Health and Networks and Exclusions

Submitted by Rick Blaine on Sat, 07/29/2006 - 16:12

Okay, here is a topic of interest for some and it might be a subject that hits some here and not in a good way!

Okay, you go out and buy into a PPO or HSA, your agent said you are now a part of a network that has built in savings or the Network Discounts or Scheldule Fee. So you go out and see the Dr., now you know its about lets say Pregnancy or Beriatric that is excluded from you policy. That is okay becuase you were told about it and it is clearly written in your policy, yet though according to Brochures from the Insurance Carrier or by the Agent that doesn't know better you expect the bill once submitted that you would recieve not the price of the Dr but the negiotaited price of the Network you belong to.

Now you go to the GYN Dr, last month you got a bill of 100 dollars minus the 40 dollar discount for a total bill of 60 dollars. You haven't yet met your deductible. Yet this month you are going becuase you are pregnant, so you know you have to pay the bill but once it comes in from the network it doesn't include the 40 dollar discount that you expected but a bill for the whole 100 dollars. You are fit to be tied, I would esp. considering I was pregnant!

So you call the Dr and say whats up with this? They say your insurance excludes pregnancy and the discount doesn't apply. Now one would be completely correct to think, wait I belong to the Network and becuase of that why does it matter if the treatment is excluded? If I had a Network card that cost around 20 dollars a month I would recieve the discount and my Insurance Card clearly states I belong to such and such Network, in fact the membership card of extra cost looks just like my medical card.

If this has happen to you please let me know! Or let me know what you think about this process of elimination of discount. I'm thinking if you raise enough hell with your provider they may go ahead and give you the discounted rate. By Humana and Golden Rule, so far they all say they submit the bill with discount but it is up to the provider to except it or charge the full price.

Posted: 31 Jul 2006 05:23 Post Subject:

Pregnancy is a kind of disability right?
If so, then the more obvious case for most of the women is to buy a disability insurance policy. Isn't it?

Posted: 01 Aug 2006 06:27 Post Subject:

LOL, no I doubt if any DI Carrier is going to pay on pregnancy! Oh well, if you give it a try let me know how it works out. That was good, the disability of pregnancy, that's good. :D

Posted: 11 Aug 2006 06:10 Post Subject:

Health carriers do not take discounts on non-covered services. None of them. It should spell it out in your policy. Secondly, your doctor has no control over this. If you have a complaint you would need to contact your carrier, but it will get you nowhere.

Posted: 16 Aug 2006 09:07 Post Subject:

"Health carriers do not take discounts on non-covered services. None of them. It should spell it out in your policy. Secondly, your doctor has no control over this. If you have a complaint you would need to contact your carrier, but it will get you nowhere."

Now this is the confusing point, carriers for the most part have little to do with this. Yet some say they should get more involved and work on fixing it and, that I can agree with, one would think "Service" should mean something.

Yet this is the language of contracts between the Networks (which tends to be third parties) and the Medical Providers. The Network says they apply the discount but it is up to the Provider to except it or charge the full amount. Now I know some Medical Providers will give the discount others will not. Since that is the case contacting the Insurance Carrier is a good idea but the best short term resolve would be to consult your Medical Provider and ask for the discount. If possible shop around for Providers, going to the Insurance Carrier will not get you the discount but they should understand that you are displeased and understand this isn't good service.

Posted: 18 Aug 2006 02:56 Post Subject:

The thing is, the discount that is applied by going to a provider within your network is a benefit, just as the payment is a benefit. Now if you go and have a non-covered procedure you are not going to get any benefits, discounts, payment, or credit on your deductible.

As for the provider, good luck with them making you pay only the discounted amount. At best they'll offer you a payment plan to pay the bill.

As for carrier, I was talking about whomever processes your claim.

Finally, I do not believe that providers are allowed per their contract with the networks to charge the full amount if the discount is taken when the bill is processed. At least not any contracts that I have seen. Now if the provider is not in the network, they are not going to accept the networks discounts, and they do not have to. In this case, the bill processor will only pay UC on the bill and pay at usually a lower precentage or not at all.

Posted: 24 Sep 2006 11:17 Post Subject:

Finally, I do not believe that providers are allowed per their contract with the networks to charge the full amount if the discount is taken when the bill is processed. At least not any contracts that I have seen. Now if the provider is not in the network, they are not going to accept the networks discounts, and they do not have to. In this case, the bill processor will only pay UC on the bill and pay at usually a lower precentage or not at all.



This is where the rub lies, your Dr. can be a part of the network including all facilities and other services. You go out and buy a policy and check with all Dr's and you find out they are in the network. You go to Dr. GYN for a check up and you get the network discount, now you go back and say you're a female (obviously in this case a GYN Dr) and you are pregnant, you get the bill an the bill is for the total amount, no network deduction.

You call up the the Insurance Company, they tell you to contact the Dr., which in turns refers you to the network. Yet you go back to your contract to find wording that would confuse most attorneys. Yet what I'm most concern with is the Brochures put out by the Insurance Companies and the training of Agents. This problem is only magnified when you take in the HSA and very high deductibles. They in all brochures and training I have seen suggest that the client is a part of the network and recieves network discounts, this being highly touted when we/they compare the HSA Vs Major Medical and OOP and tax savings.

So in the end one has to ask does the participant of say Assurant, UHC, Celtic is truly a Network Member within the Health Policy, this seems at best somewhat ambigious. Most of the time the Network is a third party participant, if one belongs to the Network why shouldn't one recieve the discount? It shouldn't matter if its a covered condition or not, that is between you and the Health Carrier not the Network. Or look at this way, if I directly go out and buy membership in the network it doesn't matter. So basically it comes down to this, if I buy a HSA from Assurant and they say I belong to Network A then I assume that I am a member. Yet it doesn't quite work that way, this should be better address by the Carrier in all brochures and Agent training.

Posted: 30 Sep 2006 10:59 Post Subject: Yes I have had this happen - but NO I don't think it should.

I had a very high deductible health plan, had not met my deductible, and the insurer did not want to discount. However, when I explained the situation to my doctor, they ran it back through the insurance company, and my bill was repriced.

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