff.

[OmahaBlueDog]

10. You are there, you need them, you do the paperwork.

This is why doctors absolutely love the idea of getting making most current healthcare plans obsolete, and replacing them with $5000 major medical plans and HSAs. They can get rid of those pesky administrators who process insurance, charge whatever the Hell they want, and take cash for it. No waiting to get paid, and no getting paid at "negotiated rates." The theory is that bringing cash back into the system will foster competition and lower rates. While that may be true to some extent, essentially, it will relegate the vast majority of Americans to doc-in-the box for the vast majority of care, and will raise credit card debt even further, as the vast majority of Americans don't have $100 a week to put into an HSA.