AboutLinda Woolsteen Expertise I can help you with questions about health insurance. If you feel your insurance company is mistreating you. Are they telling you they are checking eligibity, pre-existing, etc. Or you just don`t understand how your insurance works or don`t understand what a PPO is.. I can help you.
Experience
Past/Present clients One company I worked for I was the underwriter for the Academy of Medicine of Cleveland and the Ohio Bar Association. I was also a supervisor of our customer service department.
Question I bought a high deductible plan from Aetna making sure it had maternity coverage and that my wife's doctor's all accepted Aetna. The deductible & max out of pocket were $5K, so I assumed that the cost of our next child would be that $5K which I have in a HSA bank account(half of which I've already been billed and paid for ultrasounds, appts, etc.)
I've now been told by Aetna that the hospital that my wife's doctor has admitting privileges to does not have a contract with Aetna. That means a separate out-of-network deductible of $10K will apply to those hospital charges. I went to the hospital to try to work out some kind of pre-payment (I had always heard to try and negotiate with hospitals ahead of time), but they wouldn't even tell me what the approximate costs would be, saying there was no way to know ahead of time and that I should just worry about working out a payment plan after the fact.
I have a bad feeling (given past dealings with other health insurers), that not only is $5K going to be nowhere near the total costs to me, but that even $15K (the in-network deductible + out-of network deductible) is not going to cover it. Is it correct that Aetna will determine the amount billed over the $10K out-of network deductible to be "non-customary and unreasonable" and therefore not cover it even though it is above the deductible amount (and b/c the hospital is out-of-network, there is nothing legally preventing them from requiring me to pay it all)? So if my final bill is $50K, I'll likely owe it all and the insurer will pay nothing?
My wife is a special case and her doctor is great and knows her history, so I would be uncomfortable trying to find another doctor at this late date, but I'm afraid we're being set up for financial disaster with insurance that is not going to pay and a hospital that will not give me a price until after I owe it. HELP!
Answer Hi, well you sound like you understand quite a bit, your asking all the right questions... most people don't even realize or go that far. First of all, your health insurance plan does have Maternity coverage right? I remember one insured of ours where the man called asking very generic questions about his wife's delivery. Out of all the Customer Service Representatives he spoke to.. not one of them reviewed his coverage. He had made about 10 calls about his wife having a baby and here he didn't even have maternity coverage. Then there were also the insured's that had invitrofertilization which is usually not covered either by insurance companies.
If you go to a provider that is out of network, the insurance company's policies, usually state that they will only pay R/C or U/C both are the same (Reasonable/Customary or Usual/Customary) charges. Or, I looked up some of Aetna's plans online and some said they have a fee schedule for out of network facility providers.
Ok, so what does that mean.. so your out of network deductible is $10,000 so for any of the providers that are out of network (facility, probably all other anciallary providers as well such has Lab, anesthesiologist, etc.) when their charges come in, they are all going to be applied to the $10,000 out of network deductible. None of their charges get reduced by PPO adjustments either then.. so say the anesth. bill is $1200.00, the insurance company may say $500 is the R/C amount so $500 is what we are allowing and that will go toward that deductible. Usually, with Anesth. charges there is a Registered Nurse Anesth. that bills as well...so that is another charge usually. so then you meet the $10,000 deductible then does your plan say for out of network they will pay 50%? Most likely it is not 100% so then you will be responsiblity for the deductible (we are just talking about the out of network deductible at the moment), any charges over and above the R/C amounts that your insurance company did not allow and then also 50% up to whatever your stop loss limit is, say $10,000 so you would owe 50% of the next $10,000 as well until you reach your stop loss at which they then pay 100% of R/C.
Also, you probably already know, but usually any inpatient stays must be Precertified like 72 hrs in advance. Especially for a pregnancy in which there was 9 momths ahead of time to tell the Precert department. A lot of times the patient thinks the doctors office precertified their stay and they didn't, you can do it as well, just make sure it is done and done within their required time guidelines or else it does not qualify and if Precertification is not done you are usually get penalties applied which means they pay at like 60%!
What you can do is Fax a Predetermination in to Aetna make sure you include your policy #, usually SS# as well and state in very BIG letters PREDETERMINATION ask them where you can fax it to. Ask them to allow and specifically name your hospital as in network and ALSO ask that all anciallary providers at the hospital be processed as INNETWORK and claims from the hospital and out of network, hospital, anciallary providers be processed towards your Innetwork benefits. In the Predetermination letter, just advise what you told me, that your wife is a special case and her doctor knows her history and you really feel it would be best for her health to stay with him at this time. It will go for review. If approved, they should put a note on their computer system so that when claims start coming in the examiners will see the note on the system and process them towards your intetwork benefits. But....sometimes and usually it is the Managed Care nurses that don't do administrative work very well and they don't note the system, claims come in and start getting processed as out of network which can then be a real mess. One way to prevent it is to make sure that a copy of the approval letter is sent along with each claim from each out of network provider. Just make sure if you get the approval that you hang on to that letter!
There are companies out that that determine the R/C for zip code areas. The Insurance Companies have that information downloaded into their computer system, we were never suppose to give out the R/C amounts, but we could look them up in our system if we had the procedure code and zip code area for the billing provider.
I have never once seen a hospital or other provider give out an amount beforehand. There are so many things that can happen that they would need to bill for that could be unforseen. I think you should ask for the Predetermination and don't get that confused with the Precertification that you need to make sure is also done.
Good Luck. Write back if you have any other questions or follow up. I had a bad migraine myself today so my mind is a little slow this evening and not as sharp.
