The In-Network/Out-of-Network Scam

Last updated on: August 22, 2014 at 3:47 pm by Rebecca Frech

The In-Network/Out-of-Network Scam 2014-08-22T15:47:56-05:00 Rebecca Frech

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Once upon a time, I thought that the way health insurance worked was simple. If you got sick, you found a doctor or a hospital on your list of providers and you went to them, because they were the ones in-network. It all seemed so simple, in theory, that I would hear tales of people going broke when they got sick and think “They must have been sick for a really long time.” or “I wonder why they didn’t go to someone on their insurance.” or most often “That’s really sad, but it won’t happen to me. We’ve got great insurance.” In my naivety, I didn’t understand that people were going broke after one or two days in the hospital. I didn’t know just how difficult it really could be to navigate through the in/out of network maze. I honestly had no idea…and then #4 got sick.

She woke up one morning with her toe all swollen and purple, but it didn’t hurt and she couldn’t remember hurting it. I took her to our family doctor (in network – $20). He confessed that he had no clue what was going on, but thought it might be broken, and sent us for an x-ray which had to be read by a radiologist (both in network, combined – $45) It wasn’t broken. We decided to watch it for a day or two and see what would happen.
Her knee swelled up a few nights later. We took her back to our family guy (in network $20). He was more confused than ever. He sent us to an orthopedist (in network $20). He asked for an MRI of her knee (in network – $225)
The knee swelled up even more and got hot to the touch. I called our family guy, who agreed with me that this sounded as if it might be an infection in the joint, and sent us to the ER at Children’s Hospital ( ER co-pay in network $100) ( ER in network – $1,167) The first doctor we saw ( out of network $325) didn’t know what was going on, so he called in a colleague to look at her ( in network – included in ER co-pay). They decided that they wanted to see an ultrasound of her knee to determine if the swelling was water or pus. ( in network – included in co-pay) The film had to be read by a radiologist we never saw ( out of network – $2,143)
The fluid was fluid and not pus. The ER doctor decided that it should be drained and analyzed. He called in an orthopedist ( out of network – $417 ) who pushed and poked at her knee for a good bit before declaring that he was uncomfortable draining it himself. He called in a different orthopedist ( in network – $115). He asked for her to be given anesthesia first (pharmacy- in network – $187) He sent the fluid to the lab (in network – included in ER copay) where it had to be scrutinized by a doctor (sorry, I can’t remember his title. I just have his name and his bill. out of network – $423 )
After 7 hours in the ER, they decided to admit her to the hospital for more testing an observation ( hospital in patient care in network $874 ). That night, she was seen by another orthopedist ( out of network $316 ) who confessed that he wasn’t sure but that he was leaning towards calling it Rheumatoid Arthritis. He decided to send her file to the other Children’s Hospital in town, where they have pediatric rheumatologist on staff, for another opinion. The rheumatologist wasn’t on call that night, but 2 more orthopedists were happy to look at her films and offer their opinions. ( One consulted for free, the other was out of network $87)
The next morning, yet another orthopedist came to look at her ( out of network – $397 ) before calling in the head of orthopedics ( in network – included in hospital co-pay )

We weren’t done yet, but you get the idea. Hospitalizations are not only stressful, they are a dizzying maze of people, procedures, and fear. In less than 24 hours, we had already amassed 16 bills totaling over $7,000. Before we were finished getting a diagnosis and seeing specialists, the total would be in the tens of thousands of dollars. While our insurance has a cap of $5,000 per family per year, that doesn’t include out of network physicians or facilities. There is no cap, no limit at all, on our financial obligation when we go out of network. It sounds as if it would be a simple thing to do until you are in a hospital and the out of network physicians are not people you ever see.

The insurance companies will tell you that it is the responsibility of the patient to ask questions and choose the doctors, even in the hospital, whom they wish to see. In practice, it is not that simple, as many of the doctors we “saw” that night never actually saw her. What do we do in real life about the in network/ out of network farce? The solution for this would be so simple. If we, through our elected officials, were to require that all medical personnel within a hospital or medical facility accept, at minimum, all the insurances which are considered in network for that hospital or facility. This would insure that once a network in listed as being covered, it truly is. Additionally, all physicians in a hospital or facility should bill out through the hospital’s billing office so that there is a centralized place for patients to send payments as the sheer volume of bills can quickly become overwhelming. One visit to the hospital should be one bill. That seems only logical.

Until such time as this reform is made, I’m now adding my own conditions to the admissions forms at hospitals and ER’s. On the page which says I am ultimately responsible for all bills incurred, I write

“We refuse all non-emergent non-life-saving treatment by any physician or personnel who are considered ‘out-of-network’ by (our insurance company’s name) when an ‘in-network’ alternative is available. Any ‘out-of’network’ care which is not necessary to save life or limb will be considered to have been performed pro-bono and will be treated in that manner.”

Then I sign and date it and make the person checking us in sign it, too. They’re never happy about it, but they always sign. Would it hold up in a court of law? I don’t know. What I do know is that since I’ve been adding my own little addendum, we haven’t had any more out of network charges which has dramatically lowered our health care costs.

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