"In Network" Referral Brings Out Of Network Bill

[GiantBozon]

My son is afflicted with a very rare form of tumor that none of the doctors in our area has experience with. We participate in managed care insurance through my wife’s employer.

In the process of getting whatever information we could find, we learned that of the 60 or so documented cases of this tumor type roughly half (around 30) have been seen by a team of neurologists at the Mayo clinic. We discussed this with our primary doctor (PCP) and local specialists in Oregon, who agreed with us our son should be seen at the Mayo clinic and proceeded to arrange a referral to that team of neurologists.

The summary plan description for our insurance states:” To receive the plan’s highest level of benefits, you must receive “in-network” care. That means care provided or referred by your PCP or an (company name) designated specialist...” I take this to mean that the process of referral will send us only to an "in network" provider where insurance pays at the highest rate. For the most part our insurance seems to agree with this. They have paid the specialists named on the referral at the best rate.

The problem is anything outside of the actual doctor’s bills is being covered at the out of network percentage. These doctors only have offices inside the Mayo clinic. Any tests or procedures regarding my son’s care are either rejected outright as unwarranted, or paid at the lowest possible rate as out of network. All of the tests were done at the Mayo, which is the facility the “in network” doctors work at.

The end result is we have good coverage for several hundred dollars of doctor consults and minimal coverage for MRIs, body scans, and neurological tests and tens of thousands of dollars of bills that the insurance has rejected all together. Very few specialists have seen our son's condition or anything like it, the doctors who ordered the tests (who we were referred to) insists that the work was needed and have sent a letter for us to try and persuade the insurance.

My questions are:
1. If the referral designates an “in network” provider isn’t it reasonable to assume that the facility they work from (in this case the Mayo clinic) and respective charges are in network also?
2. If #1 has merit, how do we proceed to encourage the insurance company to act in good faith and pay the claims correctly?

This is just the latest and so far most expensive in a string of problems with this company. Reviewing our explanation of benefit advisories and contacting the insurance company has become a part time job for me. At every opportunity they deny, reduce or question validity of coverage, even when claims are straightforward and simple. It seems that we have made it onto their “bad” list and they are hoping that we will go away if they make it miserable enough for us.

Thank you for any help and advice!

[gigirle]

1. If the referral designates an “in network” provider isn’t it reasonable to assume that the facility they work from (in this case the Mayo clinic) and respective charges are in network also?

It is reasonable to assume this if you were local. But since travel was involved, it is not. This doesnt mean that you would know this but it is expected of you.

You are going to hit a brick wall on more than one occasion and I will also assume that they are trying to hit the cap on your policy, then will promptly drop you. I'm sorry to sound cold but you are sitting on the mound of bills and can see how easily it adds up.

Here are future options...Given your sons condition, tell the Dr's there (they probably already know your circumstance but remind them, they have tons of patients) and ask them to accept any routine testing from your local hospital...ie, blood work, MRI, ct scans, they might work with you and your PCP.

Apply for disabilty for your son via SSI, you may not need the money but he may need the coverage later (not sure of son's age and if he will qualify or not)

If you have the ability to get coverage thru your work, get it now. It will take 1 year (usually) before the new insurance company will kick in if they allow this pre existing conditions.
I wish your son a speedy recovery, I will keep your family in my prayers.

[GiantBozon]

Thank you for your reply. My son "Casey" is nine.

Your idea about getting some of the tests run locally is good, and we may be able to do that for some in the future. Many of the tests they initially ran are not available here (we had been going to the university hospital in Portland, Or.).

Just an aside: the care at the Mayo Clinic is unlike any we have ever experienced. They were thorough, compassionate and had knowledge of his underlying condition beyond anything available to us locally. I do not think he would have received this kind of care anywhere else we have been. Ultimately that makes it worth it, no matter what it costs me in the long run.

I was hoping that the referral to “Doctor at Mayo Clinic” would equal a referral to the facility as well. There is really nowhere else to go for at least the technical part of his care. Any suggestions on how to make sure future referrals do not allow the insurance companies so much wiggle room? They have been so inconsistent in what they allow and do not allow, it is a mystery to me (and I think to some extent to them also) what their true policies are.

I am not sure I follow your suggestion of SSI. Is there something available for dependents that I am maybe not aware of?

I think we are many years away from the $500,000 cap, at least I hope we are. I suppose it is something we better consider for his sake. I had not really considered it yet, still just working this thing a day at a time.

Thank you again for your input,

[gigirle]

I am not sure I follow your suggestion of SSI. Is there something available for dependents that I am maybe not aware of?

It would depend on if he is considered disabled and your income, etc. Here is the site link you want...http://www.socialsecurity.gov/pubs/10026.html

think we are many years away from the $500,000 cap, at least I hope we are

Consider changing your thoughts. It takes very little to run up a 500,000 cap. Espically with the problems your already running into with his condition being so rare. I'm not sure of his prognosis or if surgery is needed, chemo, medications etc. Just keep in mind that you usually have to wait until open enrollment at work, which comes only 1 time per year, then you need to wait 1 year before they will cover a preexisting condition. I was merely trying to give you a heads up kind of thing.

I will keep Casey in my prayers.

[momm2500]

is the insurance plan you are through a self-funded plan or is it an insured plan. that can mean a big difference in how you can proceed with getting help. self-funded means that your employer pays for everything. insured is thru the insurance company. if it is a self funded plan......than you go right to your employer/hr and talk to them about it.

[GiantBozon]

Thanks for your suggestion.

That is where we have ended up, and it does seem like the most hopeful course of action. I detailed the problems over the last 6 months to our employer HR people (it is funded through work).

They seemed fairly appalled at the treatment we have received.

Insurance has also paid a few recent bills as "in network" to providers that they claimed were "out of network" three months ago. I do not know if I should point out these more recent payments in an attempt to revisit the bills they deemed out of network; or if doing so will cause them to about face and go back to the lower rate on these also.



It is too early to see if HR will actually effect any change for us, but so far we are hopeful. Maybe if we make progress on that front, we can revisit previous determinations based on the most recent payments.

[momm2500]

i deal with self funded accounts all the time. (i am in the insurance field) i personally were in a similar situation with my own child 12 years ago. no pediatric oncologists to treat him. i fought with my employer (since the plan was self funded) and they saw my point and understood and gave me an exception to the plan for 1 year. then i would renew it every year thereafter. go back to your HR and ask if there is anything they can do? They have the power to over ride the insurance plan (if they are self funded)

if you need help, let me know and i can help you out!