<p>Plenty of things are the fault of the ACA, but both Calmom and I are trying to figure out how this particular situation is the fault of the ACA.</p>
<p>Employer could have changed plan for this year to one that was ACA compliant, which may have narrower networks. </p>
<p>Or one that was more affordable for employer co-pays. </p>
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Actually, my guess would be that the patient wants Dr. X to do the surgery at Hospital X (because Dr. X has impressive credentials and Hospital X is a well known research hospital) – and the insurance would have authorized the same surgery to be done by the less well-regarded Dr. Y at the less well-regarded Hospital Y. </p>
<p>(I find the assertion that there is only one doctor capable of doing the surgery a little bit questionable, though without knowing the exact nature of the surgery it’s hard to draw any conclusions. I understand why a parent might strongly feel that they want the eminently qualified Dr. X operating on their child, and not some doctor they never heard of – but that’s opinion, not fact - and would anticipate the insurance company is likely to hold a different opinion)</p>
<p>In any case, it doesn’t sound like an ACA issue because it’s really too soon – the new metal-plan policies have only been in effect for 3 weeks at this point. If it was planned surgery, the surgery could have been schedule earlier (before the insurance changed), or the groundwork could have been laid for getting approval. If it was emergency surgery, then its far less likely that anyone had the chance to think about network status of the surgeon, but there would be procedures to follow to get approval of the payments. </p>
<p>Samiamy has the right to have first an internal appeal, and then an external appeal. The hospital has to give their side of the story, and their side doesn’t get to be, “We don’t have any doctors in network to do the treatment so you have to go out of network and pay for it.” If insurers were allowed to do that, they’d have a network with no doctors or hospitals in it! </p>
<p>Rather, the insurer either has to claim that there was an in-network doctor and the family declined to use his or her services, or the treatment just isn’t covered.</p>
<p>trying to bring rates down by having narrow networks. Think I would phrase that: bring down rates by clamping on what they are willing to pay. The result can be narrower networks if docs hold their ground.</p>
<p>Samiamy may want to check healthcarebluebook,com re customary rates. </p>
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<p>My understanding is that IF the service cannot be provided within your network, AND the doctor goes through the Out of Network Referral process, then the patient will be charged as if the service had been done in-network.</p>
<p>^^But samiamy said that they would only pay medicare rates for out of network, so perhaps it’s not standardized with every insurer?</p>
<p>They’d only pay Medicare rates if someone chose to go out of network when they could have had the treatment in network. That’s fine; the insurer doesn’t have to pay anything at all if the patient chooses to go out of network.</p>
<p>As samiamy tells it, this is a different situation. Samiamy didn’t choose to go out of network. Insurers don’t get to avoid covering a treatment by not having any doctors in network that are qualified to administer it. </p>
<p>The insurance plan changed June 2013 to ACA compliance, same exact plan a $22,000 cost to employer plan. first part of surgery done by same surgeon May 2012, out of network as current situation. Insurance company paid usual and customary charges, this particular surgery in May 2012 was 36,000, we had to pay 9,000 out of pocket. </p>
<p>This was a major national insurance carrier. When we were looking for alternative options, no doctor I spoke to would pick up a patient mid care, as it was a multi step surgery, this particular procedure is not done often. </p>
<p>You may believe it is not the direct effect of ACA, in the minds of the insurance carriers it is. The network of available doctors agreeing to participate shrank, the reimbursement rate for out of network providers was switched to medicare rates. Our out of pocket expenses will not be applied to our maximum yearly cost. </p>
<p>In fact and its kind of comical, this child has only satisfied $200 of her yearly individual cost of $500. And that was just some labs and X-ray costs. </p>
<p>Medicare rate reimbursements will be the new phenomena, call and ask your providers which method they use. You might be shocked how many are now using it. </p>
<p>Who cares what is in the minds of insurers? Insurers will blame everything on the ACA, including the drought in California, if they think it serves their needs.</p>
<p>If none of the doctors in their network would have done the surgery, then you will win your appeal of their denial of coverage.</p>
<p>“If none of the doctors in their network would have done the surgery, then you will win your appeal of their denial of coverage.”</p>
<p>This is a naive comment. The facts are never this cut-and-dry. The insurer will argue the surgery could have been done by someone in the network. The real problem is the surgeon you choose to do the surgery, because this person is the one you trust the most, is not an in-network surgeon. This will become commonplace under Obamacare.</p>
<p>Was there an Out Of Network Referral request? Ie, a formal request to cover at in-network rates? On the basis of the prior relationship, lack of alternatives and necessity.</p>
<p>It sure seems the problem is the doc payment caps the insurer put in place. So, in some areas, docs won’t participate. But it’s your insurer who chose how to structure plans and pricing. And, I saw note that al 50 states have some form of insurance commission for oversight and approval.</p>
<p>I do wonder why folks don’t so easily blame those commissions or state legislatures that, in effect, said, fine.</p>
<p>GP, seems Samiamy could and would protest that there was no alternative doc.
You can;t predict this will become commonplace. That depends on the area and particulars. </p>
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<p>But I gave an example of services rendered within the past 3 weeks, under an exchange-purchased policy, out-of-network provider – and my insurance company “allowed” amounts that I am pretty sure are well above Medicare rates, and definitely is applying the “allowed” portion of the charges (78% of the whole bill) to my deductible. It will also be applied to an out-of-pocket maximum, albeit a maximum that will be raised by virtue of the provider being out-of-network. (Unfortunately, my EOB doesn’t have a procedure code – so I can’t be absolutely certain – but either my insurance company is using a different metric, or Medicare is more generous than I had assumed. Either way, my insurance seems to be willing to authorize a fair amount for out-of-network care, and under my plan if I had $30,000 worth of out-of-network coverage, the insurance would be paying roughly $20K of it)</p>
<p>So you are extrapolating the actions of one insurance company – which happens to be an ACA-compliant, employer-sponsored plan --and assuming that is the effect of ACA – when I can easily give you a counter-example of a true, individual market plan. Neither one of us has sufficient data to know what is most typical – but obviously insurance companies are free to be more generous under ACA if they so choose. </p>
<p>Your employer has bargaining power. As you noted, you had no choice – you’ve got a “Gold” plan that your employer selected. It’s quite possible that your employer opted for one company or one plan with a smaller network and greater restrictions on out-of-network care in an effort to secure a lower premium. Depending on the size of your employer, the employer may or may not have been aware of what it was doing at the time. (I think larger employers tend to have more sophisticated HR departments, smaller companies probably rely a lot more on the recommendations of their insurance agents).</p>
<p>As an individual, I did have choice, and I did look at those issues in making my choice. I did not pick the plans with the cheapest premiums. Since I was shopping for one, I could afford to pay a little more in premium dollars to get the plan that offered more flexibility to me. I can understand that if I was shopping for dozens or hundreds of employees, and my company was on the hook to subsidize all the premiums, I’d probably be more inclined to go with whatever insurer offered the lowest premiums. </p>
<p>But what you are looking at is the result of market forces that existed before ACA – the rising cost of medical services. Nothing in ACA should have caused a change in premiums for most employer based plans, because most of the “essential health benefits” were already included in employer plans. (I mean – can you give me an example of a benefit in your new ACA-compliant plan that wasn’t covered under your old plan?)</p>
<p>I understand that your insurance has changed and is much less generous than it was 2 years ago – but that sort of stuff happened before ACA. My son had that experience in 2010 – an employer shifting to a less generous plan – it impacted my son because his wife was pregnant at the time, and the new plan didn’t cover the doctors and facility they were using. That was several months before the passage of PPACA, at a time when most people doubted that the bill would get passed.</p>
<p>I’m sorry that you are experiencing this problem – I’m not discounting the hardship it creates – I just think its the result of long-standing market forces, not PPACA, which doesn’t really impact the employer insurance market in the short term. </p>
<p>GP wrote,
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<p>GP, if you read [Samiamy’s</a> post](<a href=“Affordable Care Act Scene 2 - Insurance Premiums - #9289 by samiamy - Parent Cafe - College Confidential Forums”>Affordable Care Act Scene 2 - Insurance Premiums - #9289 by samiamy - Parent Cafe - College Confidential Forums) you will see that the surgeon was out of network under their old plan as well. </p>
<p>The difference isn’t in the size of the network – the difference is in the reimbursement rate. </p>
<p>Samiamy’s old plan used “usual and customary” and applied an upper limit to the costs; the new plan assigns Medicare rates and apparently no upper limit.</p>
<p>I have an ACA plan that promises to pay “usual and customary” rates and has a $9500 maximum limit on out-of-network costs. </p>
<p>So the issue isn’t ACA. It’s a choice being made by the insurer (and by the company that chooses that plan over another for its employees).</p>
<p>Calmom, don’t forget the balance billing problem of going out-of-network. If you go to your doctor because you have the flu that’s one thing, but it is quite another if you have surgery or need to be hospitalized. Then you are going to be paying big bucks. Please don’t tell me you’re going to use your extraordinary negotiating skills to make this problem go away. Trust me, you don’t want to be in a position where you are relying on the provider to greatly reduce its bill, because it may not happen. Also, it is not an acceptable solution for the problem of very narrow networks and formularies.</p>
<p>Today, you can’t even figure out who the heck is in the network for Anthem. The website is screwed up and you can’t get anyone on the phone who knows what they are talking about. Please stop the endless rationalizing, the law is a mess. No objective observer would deny this simple fact.</p>
<p>GP, I agree with you that the Anthem web site and information is screwed up. That is why I decided not to buy a policy from Anthem. I don’t like the way they do business, so I don’t want to deal with them. (I have that attitude about a lot of things – basically, for me, good customer service is more important than price)</p>
<p>My point isn’t that the out-of-network thing hasn’t really changed all that much, at least not in an a way that is particularly connected with ACA. My ACA policy has a LOWER out-of-pocket maximum for out-of-network than my previous policy had. Higher deductible, higher in-network max, but the out-of-pocket max is actually an improvement. (I think it was something like $15,000 before – I posted the numbers way up thread but I don’t remember now). </p>
<p>I wouldn’t use an out-of-network provider for a major expense without advance planning. That is, if I needed surgery and I wanted it from someone who was not in-network – I’d work with the insurer in advance to see if there was a way to get coverage, and I’d work with the provider in advance to nail down costs. I didn’t bother with my recent doctor’s visit because, quite frankly, I kind of wanted to experiment and see what would happen. I figured the doctor’s bill would probably be about $120 per visit, and the I was curious about the way the doctor would handle this issue because that will help me decide whether I want to line up a new, in-network doctor right away. </p>
<p>There is no material change for me in terms of the hospital or medical center I would use for major services. That is, the hospitals I would choose are in-network; most specialized services are closely affiliated with those hospitals and are thus also in-network. The out-of-network doctor is a small town doctor with a limited practice, who has not accepted new patients in years (she’s got a waiting list) – so we’ll see what she wants to do. But I really don’t care all that much – my guess is that I’d probably get better care from a doctor who was part of a group practice anyway. If the doctor doesn’t join the network, I’ll probably opt for an in-network doctor for my next annual physical (since the insurance pays for that) – but it really doesn’t matter to me as long as I haven’t met the deductible. </p>
<p>Calmom, I have a PPO too, which is the most generous in terms of out-of-network.
It is possible Sam’s employer changed to an HMO with no Out of network coverage and no out of network max OOP. I have seen some plans like that.</p>
<p>However, I am optimistic that Sam would be successful in an appeal is s/he can document the refusal of network doctors to pick up the case mid-process. I’m also confident Sam’s child will not be denied healthcare the rest of his or her life over a pre-existing condition, which was previously theoretically possible.</p>
<p>Best wishes for a successful fight on this one. I truly wish there was no such thing.</p>
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I’d also thought of that. </p>
<p>Without ACA, that time might have been a lot sooner as well – remember, the age-26 thing came in with ACA. </p>
<p>. </p>
<p>Has anyone attempted to refill a script since the new year started?</p>
<p>My brother states he went to Target to get his usual generic blood pressure medicine and the price had quadrupled. Target stated that they had to do that as they were unsure what was going to happen with reimbursements in general. So then he went over to COSTCO and the price of the same script was amazingly much, much lower. He states he went back to Target and told them. Target then stated if he brought in the receipt that they would match that price.</p>
<p>Has anyone seen a major increase in the price of their meds with the same insurance?</p>