Question about health insurance and how it pays benefits

[PinkTiger]

Ok,here's the situation.
I work at a small midwestern university as a professor, where I've been for five years. We have been through three overhauls of our insurance coverage, and now for the last year we have had Blue Cross Blue Shield, which is OK.
Before I worked here I was at a larger University in a neighboring state (I live right across the line.) Our insurance there was not Blue Cross, but it was a good plan.
My husband had a heart attack when I was there and the only charge we paid was $100 toward the ambulance. He had open heart surgery and the whole thing. And that is all we paid.
After I took the job I had now, he was diagnosed with cancer of the prostate and has had a stent put in. The cancer cost us about $6,000. (We had to change doctors because the insurance didn't cover him in the other state.)
The stent, which was early this year under the new Blue Cross plan, cost us about $4,000.
Ok --now I find out we can go back to our old doctors, because Blue Cross Blue Shield covers it. So I did. I had bloodwork done and expected to pay about $200, like I did with the other doctor. Guess what? The charge was a $20 copay.
My question:
Is this because of the agreement that Blue Cross has with the hospital in the other state? It is Blue Cross Blue Shield Alliance, and is a PPO.
So, instead of being angry at the insurance company, is it the HOSPITAL PPO that is to blame?
If so, is there something that can be done about it?
This is terrible, that there should be such a disparity with the same plan, with the only difference being the hospital PPO we are going to.
I really did think that if you had a policy, it covered you the same.
AND, does anyone know of a good internet site I can go to so I can find out more?

[brainshrub]

1. Reading your story breaks my heart.

I don't have an answer for you, but your story makes me so mad that we don't have a single-payer system in this country. You should be able to focus on caring for your husband, not chasing down an insurance claim.

So sad.

[Massacure]

2. Hospitals often give insurance companies discounts.

Which is bullshit if you ask me, because then the uninsured end up getting stiffed by paying the hospitals profit margins.

The health care industry would be a lot more balanced if a hospital had to charge everybody the same amount no matter what insurance they did or did not have.

[ikojo]

4. The hospital does not GIVE the insurance company a discount...

it is negotiated between the insurance company and the hospital. If a hospital agrees to be a part of a given insurance company's network of providers then it agrees to accept whatever the insurance company paid and write off the amount over what the insurance company allows. It can charge $20k for a cardiac cath, but most of the time the insurance company will pay only around $6k to the hospital for that cardiac cath. The remaining $14k is written off as the discounted amount. The patient is not responsible for that amount.

The $20 copay is due because you did go to an in network hospital.

Without knowing the plan or the hospital in question then all I can say is that you have a greater out of pocket expense for the stent and other stuff because it appears that the provider may not have been part of the insurance company's network of providers.

I believe that, until we get national health care, if an uninsured person comes into a hospital that person should not be responsible for any more than he/she would if he/she were on Medicaid. The hospitals know what Medicaid would allow because they have a copy of the contract they signed with Medicaid and it includes what they will pay for a given procedure.

[PinkTiger]

6. No, the Missouri hospital is IN the NETWORK of providers.

That is why I was so shocked at the difference!
The hospital we go to in Missouri, which also employs the doctors, just like the one in Arkansas, by the way, is the only one in the region we can go to under the plan.
So that doesn't explain it.
There is something fishy here.

[ikojo]

24. This may sound complicated but this is what I understand from

your post...

Doc A works for a hospital in MO and AR...

The hospital in MO is part of the insurance company's preferred network.

The hospital in AR is not part of the insurance company's preferred network.

At the insurance company when Doc A bills under the Tax ID Number (TIN) of the hospital in MO or for services at the hospital in MO, claims are processed as in network.

When Doc A bills under the TIN of the hospital in AR or for services at the hospital in AR, claims are processed as out of network.

Doc A is considered to be in network only when he/she bills under the TIN or for services at the hospital in MO.

This is the most basic way the claims are processed. Under SOME plans if a person receives services from an out of network hospital all charges (pathology, radiology, doctor visits) associated with that out of network hospital will be processed as out of network, even if the individual doctors/providers are in the insurance company's network.

Given that you have Blue Cross, I am surprised you are having this problem. Most Blues have a reciprocal agreement with Blues in other states. What that means is that if you go to another state and need to see a doctor or go to a hospital, that claim will be processed by the Blue Cross plan in that state and that Blue Cross plan will contact your home Blue Cross plan to recoup the money they paid on your claim. That's the way it used to work when I was at BCBS.

It may be different now that Blue Cross is owned by Anthem/Wellpoint.

[lovuian]

21. I totally agree with you here this different charges for the same

procedure is ridiculous!!! This is destroying Healthcare in America!!!

[Lydia Leftcoast]

3. The two sets of doctors are in two different states; that's the key

Insurance is regulated by the states. What you get for your premiums depends to some extent on how your state regulates insurance.

[PinkTiger]

5. So - what you are saying is, we should go to Arkansas for healthcare then.

Because the insurance pays so MUCH more in Arkansas. In Missouri it is terrible. We pay 80 percent of the bloodwork, etc. and a copay on top; in Arkansas, just the copay.
This should be illegal.
I have half a mind to tell everyone I work with to take their bodies to Arkansas for healthcare. And now my poor husband wants to change doctors again -- and go to Arkansas for his heart issues.
I think he would be better off, too, because the Arkansas hospitals have much better care for heart patients than the ones in Missouri.

[proud2BlibKansan]

9. I live in KS and work in MO

and there doesn't seem to be much difference in health care and insurance across the state line here.

As for your question, I used to sit on my employer's health and dental task force. We shopped for insurance providers and negotiated our contract with our insurance company. I learned from that experience that the insurance company dictates to the employer, not the other way around. It is disgusting. My employer is one of the largest in this area, yet when we put our insurance contract up for bid, we rarely had more than one company bid for our business. So we were definitely at their mercy.

I also had a neighbor at the time who worked for a different company but had the same policy I had with the same provider. She paid $40 a month for family coverage, I paid $200.

[PinkTiger]

14. That was probably because your company paid less of the premium

and the premium probably wasn't that different, right?

[proud2BlibKansan]

18. No it was very different

The premium is based on usage. The employees in my company cost the insurance company more than my neighbor's company. I guess we were sicker.

Every year when we re-negotiated our contract, the insurance company showed up with volumes of paperwork detailing how expensive our employee group was. Their attitude was they were doing us a favor by agreeing to insure us in the first place.

[PinkTiger]

20. That is really too bad.

I think ours at the university is high, too, because we have an older population than most workplaces.

[proud2BlibKansan]

22. Insurance companies don't like educators

I am a teacher. Our carrier told us this - health insurers don't like teachers, doctors or lawyers. We are too expensive.

[ikojo]

7. If a company has employees who live in bordering states,

the insurance company will also have participating providers in both states. For instance I live in St Louis MO which borders Illinois. Every insurance company here has providers on both sides of the Mississippi River because people who work for the employers who carry the insurance live in Missouri and Illinois.

Insurance is regulated by the states and federal government (ERISA laws) however, when it comes to physicians, all the regulations cover is the contract language between the insurance company and the providers. Regulations don't mandate that just beccause a physician is in one state and a patient lives in another that physician cannot be part of an insurance company's network.

Regulations do cover what an insurance company can exclude. For instance in some states In Vitro fertilization treatments are mandated while in others, even neighboring states, they may not be mandated.

[proud2BlibKansan]

13. And don't the insurance companies and doctors

have to abide by the laws in the state where THEY are located, regardless of where the patient lives?

I am in KC. Other than malpractice premiums, there doesn't seem to be much difference in health care between KS and MO. My cousin is a doctor. Last year, she moved her practice from MO to KS because of the (much) higher malpractice premiums in MO. I was stunned when she told me how much she had to pay and the difference in the two states.

[ikojo]

23. Yes, insurance companies must abide by the laws of the states

where they are authorized to sell policies, not where they are located.

The same thing regarding docs closing practices due to high malpractice insurance rates has happened in Illinois. It's not that awards are increasing but that insurance companies have not done well on their investments so they pass that savings on to the doctors.

Of course the media, favoring tort "reform", claim high malpractice rates are due to high awards in lawsuits. In reality, most settlements are negotiated downward but we, the public, don't hear about that, do we?

[Indykatie]

8. Structure of PPO Design

PPO benefit designs include a feature that provides coverage for services provided in the doctor's office at 100% after the stated co-pay, typically $20 or $30. Other services including surgery, hospialization are covered typcally at 80% after a deductible is met. There is a stop loss feature that limits the out of pocket expenses for a patient, typically in the $2000 to $4000 range. These are calendar year limits so every year you start over with new deductibles. Hope this helps.

[PinkTiger]

11. Now I see. It is because the Missouri hospital billing it is hospital.

In the Arkansas situation it is shown as doctor's office.
The insurance doesn't pay more -- it is just billed differently.

So the Missouri hospital is ripping off the customer by doing its billing differently.
This should be illegal.

[Indykatie]

10. Effect Of Networks on Coverage

PPOs allow you to use any medical provider you wish, however, if you use a provider who is "out of network" the coverage is reduced to 50% or 60% and the stop loss threshold is usually higher than if you had used providers in the BCBS netwrk.

[PinkTiger]

12. Yes, I know that.

All this is IN NETWORK, with the only difference being how the bill is covered by the insurance company.

[Indykatie]

15. Reciprocal Agreements Between Plans

One last point. BCBS plans in the different states have agreements that allow BCBS members to access each other networks and be considered "in-network". This feature is a big positive to BCBS members and makes the companies attractive to companies with many locations.

[PinkTiger]

16. And I'm so glad.

This means that even when we are in Idaho visiting my mother, my husband has good healthcare coverage -- the Blackfoot physicians accept BCBS Alliance.

[Indykatie]

17. Place of Service Impact

A hospital out-patient setting is different than a doctor's office an not covered by the co-pay rule. The hospital is not doing anything illegal.

[PinkTiger]

19. Bull. The setting was exactly the same.

They just bill it differently.
The doctor's office is located in the hospital in Missouri. The lab is right there.
The doctor's office in Arkansas has a lab.
Same deal.
Just billed in Missouri through the hospital instead of the physician's group.
A scam.