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FTA St. David’s is out-of-network on his school district health plan So apparently the "max out of pocket" on the cover sheet of your plan is b.s. and only app

by cmurf 8y ago

FTA St. David’s is out-of-network on his school district health plan So apparently the "max out of pocket" on the cover sheet of your plan is b.s. and only applies in-network. I guess good luck having in-network coverage if you're on a vacation and have an emergency.

throwawayjava 8y ago
The article goes on to clarify the problem: the school district has a self-funded insurance plan. Actionable advice: check if your employer-provided healthcare is a self-funded insurance plan or a fully insured plan. And then look up the relevant consumer protections in your state for that type of plan. Also, in case you're wondering what the hell all those hospital administrators are dong, the answer is "shaking down your employer and screwing you over": > In a statement, St. David’s HealthCare defended its handling of Calver’s bill and sought to blame the school district and Aetna for offering such a narrow network. >“While we did everything right in this particular situation, the structure of the patient’s insurance plan as a narrow network product placed a large portion of the financial responsibility directly on the patient because our hospital was not in-network,” the hospital said. > WellRithms reviewed Calver’s bill in detail at the request of Kaiser Health News and determined that a reasonable reimbursement would have been $26,985. That’s less than half what Aetna paid.
- cmurf 8y ago
  I wonder if the local county this school district is in, also provides only a "self-funded" plan to their employees. Are all the government employees getting screwed or just the teachers? It's a quaint ethical puzzle which is worse. So the last line, "less than half what Aetna paid", does that ostensibly mean the hospital is definitely charging an unreasonable price, and by having been paid twice what is reasonable by Aetna that ostensibly this teacher shouldn't have to pay a dime? It's just a contractual reason he owes this money?
  - throwawayjava 8y ago
    > does that ostensibly mean the hospital is definitely charging an unreasonable price Not ostensibly, but actually. The article goes on to identify some concrete charges that independent auditors felt were ridiculous, including charging $19k for stents that the hospital most likely purchased for about $2K. > It's just a contractual reason he owes this money? The hospital just straight up dropped all but $800 of the charges when they got PR heat.
  - ubernostrum 8y ago
    It's useful to understand what a "self-funded" plan means. People in the US are used to their employers purchasing group health plans from insurance companies. In that model, a premium (often part paid by the employer, part by the employee) is paid to an insurance company in return for coverage. When there's a claim, the insurance company pays, out of its own money, and the insurance company's profit comes from taking in more money in premiums than it pays out in claims. In a self-funded plan, the employer and employees still pay premiums, and all that money goes into a pool which is used to pay the claims. Typically a company is hired to administer the plan, but that company is not an insurer, and that company does not pay claims; the money to pay off claims comes directly out of that pool of premiums. What this means is that the administrator just pays whatever it's told to pay by the company that hired them to run the plan. It's not the administrator's money being spent, and their profit is in the fees they charge to run the plan, not in denying or underpaying claims. My very first real job out of school, years and years ago, was a place that did administration for self-funded plans. About once a month we'd get a call from one of our client companies saying "yeah, we know our plan's rules say not to pay that claim, but we want to pay that claim". And we'd say "OK, it's your plan and your money, you make the rules". The downside is that if the company gets into financial trouble, its contributions to the pool of money that pays claims are often one of the first things to stop happening. I remember pretty clearly one client company that went bankrupt and just stopped paying into its plan, and once the money in the plan's pool ran out there were no more claims paid.
woobar 8y ago
Yeah, out-of-network coverage (if provided) is often limited by terms like "the usual, customary, and reasonable amount". When a provider charges unreasonable amount the insurance will not have any contracts that enforce the cost of services. And the patient left holding the bag. ;( My guess is in a situation like this I'd get the reasonable amounts for services provided from my insurer and use them as a basis to refuse any unreasonable charges.
- nerdponx 8y ago
  The whole warped part of this is that the consumer has no way to anticipate cost in advance, and often the individual providers (doctors, nurses, etc.) don't either. Shouldn't the burden be on the insurance company to investigate and discourage excessive billing? Or are they too strict as it is, leading providers to play games with billing?
  - woobar 8y ago
    I think in this particular case insurance did investigate actual (or within a reason) costs and paid them. But there is no business relationship between the insurance company and an out-of-network provider. Should they go to the court on behalf of the patient? As a customer I'd like this. But it looks like combining health and legal insurances. Another option is maybe to require that language on the "patient responsibility form" to include the blurb about fair prices. For instance: In the event that my health plan determines a service to be “not payable”, I will be responsible for the complete charge and agree to pay the usual, customary, and reasonable costs of all services provided.
    - nerdponx 8y ago
      Is there an analogy in the car insurance world? Let's say I know nothing about cars and I get in a collision somewhere far away from home. I need a repair th let's say I know nothing about cars and I get in a collision somewhere far away from home. I need some bodywork and a replacement for the flimflam crankslap in the engine. The shop knows that I don't know anything about cars, and they know that I am covered by insurance. What is stopping them from charging me an exorbitant rate for a new crankslap, and then me getting screwed when the insurance won't cover it?

by cmurf 8y ago

throwawayjava 8y ago

The article goes on to clarify the problem: the school district has a self-funded insurance plan. Actionable advice: check if your employer-provided healthcare is a self-funded insurance plan or a fully insured plan. And then look up the relevant consumer protections in your state for that type of plan. Also, in case you're wondering what the hell all those hospital administrators are dong, the answer is "shaking down your employer and screwing you over": > In a statement, St. David’s HealthCare defended its handling of Calver’s bill and sought to blame the school district and Aetna for offering such a narrow network. >“While we did everything right in this particular situation, the structure of the patient’s insurance plan as a narrow network product placed a large portion of the financial responsibility directly on the patient because our hospital was not in-network,” the hospital said. > WellRithms reviewed Calver’s bill in detail at the request of Kaiser Health News and determined that a reasonable reimbursement would have been $26,985. That’s less than half what Aetna paid.

cmurf 8y ago
I wonder if the local county this school district is in, also provides only a "self-funded" plan to their employees. Are all the government employees getting screwed or just the teachers? It's a quaint ethical puzzle which is worse. So the last line, "less than half what Aetna paid", does that ostensibly mean the hospital is definitely charging an unreasonable price, and by having been paid twice what is reasonable by Aetna that ostensibly this teacher shouldn't have to pay a dime? It's just a contractual reason he owes this money?
- throwawayjava 8y ago
  > does that ostensibly mean the hospital is definitely charging an unreasonable price Not ostensibly, but actually. The article goes on to identify some concrete charges that independent auditors felt were ridiculous, including charging $19k for stents that the hospital most likely purchased for about $2K. > It's just a contractual reason he owes this money? The hospital just straight up dropped all but $800 of the charges when they got PR heat.
- ubernostrum 8y ago
  It's useful to understand what a "self-funded" plan means. People in the US are used to their employers purchasing group health plans from insurance companies. In that model, a premium (often part paid by the employer, part by the employee) is paid to an insurance company in return for coverage. When there's a claim, the insurance company pays, out of its own money, and the insurance company's profit comes from taking in more money in premiums than it pays out in claims. In a self-funded plan, the employer and employees still pay premiums, and all that money goes into a pool which is used to pay the claims. Typically a company is hired to administer the plan, but that company is not an insurer, and that company does not pay claims; the money to pay off claims comes directly out of that pool of premiums. What this means is that the administrator just pays whatever it's told to pay by the company that hired them to run the plan. It's not the administrator's money being spent, and their profit is in the fees they charge to run the plan, not in denying or underpaying claims. My very first real job out of school, years and years ago, was a place that did administration for self-funded plans. About once a month we'd get a call from one of our client companies saying "yeah, we know our plan's rules say not to pay that claim, but we want to pay that claim". And we'd say "OK, it's your plan and your money, you make the rules". The downside is that if the company gets into financial trouble, its contributions to the pool of money that pays claims are often one of the first things to stop happening. I remember pretty clearly one client company that went bankrupt and just stopped paying into its plan, and once the money in the plan's pool ran out there were no more claims paid.

woobar 8y ago

Yeah, out-of-network coverage (if provided) is often limited by terms like "the usual, customary, and reasonable amount". When a provider charges unreasonable amount the insurance will not have any contracts that enforce the cost of services. And the patient left holding the bag. ;( My guess is in a situation like this I'd get the reasonable amounts for services provided from my insurer and use them as a basis to refuse any unreasonable charges.

nerdponx 8y ago
The whole warped part of this is that the consumer has no way to anticipate cost in advance, and often the individual providers (doctors, nurses, etc.) don't either. Shouldn't the burden be on the insurance company to investigate and discourage excessive billing? Or are they too strict as it is, leading providers to play games with billing?
- woobar 8y ago
  I think in this particular case insurance did investigate actual (or within a reason) costs and paid them. But there is no business relationship between the insurance company and an out-of-network provider. Should they go to the court on behalf of the patient? As a customer I'd like this. But it looks like combining health and legal insurances. Another option is maybe to require that language on the "patient responsibility form" to include the blurb about fair prices. For instance: In the event that my health plan determines a service to be “not payable”, I will be responsible for the complete charge and agree to pay the usual, customary, and reasonable costs of all services provided.
  - nerdponx 8y ago
    Is there an analogy in the car insurance world? Let's say I know nothing about cars and I get in a collision somewhere far away from home. I need a repair th let's say I know nothing about cars and I get in a collision somewhere far away from home. I need some bodywork and a replacement for the flimflam crankslap in the engine. The shop knows that I don't know anything about cars, and they know that I am covered by insurance. What is stopping them from charging me an exorbitant rate for a new crankslap, and then me getting screwed when the insurance won't cover it?