Out of Network

Out of Network

   You didn't see it coming.  After all, the day was going so well;  another day to run errands, the same streets, about the same time.  So who would have thought that that person would have run that stop sign?  And wouldn't you know,  now your car door is jammed just enough that you can't open it;  in fact, the paramedics are there telling you not to move, to stay where you are, that they're almost in.  But you feel fine...it seems.  Okay, a bit of a blood taste in your mouth but nothing too serious;  probably just banged your lip or something.  So you stay quietly still, moving your head just a little to see the ambulance arriving and...are they pulling out a stretcher?

   It can happen that quickly, as anyone who has watched or read or heard about such tales.  The unexpected accident.  Which is really no huge deal, unless you're suddenly unable to move, or being rushed to the hospital or even worse, realizing that all of this is happening to you and you're out of town.  Which is where your insurance coverage enters the picture, especially now with the deadline for healthcare coming to a close.

   That ambulance?  $500 minimum, even if the hospital is only a few blocks away.  Did they place an oxygen mask on you?  That's an extra $100.  IV line, neck brace, Epipen injection?  Yikes, get ready, and that's just the ride to the hospital.  The upsetting part is that once you get through all the tests and the ICU room and the surgery, you may return home to find that none of your expenses were covered.  You were, as the policy says, "out of network."   Granted, there's much confusion over the terms but unless your healthcare plan goes well beyond your region (which might be limited to a small area in your state or just a few surrounding states), you may find that many of today's plans don't offer out-of-network coverage, as exemplified by one family's discovery as reported in the New York Times.

   Add to this confusion, the various charges within a single hospital.  Surgeons operating on you in the hospital might not actually be in your network, even if it would seem that your hospital is indeed, in network.  Huh?  Specialists and surgeons, not to mention anesthesiologists and other lab technicians, can bounce around from hospital to hospital, often lucratively for them but not so for the patient.  This was scarily but carefully pointed out by author and practicing surgeon, Paul A. Ruggieri, in his book, The Cost of Cutting.  In the book, he cites one patient who was billed $17,000 for the exact same operation another patient was billed $4.600.  The difference?  One operation Dr. Ruggieri performed in a hospital and the other he performed in an outpatient clinic.  Same amount of time, same equipment, same procedure, just two different locations.  But the billing?  Even Dr. Ruggieri was at a loss to decipher the entire bill (he gets paid the same from both locations).

   So imagine you're the one with the $17,000 bill and gulp, it was out-of-network and now you're fighting to reduce the charges.  According to Dr. Ruggieri, you might be out of luck.  Unless you have out-of-network coverage in your healthcare policy, your limits might be well beyond the individual maximum on your premium (currently $6,600 for 2015).  Jump to the government's page and you may find the shocking addition to what's beyond that out-of-pocket limit:  This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing, or spending for non-essential health benefits.  Need I emphasize that section?  This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing, or spending for non-essential health benefits.
   
   So who has out-of-network coverage?  Many of the larger providers such as Blue Cross and Aetna can cross-reference their connected hospitals.  The mid-sized networks such as Kaiser can also prove quite extensive.  But if your local clinic or doctor's group is limited in its area, you may have to simply ante up the premium.  For my wife and I, our premiums were close to $1000 with United Health Care...each.  But we were covered (albeit at a reduced percentage) out-of-network (as a side note, our coverage in 2015 has now changed and our out-of-pocket deductible now jumps to over $12,000 before our insurance kicks in).  Could we have gotten coverage that was both local and far less expensive?  Absolutely...but none of the plans offered featured out-of-network coverage.

   It's a dilemma we are not alone in for many of today's seekers of healthcare coverage are facing the same Catch-22;  should one take a chance and hope that if an accident happens, it will be locally and you'll be covered?  Or should one pay the premium to be covered over a greater distance?  And what if you can't afford the premium?  Or the deductible?  Or the out-of-pocket maximums?   Like many of us, the gamble is not one of choice but one of necessity.

   As Dr. Ruggieri says in his book, "Over the last ten years, healthcare costs have spiraled out of control.  The average person knows something is awry but not exactly what, or how to address the problem.  What we do know is that there is a limit to the amount of federal money we are comfortable designating for medical care, and insurance companies are in business to make money.  We want greater access to care and we want quality care and we want lower insurance premiums.  So who's going to foot the bill for all that quality care?"

   $2.7 trillion is what the U.S. spends for healthcare.  17% of the entire U.S. budget.  But for the everyday person, healthcare might prove to be a lot more unless you choose wisely.