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Medical insurance booby traps

Consumer Reports News: June 17, 2008 04:42 PM

When Austin, Texas resident, Bill (right), went to the emergency room for an injury, he did the right thing. He called his insurance company and confirmed that the hospital was in-network. As he told our Cover America Tour, after receiving the bill, he discovered that the doctor who treated him was out of network. Andrea, from Murphy, Texas, was also faced with a large bill after her infant son was treated in the neonatal intensive care unit by a physician who, it was later revealed, did not participate in her plan. Anyone can fall victim to our fragmented health delivery system. It's happened to me more than once.

I'd like to consider myself a savvy health care consumer—I run a medical practice and handle all my family’s health insurance claims. But when I went for an annual mammogram and received a bill for the radiologist’s fee a few weeks later, I learned that the radiologists had left my plan much as Bill did. No mention had been made by the out-patient billing department when I called for pre-admission clearance (and confirmed my insurance information), by the radiology department (when I arrived and filled out more insurance forms), nor, needless to say, by my insurance company through a letter of notification. And when I had a Pap smear at my gynecologist’s office, and blood work drawn at another hospital just two years ago, I discovered again that I wasn’t covered. The analyses were performed by non-participating vendors even though I had made sure that the hospital phlebotomy lab and my doctor were in-network.

To admit that I was on the staff of both the hospitals just adds to my embarrassment, but it sure gave me pause. How many patients that I send for services could be caught in the same insurance booby trap, and what could I do to prevent it in the future?

Even if you ask the right question—do you participate in my plan?—of everyone you encounter, how do you check on behind the scenes personnel? And what if the practice or hospital cannot give you this information? My hospital Web site doesn’t list participating insurance companies and the radiology department receptionist still couldn’t provide me with the answer. And for my insurance company to check on any in-network status, I need the exact names of the various providers and labs.

This lack of transparency affects too many aspects of our health care and is confusing even when we have time to investigate benefits in advance. As a last recourse, you can always appeal the claim. But when we’re faced with a stressful illness or a medical emergency, we have little choice. The system can and often does take full advantage consumer's vulnerability the exact moment they need the services most. As Andrea discovered when she had to take her baby to the emergency room a second time, its physicians were not in her plan—none of the ER docs in the entire state of Texas were.

Orly Avitzur, M.D., medical adviser, Consumers Union

For more information, read our reports on health insurance and health reform.


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