Ok, it’s been a while since I ranted a little on here.  And truthfully, there’s a calmer gentler me who decided this is not a forum for ranting.

So instead, let me tell you a story.

Once upon a time, there was this guy, who was a partner in a small business.  Now, business is good, so the partners decide that they should start a health care plan for the team.  They do everything by the book, use a consultant to help them, and settle on a program administered by Group Health.  Now Group Health has to be reputable, because they sure do a lot of advertising that says they are.

Now when one of these team members was under their own insurance, they were diagnosed with an issue that would need some special testing that would require a small procedure.  All of this previous work was done under the watchful eye of another insurance company and accredited physicians.

This is where the fun begins.  Here’s a paraphrased transcript between Group Health and the patient.

Patient: Hi Group Health Insurance.  I got a weird call from the surgeon’s office.  Even though I was referred by a doctor, they said you aren’t sure you will cover it.

GH: Well was the referring physician In Network or Out of Network?

P: Well I don’t know. They were covered by my old insurance company.

GH: (Exasperated sigh) Well let’s see.  Well that physician is out of OUR network, so if you go to the surgeon, it counts as a self-referral.

P: How could it be a self-referral if another doctor did the referring?

GH: Maybe you didn;t hear me.  Because they are out of network.

P: So what does that mean? Do you cover it or not?

GH: Of course we do.  Don’t be silly.  We’re the greatest people on earth.  Even though you have clearly abused the system by going out of network, we – out of the goodness of our heart – are still going to cover 80% of the procedure, after the deductible of course.

P: Well what would you have covered if I was referred by an In-Network doctor?

GH: 80% after the deductible

P: So whats the difference?

GH: Nothing really.  If your surgeon has a contracted rate with us, he’ll charge the contracted rate and we’ll pay 80%

P: Wait, what’s this contracted rate thing?

GH: Oh it’s nothing really.  We work really really really really hard to get you the lowest rates from doctors, so that your 20% is nominal.

P: What if my suregeon isn’t on contract rate?

GH: Well then we pay 80% of what we WOULD HAVE PAID if the doctor was on contract with us.

P: So who pays the rest?

GH: Well I guess you would.

P: So…..you are going to pay the same amount either way, it’s just in some cases I have to pay more.

GH: But we negotiated these lower rates for you.

P: But…..you pay the lower rate.  I pay the difference.  Actually, the lower the rate, the more I pay.

GH: Well that’s ONE way to look at it I suppose.  Now, that’s only if you don’t see an IN NETWORK Specialist first.  It’s different if your surgeon is in network, under contract AND you get referred by an IN NETWORK specialist.

P: And has a dog named Blue?

GH: Huh?

P: Never mind.

P: Ok, so I guess I need do make an appointment with one of your in-network specialists so I can make sure my contracted, IN Network surgeon doesn’t charge me an arm and a leg.  No pun intended.  So, can I make an appointment?

GH: Of course.  Not a problem at all.  I will get you down for the next slot we have open for an IN NETWORK specialist.  Now that will be the 2nd week in June.  Should I put you down?

P: It’s March.

GH: So would you prefer morning or afternoon?

P: I’d prefer March.  

GH: Well June is the next time we have available for an IN NETWORK specialist who can refer you to an IN NETWORK contracted surgeon.

P: So even though a doctor suggests I get this tested, you want me to wait 3 months.

GH: No, you can just go ahead and do the procedure.  Like I said – and geez are you frustrating – we’ll still cover 80% of Necessary and Usual costs associated with the procedure.

P: Wait, what does that term mean?

GH: (SIGH) What term?

P: Necessary and Usual.

GH: Well like I said before, we cover what we think is fair.  We can’t be responsible for any extra fees the doctor tries to stick you with.

P: So let me get this straight.  You lowball the doctors into a “Necessary and Usual” rate in order to allow them in your sales pipeline.  Then you make the patients responsible for anything the doctors want to charge above that “Necessary and Usual” rate you’ve forced them into.  And the only way a patient can avoid those extra charges is if they are referred by an IN NETWORK specialist.  

GH: That’s right.  

P: BUT, AND A BIG BUT HERE, YOU DON”T HAVE ANY IN-NETWORK SPECIALISTS.

GH: Well we do have one in June.

P: Who’s on First?

GH: Huh?

P: Never Mind.

Now lucky for mortals like our Patient, there are people at the doctors offices who are fluent in the language of insurance phone reps.  Those people can actually explain how to avoid the traps that companies like Group Health try to put in your way.  Not that the doctor’s office is any saint in this matter when you think about it.  They’re playing the same twisted game, allowing the insurance companies to claim “80%” coverage when really just being responsible for 33-50%.  In fact, they are the ones who actually lose out if the patient is able to find an in network doctor to make the referral, though you have to imagine there’s a back door way it all gets settled later.

Anyway, here’s a toast to Health reform.  Thank goodness it’s taking such care to take care of the patients who need the care to begin with.