<p>In California, all one has to do is take a look at the Shield Spectrum PPO network vs the 2014 individual and family PPO plans for Blue Shield. The difference is night and day. I have the Shield Spectrum network (group plan), which includes just about every provider in Ca. </p>
<p>There may be some who don’t take insurance from any insurance company, but I can promise you these providers are not in the directory and the office staff is fully aware that they don’t take insurance. However, any provider that does accept insurance (probably 98% of all providers) are in the Shield Spectrum network. It is the 2014 PPO plans for the individual market which are experiencing all the problems. </p>
<p>"Narrow network plans pit two basic consumer demands against each other. On one hand, patients want choice and the ability to seek care at whichever hospital can best treat their condition. On the other hand, consumers want affordable premiums at a time when health-care costs are rising nationwide.</p>
<p>U.S. health spending is expected to grow more than 6 percent this year to $3.1 trillion as the health-care overhaul takes full effect and millions of Americans gain insurance, according to the Centers for Medicare and Medicaid Services. The average premium for family coverage has increased 80 percent in a decade."</p>
Keep in mind that many of those people don’t have existing relationships with any particular provider, and may be very grateful to be able to see any doctor at all. If they haven’t had insurance, the only “doctor” they may have had is whoever was on duty in the emergency room – or whoever was staffing community clinics. </p>
<p>It’s a problem if the directories are inaccurate, but not necessarily a choice issue – it’s just that a newly insured person should be able to use their company’s directory to find out who to call for an appointment. </p>
<p>I was thinking the same thing, Flossy. There are 800,000 people in Ca. who had their plans cancelled and many of them are very unhappy with these narrow networks</p>
<p>" Covered California™ and the Department of Health Care Services released updated numbers showing that consumer interest in the agency’s health insurance marketplace and Medi-Cal remains strong. </p>
<p>The number of enrollment applications started continues to increase, from 1,522,149 on Jan. 25 to 1,692,773 through Feb. 1, 2014."</p>
<p>“If they haven’t had insurance, the only “doctor” they may have had is whoever was on duty in the emergency room – or whoever was staffing community clinics.”</p>
<p>I would wager these people will continue to go to the emergency room or the community clinics. There will be very few primary doctors who will see them. Many doctors are no longer accepting new patients</p>
<p>Many docs I know only accept new patients by referral. One of the many reasons is that by law, the DOC has to provide and pay for any needed translators for patients, some of the patients do NOT show up, do NOT follow medical orders, and a host of other things, as well as very poor reimbursement. </p>
<p>It is very challenging for the docs I know who have independent practices. They are swamped by paperwork and under-reimbursed for all the services they provide. Their claims often have to be submitted numerous times before payment as well. </p>
<p>HImom, and now they will have to hope these people will pay the bills which don’t exceed their deductibles and co-pays. If they don’t, they are left holding the bag.</p>
<p>So basically the family that is profiled in the article has a choice that they probably wouldn’t have had without ACA: to choose a more expensive plan for the family member with specialized needs, and a less expensive plan for the other 4 family members. </p>
<p>Given that the family was paying $900 a a month for the Premera plan, we can project out that the family income is at least $114K/annually. (Unless there is a subsidy that is not accounted for). They are not paying $200 more overall for the sick baby’s insurance – but rather they picked up a $200/plan for the baby and dropped a policy that cost somewhat less. Because the good plan is on the exchange, if family income is lower, they would be able to apply their tax credit subsidy to the plan. Premera appears to have agreed to cover the care at Children’s throughout the open enrollment period, so there was plenty of time for a change.</p>
<p>Of course, pre-ACA there would have been no possibility of changing insurers for that child because that “rare birth defect” would have been deemed a pre-existing condition. And as I’ve posted before, Children’s Hospital accepts Medicaid. So it looks like exchange buyers in Washington have a choice: they can opt for one of the less expensive plans that won’t pay for Children’s, or opt instead for a costlier plan that does. </p>
<p>I certainly see the problem with New Hampshire, with only one insurer on the exchange – but it seems to me that Washington is operating exactly the way the law intended. There is a health insurance “marketplace”, and consumers seem to have a choice. </p>
<p>Calmom, you forgot to quote the part about if it happened outside of the enrollment period, they would have been unable to pay for the services from Seattle Children’s Hospital. In future years, the enrollment period is only around 6 weeks.</p>
<p>CF, you only read selective parts of the article. Read it again. You will find out why they charge more.</p>
<p>GP, you apparently missed the part where their insurance company AGREED to pay for Children’s Hospital for the child, including all unique or specialized services whenever they happened. </p>
<p>The big hoo-hah of the article seems to be that the claim had to be resubmitted or appealed before it was paid. Apparently this all happened rather quickly, as opposed to the 4 months I spent battling United Health Care over payment for services that were explicitly covered under my daughter’s policy, while the insurer told one lie after another. (For example, telling me that something wasn’t covered based on an assertion that the procedure code meant something other than what it actually meant.)</p>
<p>I read the whole article. Seattle Children’s CLAIMS that the kids they perform routine surgery on are sicker than the usual. But I don’t believe them. That is to say, some of the kids they give appendectomies to may be somewhat sicker, but I’m certain they also handle plenty of kids who are just normally sick, and they charge their jacked up prices to all kids. </p>
<p>And, of course, as Calmom points out, those prices get passed on to people who don’t have sick kids, but who are paying for other people’s sick kids to be overcharged.</p>
<p>The problem with these specialized hospitals is, they charge too much. Their administrators are shameless moneygrubbers. We shouldn’t knuckle under and merely keep paying their overinflated prices. </p>
<p>Yow, that line, grant exceptions for some of Seattle Children’s unique services, but won’t cover non-unique services such as asthma visits and tonsil procedures
isn’t even in quotes. Crafty. And it’s followed by focus on the non-unique. Don’t hang on the word “some.”</p>
<p>Calmom, my concern about people picking based on lowest pricing: any plan that requires the deductible to be met before coverage kicks in, means med service may still have a functionally prohibitive cost, for some, til that ded is met. A lot depends on what those deductible are. But it can be a vicious cycle.</p>
<p>About this, the “simple” question: “So if the insurers are not accurate and the front office staff can’t tell the patient, how do the subscribers know who is in their network?” Arabrab already gave this answer: Call the doctor’s office and ask to speak to the person who handles billing and insurance. Way more likely to get accurate information from that person (who might be in a completely separate office) than from the front office staff.</p>
<p>Prior to ACA, when I had a billing question, I spoke with the billing staff. Last quarter, in verifying my 2014 coverage, I spoke with the billing staff. Front office checks me in and out, sets appts and takes messages.</p>
<p>The appendectomy issue came up long ago, in articles about SC’s negotiations- a cancer kid needing that surgery, best handled at SC, versus a case where it’s not necessary it be performed at SC, at its rates. </p>
<p>Hospitals pile on charges for each procedure, so if a sicker-than-usual kid has an appendectomy, there would be other charges to add on to the basic cost – for whatever additional support or medication that kid needed. </p>
<p>And of course Children’s treats healthy kids with routine problems – my grandson with the broken leg being one of them. (The one on Medicaid-- I assume that Children’s will get paid whatever Medicaid authorizes.) </p>
<p>They could adopt a different pricing model that differentiated between specialized and routine care. Whether the insurers would pay for that, I don’t know. </p>
<p>But the big problem historically with our system of health care delivery is that the people who can pay get charged extra for the costs incurred by the people who can’t. And apparently Childrens’ pricing model includes shifting the cost of highly specialized care onto their charges for routine procedures. That’s probably not something that middle income parents of healthy, normally developing kids ought to have to pay extra for. </p>