In this reaction I use my knowledge as a patient to give you good information on what to do if your insurance company denies you medical care, how to expedite services, and how to deal with your health insurance when they deny coverage for out-of-network physicians.
In this video I discuss some things you need to know if you too are fighting with a health insurance company for coverage.
Below is a transcript if you prefer to read it:
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Hi, I’m Victoria, and I happen to be disabled.
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Today I’m going to react to a video that I saw pop up in my feed
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little while back from CBS News
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regarding
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an insurance company that initially denied a claim for an out-of-network physician for brain surgery that was critically needed.
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Mornings, where we are learning about a type of health insurance that can lead to unexpected medical debt. And speaking of debt, 100 million people in America are saddled with health care debt, according to a KFF study. And that includes, believe it or not, people with health insurance. Our series Medical Praise for That looks at how one Tennessee family potentially faced hundreds of thousands of dollars in medical bills, even though they thought they were covered by their insurance plan.
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Consumer investigative correspondent Anna Werner has their story. And good morning. Good morning, Tony. Yes, So let’s say you have a job that comes with a health insurance plan and your family’s doctors are in the Plans network, but suddenly in an emergency, maybe they’re not. That was the scenario faced by one family in Chattanooga.
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53 year old Jo Smith is a father of four and a runner who seemed perfectly healthy. His wife, Stacey, says until one night in February at the dinner table, he was saying things that weren’t making sense. Not putting information together properly. At the emergency room, she says, doctors could find no clear cause for his symptoms. But what? A CT scan did find a brain aneurysm.
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As soon as they said the words brain aneurysm. I mean, that’s terrifying. I just knew that if you had one, that that’s usually something that ruptures in you. You don’t make it put in there. Within days, a neurosurgeon confirmed Jo would need surgery as soon as possible to prevent a life threatening rupture. We knew that he kind of had this ticking time bomb in his head.
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The surgery was scheduled for a monday in March, but the Friday before the doctor’s office called, the surgery had to be canceled because the Smiths health insurance company was refusing to pay for it. Why the denial? Joe’s Health insurance through his job, Blue Cross Blue Shield of Illinois said that local neurosurgeon Dr. Mason Gyasi, who specialized in brain aneurysms, was out of network.
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And the Smiths health insurance provides no coverage for out-of-network doctors and hospitals. The insurer calls it a high performance network or hpn, but they’re generally called closed networks with cheaper premiums for employers and employees. But zero out-of-network options.
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so
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for those of us in the United States, we are kind of used to the whole crazy insurance thing. But I know around the world that a lot of other countries don’t have to deal with this because you guys have socialized medicine. Unfortunately, we don’t have that here. And I don’t know when we’re ever going to get it here.
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So most people get insurance through their employer,
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and
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employers offer a vast variety of plans. It really depends on how large the employer is.
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The smaller the employer is, the more difficult it is for them to give you a lot of different options. There are companies that can help smaller businesses to offer a more wide variety of plans by getting into group networks, that kind of conglomerate.
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A lot of small businesses together. But a lot of times you’re left with very few options. Another thing that tends to happen a lot when you’re choosing your insurance plan with your
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company is a
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the company does not have very good information as to exactly what the plan is.
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B,
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The plans that are offered are few and far between.
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A lot of times HMO.
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High deductible plans or PPOs that have very restrictive networks.
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And
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if
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you ask your insurer
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about
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the plan itself, a lot of times the H.R. person kind of can give you like just the rundown that’s in the summary of benefits. But that doesn’t necessarily mean that that’s exactly what the plan covers. So if you are going to be shopping for a plan through your employer,
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I would highly recommend getting something called the E.O.
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C.
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Evidence of Coverage booklet. That is a document that is 9100 pages long. It kind of depends. That actually details every single part of your plan, what they will cover, what they won’t cover
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in there. You can tell whether or not you have out-of-network coverage for any sort of physicians.
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A lot of times, HMO plans, no way. You’re not going to get out of network coverage. Out-of-network coverage tends to happen with PPO plans,
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So this gentleman had a high performance network plan, which
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in reading about seems similar to an HMO where you’re basically restricted to a certain set of physicians to see simply because they can offer your employer a lot lower rate
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for
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insurance coverage overall
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because the medical providers have contracted rates within this particular preferred network of individuals.
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But if I’m completely wrong about that, please leave a comment down below. I am not the end all, be all in terms of no ability of insurance.
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Georgetown University professor Sabrina Corlette studies health insurance reform. Some employers are increasingly introducing these closed network plans or narrow network plans as a way to cut back on their health care costs.
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So Stacy Smith went looking for another neurosurgeon anywhere near their home in Chattanooga, Tennessee. Who was in that network and could perform the surgery? She couldn’t find a single one. I spent all day Monday,
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So this is not unusual, particularly in certain parts of America. There are very few specialty physicians for a surgery such as an aneurysm clip. It is highly specialized. And so therefore, in a lot of parts of the country that are not, say, on the coast or near super large cities, you’re not going to have the specialists that you need.
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Therefore, these very limited networks are not necessarily the best way to go when you have a critical need. But let’s continue.
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I think, in tears on the phone with anybody who would listen to me at the insurance company saying, look, he needs this surgery now.
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What do we do? And what they tell you, sorry, there’s no policy. There is no protocol. There’s no plan. I mean, you were staring down the barrel, essentially, right? Yeah, it was very scary. What was the greatest fear? That he wouldn’t survive, that it would rupture before. Before we could get the surgery.
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So the surgery was on Friday and then it was canceled. And so what did she do? She contacted her insurance carrier on Monday and she talked to a whole bunch of different representatives asking them all sorts of questions. And they kept telling her that they didn’t have the answers. Well, the answers a lot of times are dictated by the evidence of coverage booklet, EEOC evidence of coverage booklet.
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That is the document that is about 100 pages long. It details what they will and will not cover. A lot of times it also has information there as to say you live in a very rural part of the United States and you need to see a specialist and the closest specialist to you
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that can potentially do something is 500 miles away.
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But you do have one in your town, but that person’s not in your network. You can get an out-of-network
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Exception.
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for that particular
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physician simply because they live too many miles away from your house.
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One of the other things when you’re calling your insurance company that I would highly recommend doing, especially when dealing with such a critical issue like this,
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is to get the reference number for the phone call.
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That is super important.
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It doesn’t matter the person’s name. A lot of times the phone calls are recorded or they’re documented in some way, shape or form and the way that they’re documented and that you can be sure they are documented is the reference number for the phone call. Any time you contact a insurance carrier, you should ask for that.
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another thing that she could have potentially done was contact the physician that stated that he needed to have the surgery immediately. Whether or not that was the end not work physician or out-of-network physician, I don’t know if it was an in-network physician, that physician could then
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request an email. Immediate appeal of denial.
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That physician could ask for a peer to peer where they talked to somebody else that is also a physician
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and tell them why he needs to go to this particular physician,
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that this is the only physician within, say, a 500 mile radius that can do this particular procedure.
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She could also file a expedited grievance.
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grievances.
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Another process to try to get your insurance company to overturn this. So first, call them document phone calls with reference numbers, write letter for a grievance, ask for it to be expedited. If it cannot be expedited, then within 72 hours, potentially speak to your
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state regulatory insurance agency that oversees medical plans. That is the fastest way to try to get something covered that has been denied.
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I know that sometimes physicians offices dropped the ball with this, but you as a patient also do have some of these abilities to try to push this forward.
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The day after the canceled surgery, the couple say Joe developed a persistent headache and went to the E.R. the next day.
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Dr. Galassi performed emergency surgery. How lucky is he that this was even caught before the aneurysm ruptured? Yeah, extremely lucky. There’s a lot of the people in this country that don’t have that bad luck, and they are not treated in the manner that he was. But when we sat down with them two weeks after the surgery, the couple still didn’t know whether the bill, possibly hundreds of thousands of dollars, would be covered.
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Is the insurance company going to pay for that or not? We don’t know. Nearly a month after the surgery and after we contacted the company, Blue Cross Blue Shield of Illinois sent the Smiths this letter saying their request for Dr. Galassi to perform surgery had been denied in error
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So there is something that people do need to know about if they are in an urgent situation and need to have a medical procedure done. It’s called the No Surprises Act.
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if you have an out-of-network physician that’s doing surgery, that’s emergency. Most of the time that out-of-network physician will be covered as an in network benefit because it is an emergency. You couldn’t necessarily choose your doctor. You could have go wander around for three months and wait for an appointment for a doctor 200 miles from your house that happens to be in your network.
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You had to have something done urgently. It was imperative. It was life threatening. I found this out when I had an appendectomy. I actually talk more about that in a video. I will link it in the little card that’s up here.
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If you want to watch that video, it goes more into kind of what the No Surprises Act does and what my experience was like when I had to have an emergency appendectomy.
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I was
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completely
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terrified that the physicians that had to do the surgery were not in network, and then I would have to pay out-of-network prices. So, yeah, go watch that video if you want to know more about that story. But
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having the insurance company send you a letter that says, Whoopsie, we did something wrong is not unusual.
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It happens a lot.
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This is the reason why if I’m trying to figure out if something is covered by my insurance or if a doctor is in network, I call multiple times because I do not trust that the one person I spoke to in the insurance company is actually correct. And is it dumb that I have to spend a large portion of my life listening to shitty on hold music, trying to contact my insurance company to make sure that this procedure is covered or this physician is in network.
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Yeah, it’s dumb, but unfortunately I have to do it because I don’t want to get stuck with the bill.
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would now be approved. The company later told us it couldn’t comment on Joe Smith’s case, but said in some situations where an in network provider is not available, a member may receive services from an out-of-network provider.
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On this speaks to the need for some basic standards for, you know, how quickly a plan has to review and act on a request for authorizing this
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Exactly.
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So most of the regulatory actually probably all of the state regulatory insurance boards do post on their websites the amounts of money that these insurance companies have been fined over, different infractions that have occurred. That is why it kind of is imperative for you to contact your state insurance regulatory
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division, because
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they have this information,
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it will eventually penalize the insurance company.
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It also gives them information as to where they could potentially focus moving forward to clarify law or to instill new laws, which is really important.
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I know in America a lot of people have been pushing for universal coverage.
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I don’t know if this is a possibility in my lifetime. So in order for me to continue to get good medical coverage without so many hoops. The only way I foresee that to happen is to have regulation. I like it. I think we should do it.
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Insurance companies are not going to make decisions on their own to do what’s best. They’re going to make decisions to do what’s best for their bottom line. They make money. And that tends to be one of the only things that they are interested in. Which is super unfortunate.
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Illinois over $600,000 for violating state laws, including failing to properly apply maximum driving time and distance standards to reflect the actual number of providers available.
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The insurance company told us it’s committed to helping our members access the care they need where and when they need it.
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So I get that they say this, and I understand that maybe some people at the insurance company feel this way. I don’t feel this way as a patient having to deal with insurance companies all the time. And I feel really bad for this family because they probably, I’m hoping, never had to deal with insurance in this particular way until a critical issue happened with a family member.
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That was life threatening.
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That is ridiculous. You’re already under a ton of stress and then your insurance company gives you more stress. Got to love America.
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But Joe Smith says, I don’t like them having that kind of power over people’s lives. You know, they shouldn’t mess around people’s lives and, you know, push it off,
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Yep.
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Yeah, they did. Oh, yeah, they did.
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So I’m going to end that there.
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I hope you learned something, especially about how to file a grievance with your insurance company.
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If they deny coverage for something that you critically need. I know I only kind of glazed over that, but it is important information to know, even if you right now do not have to use it. I bet you you could help a family member or I’m hoping you will never have to use it in the future, but at least you have the information now.
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If you’re interested in learning more about how to navigate your health insurance, advocate for yourself or a family member or you’re interested in just chatting about all things disability, please subscribe and I’ll see you next time.