Health insurance out of state?

[RugBug]

[QUOTE=hype;7898440]

Just because you are in an approved facility, it doesn’t mean that all of the providers in the said facility are approved. If you go to the ER (and this is her example not mine) and need a MRI and surgery, it might not all be covered in network. While the ER may be an approved facility, the radiologist who reads the MRI might not be in network, ditto with the surgeon and the anesthesiologist. Last surgery one of my family members had, we had I think four different charges on it. Facility, surgeon, anesthesia, professional nurse care. This was for a straightforward outpatient surgery. [/QUOTE]

this is true…and it’s even gotten to the point that I am tempted to recommend that employees have a doctor or facility sign something with verbiage to the affect that they have verified contracting status of all known providers and if someone that was previously unknown, like a surgical asst, is brought in that they will not be responsible for any charges over the in-network contracted rates. I doubt it would mean anything, however, it may make someone sit up and take notice.

In the past if you were at an in network facility, everything was covered in network because it was understood that you didn’t get to choose your anesthesiologist or radiologist.

this is not the case. It has always been the patient’s responsibility to verify contracting status of all providers when on a PPO. If you are on an HMO, it is your PCP’s responsibility.

I did ask prior to my daughter having surgery last year which groups were responsible for all of the extra care and determined if they were in network or not prior to the surgery. It was planned so I was able to do so but this is something new that has come up and I know people who have been hit with really large bills not understanding this new loop hole.

Excellent! This is exactly what you need to do when you are on a PPO. It is your responsibility. It’s not a new loophole and has always existed.

Be informed and advocate for yourself. It can save you thousands.

Yes!

As for the PPO/HMO decision, it’s really personal. The coverage isn’t better or worse. The financial risk level can be very different, though.

I am in the industry and am 100% an HMO lover. They are super expensive in my area, though, so I am not on one currently. When I fell off my horse and broke my arm, I was…and it cost by about $700 total (ER visit, 11 months of doctor’s visits/x-rays/mri/bone density/ct-scan/muscle myopathy/nerve conduction/9 months of physical therapy. Had I been on a PPO, I would’ve met my out-of-pocket of $2500 twice…once in the year I fell (accident happened in October) and then again the following year as I was not finished with treatment until November of the following year.

[Ponyplusaninch]

I’m following this thread very attentively because I’m in a profession where I am always traveling and don’t really have a home base. So if I have a work engagement in North Dakota and get a severe sinus infection, I can’t just high-tail back across to the East Coast for treatment without losing whatever job I was hired for that week.

I thought I had a clue about what plan I’d be switching to this upcoming year since I’m surrendering my Cadillac BCBS PPO plan, but now I really don’t know.

[equisusan]

Very similar to me Pony+. It’s a practical impossibility for me to determine which state I’m actually a resident of each year until the end of the year now that I no longer own a home or keep a long term lease. This is why I think I need a PPO with a nationwide provider network like Assurant in FL ie Aetna.

[hype]

"this is not the case. It has always been the patient’s responsibility to verify contracting status of all providers when on a PPO. If you are on an HMO, it is your PCP’s responsibility.

Excellent! This is exactly what you need to do when you are on a PPO. It is your responsibility. It’s not a new loophole and has always existed."

The above is not true. I know this for a fact. I can’t remember what insurance company I was on when my husband had surgery. The facility and surgeon were both in network (which is what I thought was all I had to check out). I was billed out of network for the anesthesia and for the professional nursing assistant (it may have been written up differently but that is what it was).

At any rate, I called the insurance company and complained that we had no choice in either the anesthesia or nurse assistant. Those were chosen by the surgeon and the facility.

They went back and forth with me for a while. I then called back a few days later because it wasn’t really sitting too well with me to pay out of network for this.

I spoke to someone else and they did indeed confirm that those types of physicians and services were covered at the in network rate IF you were at an in network facility.

They covered them at the in network rate however it was a little bit of a fight to get it done.

Now, this is no longer the case.

The surgery was about 10 years ago so maybe things changed earlier than last year’s benefit meeting but this was the first time it had ever been mentioned to me by an insurance rep and how she explained it, it was a new policy for her company that year.

Bottom line is to fight for what you think they should cover and ask questions and be persistent. It does make a big difference in what they will pay and what they won’t pay.

[DMK]

Assurant Health is the brand name for a family of health insurance products focused on providing a variety of affordable plan choices to consumers. The portfolio of health care products includes major medical and supplemental plans for individuals, families and small employers. Assurant Health is committed to providing access to convenient health care delivery, easy-to-understand products and value-added services that help customers better manage their healthcare dollars and get the most out of their coverage— ultimately seeking to protect not only financial security but also the health and well being of its customers. Assurant Health’s products are underwritten and issued by John Alden Life Insurance Company, Union Security Insurance Company and Time Insurance Company, which has been in business since 1892 and is headquartered in Milwaukee, Wisconsin.

Assurant is not and has never been Aetna.

[equisusan]

[QUOTE=DMK;7899348]
Assurant is not and has never been Aetna.[/QUOTE]

Sooo when I buy the Assurant silver level PPO in FL and I look at the providers it says it has a nationwide network of providers and it is multistate and it lists the Aetna signature administrators ppo network. I signed up for it so hopefully it wasn’t a bad idea. All very confusing.

[DMK]

Assurant is primarily a financial player. They probably rent Aetna’s PPO network (that is the negotiated rates with those providers), they may even possibly have Aetna process claims (less likely), but they are ultimately responsible for the financial decisions associated with the plan (profits, losses, guidelines on what is/is not covered, etc.).

LOL, yes it is confusing! Insurance, banking, and other large “service” corporations… once you get under the hood of these creatures, it’s enough to make your head spin!

[RugBug]

[QUOTE=hype;7899004]

The above is not true. I know this for a fact. I can’t remember what insurance company I was on when my husband had surgery. The facility and surgeon were both in network (which is what I thought was all I had to check out). I was billed out of network for the anesthesia and for the professional nursing assistant (it may have been written up differently but that is what it was).

At any rate, I called the insurance company and complained that we had no choice in either the anesthesia or nurse assistant. Those were chosen by the surgeon and the facility.

They went back and forth with me for a while. I then called back a few days later because it wasn’t really sitting too well with me to pay out of network for this.

I spoke to someone else and they did indeed confirm that those types of physicians and services were covered at the in network rate IF you were at an in network facility.

They covered them at the in network rate however it was a little bit of a fight to get it done.

Now, this is no longer the case.

The surgery was about 10 years ago so maybe things changed earlier than last year’s benefit meeting but this was the first time it had ever been mentioned to me by an insurance rep and how she explained it, it was a new policy for her company that year.

Bottom line is to fight for what you think they should cover and ask questions and be persistent. It does make a big difference in what they will pay and what they won’t pay.[/QUOTE]

Actually, members have always been responsible for their choices with a PPO and it is their responsibility to stay in the network.

If there are not reasonable in-network providers to be used, the insurer will most likely pay at the in-network rate but the member can still be balanced billed by the provider.

For instance, anesthesiologists are notorious for not contracting. The anesthesiologists in my town do not contract and they are the only game in town. Since you must have reasonable access to an in-network anesthesiologist, our insurers pay at the in-network rate…but the provider can still balance bill the member. They may or may not…and they may or may not waive the charges if the patient protests.

We actually had a situation where a patient was billed for a service and the anesthesiologist was on a plane during the time of the service. They waived the charges. (but cases like that aren’t the norm and it really is up to the provider and possibly the tenacity of the patient).

If you are on a PPO, you are responsible for verifying the network status of your providers. There are situations that you can negotiate with insurers or providers, but it isn’t in your best interest to rely on that ability.

[equisusan]

[QUOTE=DMK;7899831]
Assurant is primarily a financial player. They probably rent Aetna’s PPO network (that is the negotiated rates with those providers), they may even possibly have Aetna process claims (less likely), but they are ultimately responsible for the financial decisions associated with the plan (profits, losses, guidelines on what is/is not covered, etc.).

LOL, yes it is confusing! Insurance, banking, and other large “service” corporations… once you get under the hood of these creatures, it’s enough to make your head spin![/QUOTE]

Yes head spinning… LOL soooo appreciate the advice of the experts here and I hope I signed up for a good plan that will support me as I galavant around the country this year working and showing. Time will tell…

[DMK]

Rugbug (who probably already knows this ) will appreciate the fact that the hospital-based physicians who are notorious for not signing a contract with insurance companies who have deals with the hospital are as follows:

Radiologist
Anesthesiologists
Pathologist
Emergency Room physicians

Because that is a lot what the billing process feels like. However it was a tad too obvious so now they are collectively known as the E-RAPs in the industry.

Whether the hospital will pay the non par docs at a par hospital or not varies by insurer and sometimes even within plans/networks within the insurance company. BUT if you are using a par hospital and it is a routine pre-scheduled surgery, it never hurts to ask if the anesthesiologist is participating. And if it is a par hospital and you are balance billed by the non-par physician, ASK if they are non-par. It turns out that balance billing by par physicians (I’m looking at YOU Emory Anesthesiologists) is a bit of a problem as well. While you probably won’t be able to scathingly humiliate them into never darkening your doorway quite as well as I did, with my industry knowledge, you can still put an end to it by calling attention to the fact.

If they are non-par, take it back to your insurance company and push them into resolving it. If you make enough noise, they will work harder to resolve the issue.

But the underlying problem is significant. Insurers do try to contract with these groups, but some refuse to sign a deal because they have the member (and thus the hospital, insurer and even the plan sponsor) between a rock and a hard place. Typically insurers do not pay non-par docs significantly more than in network because there would be little incentive to sign a deal (and remember, right now private insurance pays more than the cost of care since it subsidizes Medicare/Medicaid payment levels, so it’s not a bad deal). But the E-RAPs have no incentive to sign a deal because if they are working in a par hospital, they get the volume directed to them without having a deal (volume is the carrot for the lower fee). But they haven’t signed a deal so they can go hold the member hostage after the fact, and depending on how it works out either shake down th emember for additional dollars or the insurer. Or both. Mind you, this isn’t all or even most E-RAPs. But when it happens it is majorly disruptive to everyone.