I guess we're screwed, right? Healthcare PPO payment issues.

Factual Questions
1

My wife is an employee of the state of California, and we both receive health coverage under the CalPERS system. It’s a PPO network.

Anyway, late last year, not long after we got settled in San Diego, my wife started looking for a primary care physician in the network. She finally found someone who seemed good at a UCSD Medical Center not far from where we live, and so she had herself a primary care physician. She went to this doctor in December and had a physical, and all seemed fine.

At the time, she spoke to the doctor about getting a mammogram, and the doctor said she should do that soon. She procrastinated a bit, but about a month ago she finally got around to it. The doctor had to give her an authorization of some sort for the mammogram, so she called the doctor’s office, they issued the permission, and she went off to get the mammogram at the same med center. Again, everything was hunky-dory.

Fast-forward to today. She gets an account from CalPERS telling her that they’ve paid about $50, and she’ll have to fork over the other $600 for the mammogram from her own pocket. Turns out that, between my wife’s last visit and getting the mammogram, this particular UCSD Medical Center had decided to drop out of the CalPERS PPO network.

Now, the person at CalPERS has initiated an appeal, but has said that it’s unlikely to bear fruit.

But my question is more about the medical center than about CalPERS. Is it really policy for a place like this not to inform their patients when they drop out of a particular plan? Surely it would be reasonable for the doctor’s office and/or the admin people where she got the mammogram to say, “Hey, did you know that we’re no longer part of the CalPERS PPO network?” when she booked or turned up for the appointment. It’s not like they didn’t know; she had to give her info for the booking and when she turned up for the mammogram.

I realize we’re probably fucked here, but when she went to the trouble of finding and going to a Primary Care Physician at a Medical Center that was part of the network, it seems pretty fucking rough that they won’t even inform their own patients/customers if they drop out of the network. Do you really have to re-check the status of your healthcare provider every single time you use them?

I put this in GQ in case there are any factual answers to be had. If Mods think it belongs in IMHO or the Pit or whatever, feel free to move it.

2

Nah, they never tell you shit. We’re covered by the same program, and it’s a rare thing when you get any notice from the doctor or dentist that they no longer are part of the system. You have to check the listing every year to make sure you go to a system doc.

Sorry you got screwed.

3

I think it’s worth fighting. Is CalPers PPO the main/only health insurance plan for state employees? Dropping out of a major network like that is a big deal and it was really slack of them not to say something. If it were some minor HMO, it would be more understandable, but you don’t drop a state employees plan without it making pretty big waves in the average medical office. Especially since I’m thinking UCSD employees are probably state employees themselves.

Fight it with the medical center as well as the insurance company. If there is a state employees union, she might also get them involved.

4

I guess i figured as much. It just seems like really poor customer service. I also have visions of them making an active decision: “Yes, we know that we’re no longer taking CalPERS, but don’t mention it to existing patients unless they ask, otherwise we might lose them.” Even if it’s not that overt, it seems like pretty shady business practices to me, when they know how much people depend on their health coverage to cover medical expenses.

It’s not the only plan, but it’s certainly the main one.

There are definitely going to be some letters written to the Medical Center and the doctor concerned. Whether they’ll do any good or not is another thing, but it won’t hurt to try.

Good idea about the union. Might be worth investigating.

5

PPO ?

6

Wel, I’m not in California, but I do deal with insurance regularly. And the doctor’s office. And I think dropping the insurance you are covered under without telling you pretty clearly falls under “not your problem.” You tell the docs if they want their money, they can pursue it with CALPers, but because you received no notice that your preferred method of payment would not be accepted, you ain’t giving them nothing.

Personally, my credit score is good enough that I can take a hit from a collection action if one is to be initiated, and they can sit on it as long as they want…or they can start behaving ethically.

7

Preferred Provider Organization.

Generally, they pay 70-90% of the bills if you patronize healthcare providers who are on their lists of preferred providers. If you go “out of network” most or all of the costs are on you. The only major difference between a PPO and an HMO (Health Management Organization) is that typically HMO plans require that you choose a Primary Care Physician (PCP) and that any visits to specialists require referrals from the PCP. Most PPOs do not require specialist referrals, but sometimes the specialists require referrals anyway. The details vary from my summary here, but basically, the differences between PPO plans and HMO plans (and there’s several other types of plans) are marginal and barely worth noting, unless you need to use your insurance and then you better know how it works.

The mammogram center in my fair city would probably not even see you if you walked in the door with a phat pocket of cash and demanded a mammogram. If you don’t have that little pink slip referral from your doc, I’m not sure if you even exist.

8

Paying even just a small amount each month usually helps to keep the collection agencies at bay. Good luck in fighting this.

Insurance companies are becoming monsters. I once had an emergency room doctor tell me that he would admit me to the hospital but my insurance wouldn’t pay for it. I was really sick and in a lot of pain and told him to admit me anyway and I would deal with my insurance company. I was there for a couple of days and got the relief I needed. The insurance paid without any problem. So why am I blaming them? They have the doctors so intimidated that they aren’t making sound decisions based on what the patients need.

9

HMO = Health Maintenance Organization

10

Same here in WV. They pulled that BS with a friend of mine and despite his trying to get the bill paid, it didn’t work out.

11

That sounds very enticing, but i think we’ll try the honey before dragging out the vinegar. :slight_smile:

As people who know me on this board might have realized, i sometimes have a tendency to pull out the cannons early on, before trying to deal with things in a civil fashion. My tendency to do this is exacerbated in situations like the current one, where i feel that we’ve been fucked over by people acting unethically (or, at least, inconsiderately).

But, this time at least, i want to start with a civil letter, outlining the exact circumstances and seeing if we can get any redress. If that doesn’t work, well, then all bets are off.

Thanks to everyone for the sympathy and good wishes. I’m going to sit down on Friday and send off the letters. I’ll let you know what comes of it.

12

This reminds me of what happened when I broke my leg. I was taken to the ER of a hospital in my network, treated, and sent home. I then received a large bill for out-of network treatment, of which my PPO paid little. Y’see:

(1) Although the hospital was in my network, the doctors in the ER had formed a separate medical group and didn’t sign up, meaning that:
(2) they billed for about three times the fee that my PPO considered reasonable, and
(3) the PPO pays only 50% of their “reasonable fee” for out-of-network charges.

I bitched to the hospital; they pointed out that there was a sign on the wall describing the insurance situation, and I pointed out that I was wheeled in on a gurney, and was looking up at the ceiling, not at the wall. This got me nowhere.

I bitched to the PPO office, which upped the payment to 80%, as if the medical group had been in-network. This was relatively decent of them, but it still left more than two-thirds of the bill uncovered, meaning several hundred dollars coming out of my pocket. Still pissed, I sent the doctors a payment of 20% of the PPO’s 'reasonable fee," along with a letter criticizing their business practices and informing them that as far as I was concerned, they had been paid in full.

They kept after it for a while, sold the debt to a collection agency, and it stayed on my credit file for years. It briefly caused a little concern when I bought a house, but I still didn’t pay it, and still got the loan.

In retrospect, I didn’t do all I could have done to get the charges reduced. In addition to the “we’re not really a part of the hospital” dodge, the fees may have been fraudulent. Y’see:

(1) I was seen briefly by the ER doc, who called a separate orthopedics group;
(2) it was the orthopedist who actually decided not to reduce the fracture (simple fracture, distal fibula), instead sending me home with a splint – after a few days to let the swelling go down, they put on a cast;
(3) the ER doc’s only “decisions” were (a) not to make any treatment decisions and (b) not to give me any pain medication (in case the orthopedist wanted to reduce surgically – narcotics would have interfered with anaesthesia) – well, I guess she decided to order the X-ray, but…
(4) the ER medical group billed for a fracture reduction, which didn’t happen, and which would have been performed by the orthopedist if it had.

To make this perfectly clear, the treatment that I did receive was all billed separately:
(1) the bed, splint, Motrin, X-ray, crutches, etc. – all billed by the hospital;
(2) the diagnosis and orders were billed by the orthopedics group, in-network.

The ER doctor billed separately and exclusively for her time and attention, which comprised three trivial decisions – good decisions, but calls that a nurse could have made – “get an X-ray,” “call a specialist,” and “no narcotic pain meds.” She never palpated my leg, she only ordered a Motrin, and I never saw her until she came in to explain that she wasn’t going to do anything. I’d estimate that I was billed no less than $100 per minute – at that rate, she could have paid her student loans before the week was out.

13

Ooops. :smack: Thanks.

14

You’re right, though not just because of the PPO/HMO thing. Last year, I had scheduled my girly-visit, and thought I’d get a head start and call to schedule the mammogram, before I even saw the gyn. The scheduler at the mammogram place wouldn’t schedule it, because they need to know whether you’re having a simple screening mammo, or a more careful look because the doc felt a lump or whatever.

Re the OP: I find it outrageous that your wife went in on the day of the mammogram, presumably showed them your insurance card right then, and nobody said anything. I’d take that tack when complaining to the practice. At the very least, it might get them to knock off some of that 600 bucks.

That said, every time I see a doctor, I sign something saying “if insurance doesn’t pay, I’ll hock my firstborn and pay up” so they may be asses and not budge.

15

That is INFURIATING. I really don’t think a hospital should be allowed to be in-network, unless all their physicians are either in-network, or agree to be treated as such. It’s not like you could have asked to see a different ER doc. I’ve heard other stories like this. Really, really messed up :mad: and hell, I’m glad you didn’t pay.

16

I’m puzzled as to why Nametag’s insurance didn’t pay for an ER visit.

Every insurance plan I’ve had covers ER visits and all the doctors no matter where you are or if they’re in-network or not.

17

That is really sucky of them and I hope you don’t have to pay. I have had a doctor’s office drop an insurance company in the past and I received a letter telling me so before the stop date. It wasn’t even my insurance company - they took the time to send the letter to all their patients. I figured that was standard practice but I guess it was just a good office. I would definitely expect them to tell me ‘we no longer take this insurance’ when I present my card at the front desk! That is truly awful of them not to tell her then. (I will be sure to check stuff like that more carefully now!)

I don’t know how government insurance works, but here at my employer we can get our HR person to intervene on our behalf for stuff like this, although that is usually with issues with the insurance company and not the doctor’s office. Is there anyone like that who could help you? If that office suddenly stopped taking the insurance that gov’t employees get without telling anyone, I can’t imagine they don’t have people screaming at them all day long now. Seriously…did they think they would retain patients after the first bill? All they have done is get one more test out of people and then piss them all off. That’s a terrible business practice.

18

They did pay for the ER visit, and they paid the contracted amount to the doctors. The problem is that the doctors billed three times the contractual amount, because they weren’t parties to the contract – that’s WHY doctors turn down insurance contracts in the first place. My PPO was under no obligation to pay whatever amount a doctor pulled out of his or her ass.

A regular insurance company may very well pay larger amounts for emergency care than a PPO, but they also charge larger premiums. A PPO is organized specifically to contain costs by making deals with doctors – if you accept their fee structure, they’ll send patients to you. My complaint is not that they didn’t pay, but that the doctor operated under false pretenses by practicing as a non-member while working in a member hospital.

19

I’ve actually had this happen to me three times. Because in hotels, the industry where I mostly work, usually every year they switch companies to save money on insurance.

Anyway when I go to a doctor the first thing they do is ask to see my card. Then they copy it. If the card isn’t valid, two times in doctors offices and once in a dentist, they’ve said to me "Mark, we no longer take your insurance, if you want to see the doctor (dentist) this visit you’ll have to pay. I saw the dentist so he could finish the capping of my tooth, but I found another doctor.

And when I’ve had tests done, every clinic and hospital I’ve been to has insisted I give them my insurance card first before I get the test done.

So I think, at least in my experience, that they didn’t see your insurance card and tell you.

20

Unfortunately, this sort of crap as described in the OP does happen all too frequently. Yes, it seems reasonable that an office would inform you that they are no longer part of your insurance plan but in fact there is no obligation for them to do so.

Keep trying to get the insurance company (or somebody) to budge on this.