Out of network care

Non-investing personal finance issues including insurance, credit, real estate, taxes, employment and legal issues such as trusts and wills.
User avatar
Topic Author
Hayden
Posts: 1533
Joined: Tue Apr 16, 2013 5:13 pm

Out of network care

Post by Hayden »

I'm looking at the ACA Kaiser plans in WA. For all out of network care except emergencies, it states "not covered". Does this mean, they pay nothing at all and charges do not count toward deductible? Or does this mean they pay what they want and I am at risk for balance billing?

I've never been with an HMO before, but my current plan is no longer being offered in my county. Right now Kaiser seems like the best option.
anonenigma
Posts: 1137
Joined: Thu Apr 21, 2011 11:58 pm

Re: Out of network care

Post by anonenigma »

Kaiser is an old school HMO with its own doctors and hospitals. If you're with Kaiser, that's who/what you use.
orlandoman
Posts: 675
Joined: Tue Oct 19, 2010 7:27 am

Re: Out of network care

Post by orlandoman »

A challenge with HMO's is that say you are a member of an HMO in, say Texas & you go on vacation to Seattle & there are no network providers there:
- you have a heart attack & go to the emergency room of a hospital on a Monday morning
- they treat you in the emergency room, stablize your condition on Monday afternoon
- they tell you they want you to stay in the hospital for a couple of days for observation
- your HMO will pay for emergency room services
- once your condition has stabilized, your HMO will not pay any further & tell you need to go to a network hospital for any further coverage

Please call your carrier to confirm the above.
"Borrow money from pessimists -- they don't expect it back"
User avatar
dm200
Posts: 23214
Joined: Mon Feb 26, 2007 1:21 pm
Location: Washington DC area

Re: Out of network care

Post by dm200 »

Hayden wrote: Thu Nov 02, 2017 10:34 am I'm looking at the ACA Kaiser plans in WA. For all out of network care except emergencies, it states "not covered". Does this mean, they pay nothing at all and charges do not count toward deductible? Or does this mean they pay what they want and I am at risk for balance billing?
I've never been with an HMO before, but my current plan is no longer being offered in my county. Right now Kaiser seems like the best option.
Kaiser is an old school HMO with its own doctors and hospitals. If you're with Kaiser, that's who/what you use.
Having been with Kaiser (happily) for much of the last 40 years (only left when job insurance required different coverage), the Kaiser model is the HMO with their own physicians, facilities, etc. Except for emergencies, I doubt Kaiser would pay anything for services provided by anyone other than Kaiser physicians/staff. I believe that the only exceptions might be when Kaiser refers you to an outside provider. Short answer - they provide nothing.

On the ther hand, in our experience, in this area, Kaiser has a very extensive array of specialists to deal with almost any condiiton encountered. years ago, however, when Kaiser was much, much smaller - they would refer patients to outside specialists for certain things. (Happened to me once 35 yers ago). Not so today. The other good news (in my experience) about Kaiser is that they quickly find the appropriate specilasts within Kaiser and you do not have to find your own and wait for an appointment.
User avatar
Topic Author
Hayden
Posts: 1533
Joined: Tue Apr 16, 2013 5:13 pm

Re: Out of network care

Post by Hayden »

dm200 wrote: Thu Nov 02, 2017 10:57 am
Hayden wrote: Thu Nov 02, 2017 10:34 am I'm looking at the ACA Kaiser plans in WA. For all out of network care except emergencies, it states "not covered". Does this mean, they pay nothing at all and charges do not count toward deductible? Or does this mean they pay what they want and I am at risk for balance billing?
I've never been with an HMO before, but my current plan is no longer being offered in my county. Right now Kaiser seems like the best option.
Kaiser is an old school HMO with its own doctors and hospitals. If you're with Kaiser, that's who/what you use.
Having been with Kaiser (happily) for much of the last 40 years (only left when job insurance required different coverage), the Kaiser model is the HMO with their own physicians, facilities, etc. Except for emergencies, I doubt Kaiser would pay anything for services provided by anyone other than Kaiser physicians/staff. I believe that the only exceptions might be when Kaiser refers you to an outside provider. Short answer - they provide nothing.

On the ther hand, in our experience, in this area, Kaiser has a very extensive array of specialists to deal with almost any condiiton encountered. years ago, however, when Kaiser was much, much smaller - they would refer patients to outside specialists for certain things. (Happened to me once 35 yers ago). Not so today. The other good news (in my experience) about Kaiser is that they quickly find the appropriate specilasts within Kaiser and you do not have to find your own and wait for an appointment.
Thanks for sharing your positive experience. As you can tell, I'm nervous about the move to an HMO.
User avatar
HueyLD
Posts: 9789
Joined: Mon Jan 14, 2008 9:30 am

Re: Out of network care

Post by HueyLD »

Hayden wrote: Thu Nov 02, 2017 10:34 am I'm looking at the ACA Kaiser plans in WA. For all out of network care except emergencies, it states "not covered". Does this mean, they pay nothing at all and charges do not count toward deductible? Or does this mean they pay what they want and I am at risk for balance billing?

I've never been with an HMO before, but my current plan is no longer being offered in my county. Right now Kaiser seems like the best option.
If you travel out of your home area, an HMO is virtually worthless. IOW, you are responsible for all (grossly inflated) costs because the HMO doesn't care about your OON visits. There may be limited exceptions for "true" emergencies, but you will need to read the insurance contract as every contract is different.

I guess you can purchase travel insurance every time you are out of the area.
User avatar
MP123
Posts: 4084
Joined: Thu Feb 16, 2017 2:32 pm

Re: Out of network care

Post by MP123 »

In WA the Kaiser plan seems like the best deal especially if you aren't eligible for subsidies. Depending on where you live in WA it may be the old Group Health Cooperative plan that Kaiser bought out a few years ago and has now rebranded.

They don't cover out of network though except for emergency or urgent care. And I would guess the goal there would be to stabilize you and ship to a Kaiser facility.

I think we're going with them for this year now that Regence has dropped out of WA. I sympathize with your nervousness about an HMO though. At first glance having your insurance company and medical providers be one and the same company seems like a major conflict of interest...
User avatar
Topic Author
Hayden
Posts: 1533
Joined: Tue Apr 16, 2013 5:13 pm

Re: Out of network care

Post by Hayden »

HueyLD wrote: Thu Nov 02, 2017 11:04 am
Hayden wrote: Thu Nov 02, 2017 10:34 am I'm looking at the ACA Kaiser plans in WA. For all out of network care except emergencies, it states "not covered". Does this mean, they pay nothing at all and charges do not count toward deductible? Or does this mean they pay what they want and I am at risk for balance billing?

I've never been with an HMO before, but my current plan is no longer being offered in my county. Right now Kaiser seems like the best option.
If you travel out of your home area, an HMO is virtually worthless. IOW, you are responsible for all (grossly inflated) costs because the HMO doesn't care about your OON visits. There may be limited exceptions for "true" emergencies, but you will need to read the insurance contract as every contract is different.

I guess you can purchase travel insurance every time you are out of the area.
I have purchased an annual travel policy that covers me when I'm out of the country, but it doesn't provide coverage when I'm traveling within the US.

I did speak with a broker and she said there isn't a good solution for snowbirds like me.
User avatar
dm200
Posts: 23214
Joined: Mon Feb 26, 2007 1:21 pm
Location: Washington DC area

Re: Out of network care

Post by dm200 »

Thanks for sharing your positive experience. As you can tell, I'm nervous about the move to an HMO.
We are with Kaiser in the Washington DC area. Some details of Kaiser vary by location.

One very intersting change Kaiser made in this area about ten years ago (while we were not with Kaiser) was the role of nurses and nurse practioners in primary care. Years ago, nurses and nurse preationers had a growing role in primary care - doing parts (or most) of the annual health assessment, seeing you for certain conditions, etc. I was always happy with this. Then, depending on the details, the Physician might see you or the nurse/nurse practioner would consult the Physician.

Now, in this area, Kaiser hired more Primary care Physicians (Internal medicine or family practice for adults) and eliminated nurses and nurse practioners from most primary care. Now, when I have an appointment for Primary care - the only medical professional I see is my Physician (mine is Internal medicine, MD). A technician takes blood pressure, weight, tells me where to sit, to undress or not, etc. Then I see the Physician. I also have direct email access to my Physician and can do about half of what I need to do with her by email (no charge). I can also, depending on the details, schedule and have a telephone appointment (no charge) with her.
curmudgeon
Posts: 2630
Joined: Thu Jun 20, 2013 11:00 pm

Re: Out of network care

Post by curmudgeon »

We have twice had major emergency "out of network" cases with Kaiser (CA). One was an emergency appendectomy for a college student away at college, the other was at the local trauma center as result of a car accident. In these cases, the billing was absolutely seamless, and we actually had no out-of-pocket costs. I suspect Kaiser paid some form of discounted charges rather than "list price", but I don't know. Follow-up care was with Kaiser, which took a little time to arrange. In the trauma case, there was a plastic surgeon involved who tried hard to sell us additional visits (and wanted $5K cash up front) which would NOT have been covered by Kaiser; while his work was excellent, his business practices were sleazy.

I currently have a Kaiser HDHP plan, and I suspect billing for an out of network emergency case would be more complex with this plan. I just assume that if something major happens, we will be likely to hit the OOP max and I make sure that much is easily available in HSA or otherwise.
User avatar
dm200
Posts: 23214
Joined: Mon Feb 26, 2007 1:21 pm
Location: Washington DC area

Re: Out of network care

Post by dm200 »

curmudgeon wrote: Thu Nov 02, 2017 2:28 pm We have twice had major emergency "out of network" cases with Kaiser (CA). One was an emergency appendectomy for a college student away at college, the other was at the local trauma center as result of a car accident. In these cases, the billing was absolutely seamless, and we actually had no out-of-pocket costs. I suspect Kaiser paid some form of discounted charges rather than "list price", but I don't know. Follow-up care was with Kaiser, which took a little time to arrange. In the trauma case, there was a plastic surgeon involved who tried hard to sell us additional visits (and wanted $5K cash up front) which would NOT have been covered by Kaiser; while his work was excellent, his business practices were sleazy.
I currently have a Kaiser HDHP plan, and I suspect billing for an out of network emergency case would be more complex with this plan. I just assume that if something major happens, we will be likely to hit the OOP max and I make sure that much is easily available in HSA or otherwise.
Glad you had these experiences with emergencies. Your experience is what I understand is the usual Kaiser HMO coverage for emergencies.
toofache32
Posts: 2349
Joined: Sun Mar 04, 2012 5:30 pm

Re: Out of network care

Post by toofache32 »

orlandoman wrote: Thu Nov 02, 2017 10:52 am
- you have a heart attack & go to the emergency room of a hospital on a Monday morning
- they treat you in the emergency room, stablize your condition on Monday afternoon
- they tell you they want you to stay in the hospital for a couple of days for observation
- your HMO will pay for emergency room services
At best, they will pay as little as possible. They will NOT pay the entire bill if out-of-network. Remember, insurance companies are not in the business of paying claims. They are in the business of NOT paying claims. Every claim paid is counted as a loss on their books.

Be very careful with HMOs. They profit by offering as little care as possible. Many models pay a fixed rate to providers/hospitals for all care. Therefore the hospital is incentivized to provide care for less than that amount. The less (or cheaper) care they provide, the more profit remains for the provider/hospital.
There have been newsworthy problems in the past where they contractually forbid their doctors to let patients know that there are other treatments available (often better treatments but more expensive) that are not covered by the HMO. These gag clauses are hopefully less common than in the past.
User avatar
dm200
Posts: 23214
Joined: Mon Feb 26, 2007 1:21 pm
Location: Washington DC area

Re: Out of network care

Post by dm200 »

toofache32 wrote: Thu Nov 02, 2017 9:20 pm
orlandoman wrote: Thu Nov 02, 2017 10:52 am
- you have a heart attack & go to the emergency room of a hospital on a Monday morning
- they treat you in the emergency room, stablize your condition on Monday afternoon
- they tell you they want you to stay in the hospital for a couple of days for observation
- your HMO will pay for emergency room services
At best, they will pay as little as possible. They will NOT pay the entire bill if out-of-network. Remember, insurance companies are not in the business of paying claims. They are in the business of NOT paying claims. Every claim paid is counted as a loss on their books.

Be very careful with HMOs. They profit by offering as little care as possible. Many models pay a fixed rate to providers/hospitals for all care. Therefore the hospital is incentivized to provide care for less than that amount. The less (or cheaper) care they provide, the more profit remains for the provider/hospital.
There have been newsworthy problems in the past where they contractually forbid their doctors to let patients know that there are other treatments available (often better treatments but more expensive) that are not covered by the HMO. These gag clauses are hopefully less common than in the past.
I believe this is an unfair and inaccurate generalization. They will pay what the plan calls for in and out of network. Many folks here have posted positive experiences with HMOs (along with those who have negatives).
toofache32
Posts: 2349
Joined: Sun Mar 04, 2012 5:30 pm

Re: Out of network care

Post by toofache32 »

dm200 wrote: Fri Nov 03, 2017 8:11 am
toofache32 wrote: Thu Nov 02, 2017 9:20 pm
orlandoman wrote: Thu Nov 02, 2017 10:52 am
- you have a heart attack & go to the emergency room of a hospital on a Monday morning
- they treat you in the emergency room, stablize your condition on Monday afternoon
- they tell you they want you to stay in the hospital for a couple of days for observation
- your HMO will pay for emergency room services
At best, they will pay as little as possible. They will NOT pay the entire bill if out-of-network. Remember, insurance companies are not in the business of paying claims. They are in the business of NOT paying claims. Every claim paid is counted as a loss on their books.

Be very careful with HMOs. They profit by offering as little care as possible. Many models pay a fixed rate to providers/hospitals for all care. Therefore the hospital is incentivized to provide care for less than that amount. The less (or cheaper) care they provide, the more profit remains for the provider/hospital.
There have been newsworthy problems in the past where they contractually forbid their doctors to let patients know that there are other treatments available (often better treatments but more expensive) that are not covered by the HMO. These gag clauses are hopefully less common than in the past.
I believe this is an unfair and inaccurate generalization. They will pay what the plan calls for in and out of network. Many folks here have posted positive experiences with HMOs (along with those who have negatives).
You are correct, but almost nobody understands the plan they signed up for. You are probably the rare exception.
http://www.pbs.org/wgbh/pages/frontline ... ation.html

http://www.investopedia.com/terms/c/cap ... ntract.asp
Last edited by toofache32 on Fri Nov 03, 2017 9:38 am, edited 1 time in total.
dk240t
Posts: 48
Joined: Wed Jun 03, 2015 12:49 pm

Re: Out of network care

Post by dk240t »

Please ignore the people generalizing that don't know what they are talking about.

I love love love Kaiser.

The Kaiser HMO will pay for what needs to be paid for.

You go to see Kaiser docs, they order lab tests, all of it happens at the same office and you never get any crazy balance billing or wacky super expensive bills from the lab.

You have an emergency - you go to the nearest emergency room and get treatment. Even if the hospital admits you and its a non-Kaiser affiliated hospital - its all taken care of (with the copay listed in the plan document). I have direct, personal experience with this yes.

And if Kaiser does not have the people to do the job they need, they will refer you to someone else. I have experience with this as well. Not as smooth as when everything is in house, but they pay the bills as they say they will and you pay the specialist co-pay.

We have had tests run, doctor consults, and even outpatient surgery and procedures by non-Kaiser docs that we were referred to.

I'm about to have my 2nd baby on Kaiser, have been in the same ER twice this year for myself and my son, surgery for my son, pediatric orthopaedist consult for my son, etc. It has been exactly as advertised. And all the EOBs, patient visit paperwork, test results, are all readily available online. We've even avoided a few doctors visits by emailing our docs.
User avatar
Topic Author
Hayden
Posts: 1533
Joined: Tue Apr 16, 2013 5:13 pm

Re: Out of network care

Post by Hayden »

dk240t wrote: Fri Nov 03, 2017 9:30 am Please ignore the people generalizing that don't know what they are talking about.

I love love love Kaiser.

The Kaiser HMO will pay for what needs to be paid for.

You go to see Kaiser docs, they order lab tests, all of it happens at the same office and you never get any crazy balance billing or wacky super expensive bills from the lab.

You have an emergency - you go to the nearest emergency room and get treatment. Even if the hospital admits you and its a non-Kaiser affiliated hospital - its all taken care of (with the copay listed in the plan document). I have direct, personal experience with this yes.

And if Kaiser does not have the people to do the job they need, they will refer you to someone else. I have experience with this as well. Not as smooth as when everything is in house, but they pay the bills as they say they will and you pay the specialist co-pay.

We have had tests run, doctor consults, and even outpatient surgery and procedures by non-Kaiser docs that we were referred to.

I'm about to have my 2nd baby on Kaiser, have been in the same ER twice this year for myself and my son, surgery for my son, pediatric orthopaedist consult for my son, etc. It has been exactly as advertised. And all the EOBs, patient visit paperwork, test results, are all readily available online. We've even avoided a few doctors visits by emailing our docs.
Thank you for sharing your positive experiences with Kaiser. That makes me feel better about the switch to Kaiser.
User avatar
dm200
Posts: 23214
Joined: Mon Feb 26, 2007 1:21 pm
Location: Washington DC area

Re: Out of network care

Post by dm200 »

dk240t wrote: Fri Nov 03, 2017 9:30 am Please ignore the people generalizing that don't know what they are talking about.
I love love love Kaiser.
The Kaiser HMO will pay for what needs to be paid for.
You go to see Kaiser docs, they order lab tests, all of it happens at the same office and you never get any crazy balance billing or wacky super expensive bills from the lab.
You have an emergency - you go to the nearest emergency room and get treatment. Even if the hospital admits you and its a non-Kaiser affiliated hospital - its all taken care of (with the copay listed in the plan document). I have direct, personal experience with this yes.
And if Kaiser does not have the people to do the job they need, they will refer you to someone else. I have experience with this as well. Not as smooth as when everything is in house, but they pay the bills as they say they will and you pay the specialist co-pay.
We have had tests run, doctor consults, and even outpatient surgery and procedures by non-Kaiser docs that we were referred to.
I'm about to have my 2nd baby on Kaiser, have been in the same ER twice this year for myself and my son, surgery for my son, pediatric orthopaedist consult for my son, etc. It has been exactly as advertised. And all the EOBs, patient visit paperwork, test results, are all readily available online. We've even avoided a few doctors visits by emailing our docs.
Your experiences and opinions match ours completely. Many folks give me a hard time about my/our Kaiser experiences and opinions. I am so puzzled how others even with the same physicians reach such different (and awful) conclusions. I think, perhaps, others may not work to be as informed about health/medical/Kaiser matters as my wife and I. We have not, fortunately, ever had to deal with outside ERs, etc. In this area (Washington DC), Kaiser has 24 hour - 7 day a week "urgent care" centers. We would only go to a hospital ER in some very rare circumstances. These urgent care (24 hour) can keep you up to 24 hours and look (inside) just like a hospital. We have seen some very, very sick folks there.

One example of my wife - last year, she had several incidents of vertigo/dizziness - several while driving. I took her to a Kaiser urgent care facility on a Wednesday afternoon. Kaiser kept her overnight, ran CT and MRI scans, consulted that afternoon/evening (by phone) with a Kaiser neurologist. She saw that neurologist at 9 am on Thursday, and had another scan on Friday morning. Conclusion - something in her inner ear - nothing dangerous/serious. All was taken care of in about 36 hours and no recurrence. The costs to us were very modest.

In our opinion, if she had any kind of traditional insurance, whether outside HMO, PPO, full choice of physicians - this would have gone on for weeks in finding an appropriate neurologist, making an appointment, carrying records, etc.
User avatar
dm200
Posts: 23214
Joined: Mon Feb 26, 2007 1:21 pm
Location: Washington DC area

Re: Out of network care

Post by dm200 »

You are correct, but almost nobody understands the plan they signed up for. You are probably the rare exception
.

I look online at all test results and any history of those results. I look at any and all medications prescribed. I always know (either from their badge/id or I ask) exactly what each and every person dealing with me medically "is". I know whether they are a registered nurse, nurse practioner, MD, DO,etc. and what specialty they might have.

It amazes me how many folks have close to zero clue about their medical providers, the drugs they are taking and details of their medical treatment.

Today, on the one hand it is great that electronic and centralized records are accessible to providers (they can see history, drugs taken, etc.), on the other hand there is often so much there - a provider can miss some things. If I think or sense that anyone treating me has missed something - I speak up. My Primary Care Physician commented to me (with a smile) that I am an "unusual" patient in this regard. While I don't know what she shares with her other patients, I am under the impression she may share more information with me than she does with others. She seems to be happy and cooperative that I am so involved.

By understanding my plan, I also catch billing errors (which are quickly corrected). Recently, I had two CT scans - different body areas - at one consecutive appointment. The charge to the patient for CT scans is $150. I paid $150 at the time, but got another $150 bill. I called and they looked at the policy details and it was supposed to be $150 per time - not per scan.
2015
Posts: 2906
Joined: Mon Feb 10, 2014 1:32 pm

Re: Out of network care

Post by 2015 »

toofache32 wrote: Fri Nov 03, 2017 9:13 am
dm200 wrote: Fri Nov 03, 2017 8:11 am
toofache32 wrote: Thu Nov 02, 2017 9:20 pm
orlandoman wrote: Thu Nov 02, 2017 10:52 am
- you have a heart attack & go to the emergency room of a hospital on a Monday morning
- they treat you in the emergency room, stablize your condition on Monday afternoon
- they tell you they want you to stay in the hospital for a couple of days for observation
- your HMO will pay for emergency room services
At best, they will pay as little as possible. They will NOT pay the entire bill if out-of-network. Remember, insurance companies are not in the business of paying claims. They are in the business of NOT paying claims. Every claim paid is counted as a loss on their books.

Be very careful with HMOs. They profit by offering as little care as possible. Many models pay a fixed rate to providers/hospitals for all care. Therefore the hospital is incentivized to provide care for less than that amount. The less (or cheaper) care they provide, the more profit remains for the provider/hospital.
There have been newsworthy problems in the past where they contractually forbid their doctors to let patients know that there are other treatments available (often better treatments but more expensive) that are not covered by the HMO. These gag clauses are hopefully less common than in the past.
I believe this is an unfair and inaccurate generalization. They will pay what the plan calls for in and out of network. Many folks here have posted positive experiences with HMOs (along with those who have negatives).
You are correct, but almost nobody understands the plan they signed up for. You are probably the rare exception.
http://www.pbs.org/wgbh/pages/frontline ... ation.html

http://www.investopedia.com/terms/c/cap ... ntract.asp
I believe if an individual has not taken the time to understand their healthcare plan they deserve all the trouble they themselves cause. I agree with the above that your former characterization of HMO's is unfair. Having only used HMO's, I have had nothing but positive experiences. In fact, I verified with my current carrier recently that I would have been covered in Mexico while on vacation in the event of an emergency. Of course, I took the time to call my carrier before leaving and obtain exact instructions on what to do in order to not be out of network. In fact, I've taken the time to understand all of my insurances (i.e., auto, home, umbrella, etc.) in an effort to get out in front of nightmare scenarios before they happen.
User avatar
dm200
Posts: 23214
Joined: Mon Feb 26, 2007 1:21 pm
Location: Washington DC area

Re: Out of network care

Post by dm200 »

I believe if an individual has not taken the time to understand their healthcare plan they deserve all the trouble they themselves cause. I agree with the above that your former characterization of HMO's is unfair. Having only used HMO's, I have had nothing but positive experiences. In fact, I verified with my current carrier recently that I would have been covered in Mexico while on vacation in the event of an emergency. Of course, I took the time to call my carrier before leaving and obtain exact instructions on what to do in order to not be out of network. In fact, I've taken the time to understand all of my insurances (i.e., auto, home, umbrella, etc.) in an effort to get out in front of nightmare scenarios before they happen.
Having been enrolled in several different HMOs over the decades, I agree with almost all of this. Many decades ago, HMOs did have a serious lack of coverage for behavioral/mental health matters -- but (probably due to changes in law/regulaitons) today that gap has been closed significantly.

When we were enrolled in HMOs that used enrolled physician's offices, I never felt that I was treated in an inferior way to other patients that had different coverage. Of course, any referrals had to be to the specialists in that HMO. I have needed an Endocrinologist on a regular basis for the last 30+ years - and my opinion is that the Endocrinologists I had through an HMO were just as competent, etc. as I would have gotten through another plan.
User avatar
Pajamas
Posts: 6015
Joined: Sun Jun 03, 2012 6:32 pm

Re: Out of network care

Post by Pajamas »

2015 wrote: Sat Nov 04, 2017 8:55 am
I believe if an individual has not taken the time to understand their healthcare plan they deserve all the trouble they themselves cause. . . . Of course, I took the time to call my carrier before leaving and obtain exact instructions on what to do in order to not be out of network. In fact, I've taken the time to understand all of my insurances (i.e., auto, home, umbrella, etc.) in an effort to get out in front of nightmare scenarios before they happen.
What you are saying is sometimes true. However, sometimes it is not true and in effect, you are blaming the victim in those situations.

Sometimes it is not possible to understand the plan because of incomplete or incorrect information and sometimes healthcare plans don't do what they are supposed to do. Frequently their member services reps and claims reps don't understand the benefits and policies, so questions are answered incorrectly and claims are paid incorrectly.

One time when I had to have surgery, I called my plan and was assured in advance that everything would be covered a in-network rates. The surgeon was not in network but had agreed to accept in-network rates in writing. Turns out that the anesthesiologist at the in-network hospital was not in network, which is not uncommon. However, the plan afterwards determined that because the anesthesiologist was out-of-network, that everything associated with the surgery and hospital stay would be considered out-of-network. They eventually covered everything as if it were in-network anyway, but only because they had a record of my call and their "incorrect" assurance that everything would be covered in-network, but acted as if they were doing me a favor.

Over the past couple of years, I have had to take a web of complaints to the state department of health because of lack of follow-through on internal complaints I made to my current plan. This was just to get them to charge the correct co-pays as outlined in the subscriber contract and to pay claims correctly and completely instead of incorrectly denying them or paying the wrong amount, which left me responsible for extra co-pays or incorrect co-pays. They won't even provide complete information about claims, so I have to find out from the providers' billing services why they were denied. Turns out their claims-processing software was not set up properly along with problems and errors in their provider database.

So the nightmare scenarios are not always because someone didn't bother to try to understand their coverage or clarify payment in advance.

At least with a true HMO like Kaiser, you can go to a doctor or facility and not have to worry about whether or not the visit is actually in-network.
User avatar
Wildebeest
Posts: 1204
Joined: Fri Dec 27, 2013 1:36 pm

Re: Out of network care

Post by Wildebeest »

If you are in good health and only need preventative care a HMO is great.

If you are sick, it may be a completely different story/ nightmare.

While I like the Kaiser model, I have been underwhelmed by their care.

I wonder if we had only had Kaiser Care in the States how we would rank world wide as opposed to 37 th. I doubt it would beat Canada (30 th).

http://news.morningstar.com/articlenet/ ... ?id=833000
Last edited by Wildebeest on Sat Nov 04, 2017 9:51 am, edited 1 time in total.
The Golden Rule: One should treat others as one would like others to treat oneself.
User avatar
dm200
Posts: 23214
Joined: Mon Feb 26, 2007 1:21 pm
Location: Washington DC area

Re: Out of network care

Post by dm200 »

Wildebeest wrote: Sat Nov 04, 2017 9:42 am If you are in good health and only need preventative care a HMO is great.
If you are sick, it may be a completely different story/ nightmare.
While I like the Kaiser model, I have been underwhelmed by their care.
Our experience differs greatly.
User avatar
HueyLD
Posts: 9789
Joined: Mon Jan 14, 2008 9:30 am

Re: Out of network care

Post by HueyLD »

dm200 wrote: Sat Nov 04, 2017 9:49 am
Wildebeest wrote: Sat Nov 04, 2017 9:42 am If you are in good health and only need preventative care a HMO is great.
If you are sick, it may be a completely different story/ nightmare.
While I like the Kaiser model, I have been underwhelmed by their care.
Our experience differs greatly.
This thread clearly shows how true the YMMV is!!

My experience with HMOs (not Kaiser) has been dismal as well. As a result, I avoid all HMOs due to bad experience. I have heard both good and bad stories from users of Kaiser, but I have never lived in an area with Kaiser. Maybe Kaiser is an exception for the D.C. area?
User avatar
Wildebeest
Posts: 1204
Joined: Fri Dec 27, 2013 1:36 pm

Re: Out of network care

Post by Wildebeest »

HueyLD wrote: Sat Nov 04, 2017 10:19 am
dm200 wrote: Sat Nov 04, 2017 9:49 am
Wildebeest wrote: Sat Nov 04, 2017 9:42 am If you are in good health and only need preventative care a HMO is great.
If you are sick, it may be a completely different story/ nightmare.
While I like the Kaiser model, I have been underwhelmed by their care.
Our experience differs greatly.
This thread clearly shows how true the YMMV is!!

My experience with HMOs (not Kaiser) has been dismal as well. As a result, I avoid all HMOs due to bad experience. I have heard both good and bad stories from users of Kaiser, but I have never lived in an area with Kaiser. Maybe Kaiser is an exception for the D.C. area?
YMMV is so right.
I live in the DC area.
The Golden Rule: One should treat others as one would like others to treat oneself.
User avatar
dm200
Posts: 23214
Joined: Mon Feb 26, 2007 1:21 pm
Location: Washington DC area

Re: Out of network care

Post by dm200 »

Maybe Kaiser is an exception for the D.C. area?
While we have no experience in any other areas, I am under the impression that Kaiser patient satisfaction/experience may be even higher in some other areas of the country, such as California.
theplayer11
Posts: 2282
Joined: Tue Jul 22, 2014 8:55 pm

Re: Out of network care

Post by theplayer11 »

Not just HMOs..just received new letter with rates and changes for BC/BS of RI. For 2018, no out of network coverage, was 40% coinsurance with $20k individual out of pocket max.
User avatar
dm200
Posts: 23214
Joined: Mon Feb 26, 2007 1:21 pm
Location: Washington DC area

Re: Out of network care

Post by dm200 »

theplayer11 wrote: Sat Nov 04, 2017 12:06 pm Not just HMOs..just received new letter with rates and changes for BC/BS of RI. For 2018, no out of network coverage, was 40% coinsurance with $20k individual out of pocket max.
Is it possible this is an HMO? I strongly suspect that are multiple BC/BS plans in RI with many different benefits (many, for example, with much lower maximums and coinsurance).
Tanelorn
Posts: 2370
Joined: Thu May 01, 2014 9:35 pm

Re: Out of network care

Post by Tanelorn »

HueyLD wrote: Thu Nov 02, 2017 11:04 am If you travel out of your home area, an HMO is virtually worthless. IOW, you are responsible for all (grossly inflated) costs because the HMO doesn't care about your OON visits. There may be limited exceptions for "true" emergencies, but you will need to read the insurance contract as every contract is different.

I guess you can purchase travel insurance every time you are out of the area.
Yes, this has been one of the major failings of the ACA and its effects on the individual market. Previously nationwide networks have been crammed down to state or even city-specific ones. If you go on a trip for a few weeks, it's all well and fine to say if there's a true emergency it's covered and you'll be returning to your home directly. But if you need to see a doctor for something fairly routine but not an ER visit while you're traveling (think strep test and maybe antibiotics), now that's 100% on you. Or maybe you need a refill on a regular medication but your trip is too long for your normal prescription period, or you need a routine checkup on some existing medical issue, etc.

It's even worse if you are a snowbird or similar and spend a summer elsewhere outside your home state - now you basically are uncovered or have to buy two policies and pay double for coverage.

As was mentioned above, most trip insurance is for travels outside the US. In addition, these policies typically only cover emergency care or evacuation, and while some of the more comprehensive ones do cover limited medical costs, those are often capped at several $10k worth of cost and come with exclusions for existing conditions.

Basically, under the ACA, if you might need any periodic medical care, you should either be super rich and self insure all your costs or you should never travel. Gee, thanks.
Last edited by Tanelorn on Sat Nov 04, 2017 1:25 pm, edited 1 time in total.
2015
Posts: 2906
Joined: Mon Feb 10, 2014 1:32 pm

Re: Out of network care

Post by 2015 »

Pajamas wrote: Sat Nov 04, 2017 9:31 am
2015 wrote: Sat Nov 04, 2017 8:55 am
I believe if an individual has not taken the time to understand their healthcare plan they deserve all the trouble they themselves cause. . . . Of course, I took the time to call my carrier before leaving and obtain exact instructions on what to do in order to not be out of network. In fact, I've taken the time to understand all of my insurances (i.e., auto, home, umbrella, etc.) in an effort to get out in front of nightmare scenarios before they happen.
What you are saying is sometimes true. However, sometimes it is not true and in effect, you are blaming the victim in those situations.

Sometimes it is not possible to understand the plan because of incomplete or incorrect information and sometimes healthcare plans don't do what they are supposed to do. Frequently their member services reps and claims reps don't understand the benefits and policies, so questions are answered incorrectly and claims are paid incorrectly.

One time when I had to have surgery, I called my plan and was assured in advance that everything would be covered a in-network rates. The surgeon was not in network but had agreed to accept in-network rates in writing. Turns out that the anesthesiologist at the in-network hospital was not in network, which is not uncommon. However, the plan afterwards determined that because the anesthesiologist was out-of-network, that everything associated with the surgery and hospital stay would be considered out-of-network. They eventually covered everything as if it were in-network anyway, but only because they had a record of my call and their "incorrect" assurance that everything would be covered in-network, but acted as if they were doing me a favor.

Over the past couple of years, I have had to take a web of complaints to the state department of health because of lack of follow-through on internal complaints I made to my current plan. This was just to get them to charge the correct co-pays as outlined in the subscriber contract and to pay claims correctly and completely instead of incorrectly denying them or paying the wrong amount, which left me responsible for extra co-pays or incorrect co-pays. They won't even provide complete information about claims, so I have to find out from the providers' billing services why they were denied. Turns out their claims-processing software was not set up properly along with problems and errors in their provider database.

So the nightmare scenarios are not always because someone didn't bother to try to understand their coverage or clarify payment in advance.

At least with a true HMO like Kaiser, you can go to a doctor or facility and not have to worry about whether or not the visit is actually in-network.
I have to agree with you at least with respect to those who think they understand their plans after making the attempt to. OTOH, in my case with a mess of a specialist's billing department for a colonoscopy, after going round and round with them and keeping copious notes and documentation, my carrier Anthem actually did a one-time payment on my behalf for the disputed bill. While I was impressed, I insisted on filing a complaint with Anthem, with the medical group, and posted unflattering reviews about that office on several sites. Anthem told me if they received enough complaints about a particular provider, they would go through a review and could be dropped.

What I am saying here is as upside down and backward as all insurances are, it is in our best interest as consumers to do as much as we can to understand our plans (think of the victims of the recent NorCal fires and the Houston and Katrina floods who found out after the fact their insurance wasn't what they thought it was). I would say that my understanding of my plan aided in Anthem volunteering to make the payment on my behalf. I would also say I think it's a shame we as insurance consumers have to jump through all these hoops when all we're really want is to get what we pay for (easy to understand coverage!) through our premiums.
User avatar
dm200
Posts: 23214
Joined: Mon Feb 26, 2007 1:21 pm
Location: Washington DC area

Re: Out of network care

Post by dm200 »

We have been fortunate to not have any health/medical issues while traveling. A friend of ours, though, is on the Kaiser Medicare plan and he was out of the area when he had some sort of emergency/urgent care problem. He called Kaiser, informed Kaiser he was a few hours away and Kaiser told him to go the nearest emergency room. His issue was taken care of promptly and to his full satisfaction.
User avatar
goodenyou
Posts: 3602
Joined: Sun Jan 31, 2010 10:57 pm
Location: Skating to Where the Puck is Going to Be..or on the golf course

Re: Out of network care

Post by goodenyou »

Pajamas wrote:
Over the past couple of years, I have had to take a web of complaints to the state department of health because of lack of follow-through on internal complaints I made to my current plan. This was just to get them to charge the correct co-pays as outlined in the subscriber contract and to pay claims correctly and completely instead of incorrectly denying them or paying the wrong amount, which left me responsible for extra co-pays or incorrect co-pays. They won't even provide complete information about claims, so I have to find out from the providers' billing services why they were denied. Turns out their claims-processing software was not set up properly along with problems and errors in their provider database.

So the nightmare scenarios are not always because someone didn't bother to try to understand their coverage or clarify payment in advance.
That is just one patient, you. Can you imagine what a practice of 9 surgical specialists has to do with hundreds of patients a day? I do. It is a nightmare as a physician dealing with this every day. Patients get angry at us when they find out what's in their policy after the fact. Insurance companies create a war of attrition with providers and patients as a business model. Plain and simple. :shock:
"Ignorance more frequently begets confidence than does knowledge" | “At 50, everyone has the face he deserves”
User avatar
dm200
Posts: 23214
Joined: Mon Feb 26, 2007 1:21 pm
Location: Washington DC area

Re: Out of network care

Post by dm200 »

Patients get angry at us when they find out what's in their policy after the fact.
This anger should be directed either at themselves (for not understanding or following the policy) or at the insurance company if it misled them.

You need to know the rules to successfully play the game.
User avatar
goodenyou
Posts: 3602
Joined: Sun Jan 31, 2010 10:57 pm
Location: Skating to Where the Puck is Going to Be..or on the golf course

Re: Out of network care

Post by goodenyou »

dm200 wrote: Sat Nov 04, 2017 2:09 pm
Patients get angry at us when they find out what's in their policy after the fact.
This anger should be directed either at themselves (for not understanding or following the policy) or at the insurance company if it misled them.

You need to know the rules to successfully play the game.
Try telling that to a patient. They just get angrier. Most people in employer-sponsored plans have no clue what's in their policy. I have know this to be a fact for over 25 years. Insurance is great to have, until you need it.
"Ignorance more frequently begets confidence than does knowledge" | “At 50, everyone has the face he deserves”
User avatar
dm200
Posts: 23214
Joined: Mon Feb 26, 2007 1:21 pm
Location: Washington DC area

Re: Out of network care

Post by dm200 »

Try telling that to a patient. They just get angrier. Most people in employer-sponsored plans have no clue what's in their policy. I have know this to be a fact for over 25 years. Insurance is great to have, until you need it.
True stories:

1. While I had no problems with insurance - many coworkers of mine at a medium sized employer had continuing problems with the company insurance and claims, etc. One of my coworkers had many health problems and the resultant hassles over insurance. She related a conversation she had with the HR person about why the company management did not do something about this horrible insurance. The HR person replied, "Well, for upper management, there is a fast track for their and their family claims".

2. There were ongoing problems with company health insurance at a very small, individual owned company I worked for. Then, the company owner was injured playing baseball - and after he encountered many hassles and delays - he took employees complaints seriously and worked to fix the problem.

Over the decades, I can honestly say that, while I have encountered challenges and difficulties from time to time, more often than not we received the benefits in the policy without a lot of "grief". On one occasion, for my eyelid surgery, it took a year for the Ophthalmologist to finally get paid. As best I could determine, though, this was clearly his fault because he took a shortcut or two in properly documenting my actual "medical need" and the nearly identical cosmetic surgery.
theplayer11
Posts: 2282
Joined: Tue Jul 22, 2014 8:55 pm

Re: Out of network care

Post by theplayer11 »

dm200 wrote: Sat Nov 04, 2017 1:10 pm
theplayer11 wrote: Sat Nov 04, 2017 12:06 pm Not just HMOs..just received new letter with rates and changes for BC/BS of RI. For 2018, no out of network coverage, was 40% coinsurance with $20k individual out of pocket max.
Is it possible this is an HMO? I strongly suspect that are multiple BC/BS plans in RI with many different benefits (many, for example, with much lower maximums and coinsurance).
No it's a PPO, the highest deductible plan they offer with HSA..switching to different provider next year to save about $4k, this will be an HMO also with HSA. A step down, but healthy family, have to save where we can.
User avatar
dm200
Posts: 23214
Joined: Mon Feb 26, 2007 1:21 pm
Location: Washington DC area

Re: Out of network care

Post by dm200 »

At least with a true HMO like Kaiser, you can go to a doctor or facility and not have to worry about whether or not the visit is actually in-network.
Yes - that is not a worry (at all) with this type of HMO.
User avatar
dm200
Posts: 23214
Joined: Mon Feb 26, 2007 1:21 pm
Location: Washington DC area

Re: Out of network care

Post by dm200 »

No it's a PPO, the highest deductible plan they offer with HSA..switching to different provider next year to save about $4k, this will be an HMO also with HSA. A step down, but healthy family, have to save where we can.
In our times with the outside plans (HMO and PPO), we found little difference in our experiences between the HMO and PPO. Our primary physician group (3 or 4 Internal medicine physicians) at that period was in both the HMO and PPO.
toofache32
Posts: 2349
Joined: Sun Mar 04, 2012 5:30 pm

Re: Out of network care

Post by toofache32 »

2015 wrote: Sat Nov 04, 2017 8:55 am
toofache32 wrote: Fri Nov 03, 2017 9:13 am
dm200 wrote: Fri Nov 03, 2017 8:11 am
toofache32 wrote: Thu Nov 02, 2017 9:20 pm
orlandoman wrote: Thu Nov 02, 2017 10:52 am
- you have a heart attack & go to the emergency room of a hospital on a Monday morning
- they treat you in the emergency room, stablize your condition on Monday afternoon
- they tell you they want you to stay in the hospital for a couple of days for observation
- your HMO will pay for emergency room services
At best, they will pay as little as possible. They will NOT pay the entire bill if out-of-network. Remember, insurance companies are not in the business of paying claims. They are in the business of NOT paying claims. Every claim paid is counted as a loss on their books.

Be very careful with HMOs. They profit by offering as little care as possible. Many models pay a fixed rate to providers/hospitals for all care. Therefore the hospital is incentivized to provide care for less than that amount. The less (or cheaper) care they provide, the more profit remains for the provider/hospital.
There have been newsworthy problems in the past where they contractually forbid their doctors to let patients know that there are other treatments available (often better treatments but more expensive) that are not covered by the HMO. These gag clauses are hopefully less common than in the past.
I believe this is an unfair and inaccurate generalization. They will pay what the plan calls for in and out of network. Many folks here have posted positive experiences with HMOs (along with those who have negatives).
You are correct, but almost nobody understands the plan they signed up for. You are probably the rare exception.
http://www.pbs.org/wgbh/pages/frontline ... ation.html

http://www.investopedia.com/terms/c/cap ... ntract.asp
I agree with the above that your former characterization of HMO's is unfair. Having only used HMO's, I have had nothing but positive experiences.
It might be unfair for your HMO, but I think my experience with multiple HMOs is just as valid as yours.
2015
Posts: 2906
Joined: Mon Feb 10, 2014 1:32 pm

Re: Out of network care

Post by 2015 »

toofache32 wrote: Sat Nov 04, 2017 7:48 pm
2015 wrote: Sat Nov 04, 2017 8:55 am
toofache32 wrote: Fri Nov 03, 2017 9:13 am
dm200 wrote: Fri Nov 03, 2017 8:11 am
toofache32 wrote: Thu Nov 02, 2017 9:20 pm

At best, they will pay as little as possible. They will NOT pay the entire bill if out-of-network. Remember, insurance companies are not in the business of paying claims. They are in the business of NOT paying claims. Every claim paid is counted as a loss on their books.

Be very careful with HMOs. They profit by offering as little care as possible. Many models pay a fixed rate to providers/hospitals for all care. Therefore the hospital is incentivized to provide care for less than that amount. The less (or cheaper) care they provide, the more profit remains for the provider/hospital
.
There have been newsworthy problems in the past where they contractually forbid their doctors to let patients know that there are other treatments available (often better treatments but more expensive) that are not covered by the HMO. These gag clauses are hopefully less common than in the past.
I believe this is an unfair and inaccurate generalization. They will pay what the plan calls for in and out of network. Many folks here have posted positive experiences with HMOs (along with those who have negatives).
You are correct, but almost nobody understands the plan they signed up for. You are probably the rare exception.
http://www.pbs.org/wgbh/pages/frontline ... ation.html

http://www.investopedia.com/terms/c/cap ... ntract.asp
I agree with the above that your former characterization of HMO's is unfair. Having only used HMO's, I have had nothing but positive experiences.
It might be unfair for your HMO, but I think my experience with multiple HMOs is just as valid as yours.
My experience is with multiple HMO's spans almost two decades. Your post was a generalization. The negative extrapolation to all HMO's implied in your post is invalid.
toofache32
Posts: 2349
Joined: Sun Mar 04, 2012 5:30 pm

Re: Out of network care

Post by toofache32 »

goodenyou wrote: Sat Nov 04, 2017 2:06 pm Pajamas wrote:
Over the past couple of years, I have had to take a web of complaints to the state department of health because of lack of follow-through on internal complaints I made to my current plan. This was just to get them to charge the correct co-pays as outlined in the subscriber contract and to pay claims correctly and completely instead of incorrectly denying them or paying the wrong amount, which left me responsible for extra co-pays or incorrect co-pays. They won't even provide complete information about claims, so I have to find out from the providers' billing services why they were denied. Turns out their claims-processing software was not set up properly along with problems and errors in their provider database.

So the nightmare scenarios are not always because someone didn't bother to try to understand their coverage or clarify payment in advance.
That is just one patient, you. Can you imagine what a practice of 9 surgical specialists has to do with hundreds of patients a day? I do. It is a nightmare as a physician dealing with this every day. Patients get angry at us when they find out what's in their policy after the fact. Insurance companies create a war of attrition with providers and patients as a business model. Plain and simple. :shock:
This is exactly right and one of the chief reasons I left the insurance world as a surgical specialist. Patients really do think we are partners with the insurance company. They have no idea we are actually at odds with the insurance company, and that insurance companies hate us because we cost them money. Since dropping all insurance, I have never been happier and never been busier. In a given period of time, I used to do 100 procedures and get paid for 70. Now I do 60 and get paid for 60. I don't make that much more income, but a little. Instead of working harder, I work smarter. Costs are significantly decreased because insurance was too expensive. Very boglehead. Patients can fight their own fight with their beloved insurance company.
SlowMovingInvestor
Posts: 3487
Joined: Sun Sep 11, 2016 11:27 am

Re: Out of network care

Post by SlowMovingInvestor »

One specific Dental HMO that I used at one time had a specific phone number for HMO plan members. Once I got through to the regular number, and the rep actually seemed annoyed and bounced me to the HMO number, which had a much longer wait time. Note this is Dental, not medical. I have no experience with medical HMOs.
toofache32
Posts: 2349
Joined: Sun Mar 04, 2012 5:30 pm

Re: Out of network care

Post by toofache32 »

2015 wrote: Sat Nov 04, 2017 8:09 pm
toofache32 wrote: Sat Nov 04, 2017 7:48 pm
2015 wrote: Sat Nov 04, 2017 8:55 am
toofache32 wrote: Fri Nov 03, 2017 9:13 am
dm200 wrote: Fri Nov 03, 2017 8:11 am

I believe this is an unfair and inaccurate generalization. They will pay what the plan calls for in and out of network. Many folks here have posted positive experiences with HMOs (along with those who have negatives).
You are correct, but almost nobody understands the plan they signed up for. You are probably the rare exception.
http://www.pbs.org/wgbh/pages/frontline ... ation.html

http://www.investopedia.com/terms/c/cap ... ntract.asp
I agree with the above that your former characterization of HMO's is unfair. Having only used HMO's, I have had nothing but positive experiences.
It might be unfair for your HMO, but I think my experience with multiple HMOs is just as valid as yours.
My experience is with multiple HMO's spans almost two decades. Your post was a generalization. The negative extrapolation to all HMO's implied in your post is invalid.
Huh? You posted opinion, I posted fact. My original post was a factual description of the HMO business model supported by the links I provided. This is their HMO business model.
Last edited by toofache32 on Sun Nov 05, 2017 5:11 am, edited 1 time in total.
naha66
Posts: 198
Joined: Sun Jul 14, 2013 6:02 pm

Re: Out of network care

Post by naha66 »

Toofache32
Do you have any medicare or medicaid patients?
toofache32
Posts: 2349
Joined: Sun Mar 04, 2012 5:30 pm

Re: Out of network care

Post by toofache32 »

naha66 wrote: Sun Nov 05, 2017 4:12 am Toofache32
Do you have any medicare or medicaid patients?
Many Medicare, virtually no Medicaid.
User avatar
yatesd
Posts: 1040
Joined: Sun Nov 03, 2013 7:19 am
Location: MD

Re: Out of network care

Post by yatesd »

toofache32 wrote: Sat Nov 04, 2017 8:26 pm
2015 wrote: Sat Nov 04, 2017 8:09 pm
toofache32 wrote: Sat Nov 04, 2017 7:48 pm
2015 wrote: Sat Nov 04, 2017 8:55 am
toofache32 wrote: Fri Nov 03, 2017 9:13 am

You are correct, but almost nobody understands the plan they signed up for. You are probably the rare exception.
http://www.pbs.org/wgbh/pages/frontline ... ation.html

http://www.investopedia.com/terms/c/cap ... ntract.asp
I agree with the above that your former characterization of HMO's is unfair. Having only used HMO's, I have had nothing but positive experiences.
It might be unfair for your HMO, but I think my experience with multiple HMOs is just as valid as yours.
My experience is with multiple HMO's spans almost two decades. Your post was a generalization. The negative extrapolation to all HMO's implied in your post is invalid.
Huh? You posted opinion, I posted fact. My original post was a factual description of the HMO business model supported by the links I provided. This is their HMO business model.
Unfortunately that is not true. Your statement implies that only insurance companies have conflicts of interests. Hospitals and doctors also want to make as much money as possible. Three potential areas of conflict. Although I am only offered a PPO at work, I appreciate the potential efficiency of an HMO and the minimized risk for the customer.

Examples:

- I had a surgeon ask me to schedule 2 separate appointments (making me take extra time off work) to remove skin cancer so he could make more money. At least he was honest...but the surgeon was looking out for him, not me.
- All the inter-party paperwork causes confusion and reduces transparency
- The plastic surgeon example in the thread
- Much hoopla is made about evil drug & medical device companies and their pandering to doctors (trips, meals, etc.). Which I think should be tightly constrained (government guidelines for bribery)...but they wouldn't waste their money if the influence didn't work. We should simultaneously blame the person who sells drugs and those who use them.
User avatar
dm200
Posts: 23214
Joined: Mon Feb 26, 2007 1:21 pm
Location: Washington DC area

Re: Out of network care

Post by dm200 »

Unfortunately that is not true. Your statement implies that only insurance companies have conflicts of interests. Hospitals and doctors also want to make as much money as possible. Three potential areas of conflict. Although I am only offered a PPO at work, I appreciate the potential efficiency of an HMO and the minimized risk for the customer.
Examples:
- I had a surgeon ask me to schedule 2 separate appointments (making me take extra time off work) to remove skin cancer so he could make more money. At least he was honest...but the surgeon was looking out for him, not me.
- All the inter-party paperwork causes confusion and reduces transparency
- The plastic surgeon example in the thread
- Much hoopla is made about evil drug & medical device companies and their pandering to doctors (trips, meals, etc.). Which I think should be tightly constrained (government guidelines for bribery)...but they wouldn't waste their money if the influence didn't work. We should simultaneously blame the person who sells drugs and those who use them.
Physicians and medical providers in so many situations are not (and/or cannot) be compensated for what is best for the patient and most financially and medically "efficient". I am not sure how they do it (to make financial sense), but my current plan allows and encourages email and telephone appointments (no charge to me at all). When I do either of these, for appropriate situations/conditions, I get the appropriate (medical) treatment/diagnosis/ignore/etc. at a very low cost to the provider (compared with an in person office visit) and much more convenient to me.
cherijoh
Posts: 6591
Joined: Tue Feb 20, 2007 3:49 pm
Location: Charlotte NC

Re: Out of network care

Post by cherijoh »

dk240t wrote: Fri Nov 03, 2017 9:30 am Please ignore the people generalizing that don't know what they are talking about.

I love love love Kaiser.

The Kaiser HMO will pay for what needs to be paid for.

You go to see Kaiser docs, they order lab tests, all of it happens at the same office and you never get any crazy balance billing or wacky super expensive bills from the lab.

You have an emergency - you go to the nearest emergency room and get treatment. Even if the hospital admits you and its a non-Kaiser affiliated hospital - its all taken care of (with the copay listed in the plan document). I have direct, personal experience with this yes.

And if Kaiser does not have the people to do the job they need, they will refer you to someone else. I have experience with this as well. Not as smooth as when everything is in house, but they pay the bills as they say they will and you pay the specialist co-pay.

We have had tests run, doctor consults, and even outpatient surgery and procedures by non-Kaiser docs that we were referred to.

I'm about to have my 2nd baby on Kaiser, have been in the same ER twice this year for myself and my son, surgery for my son, pediatric orthopaedist consult for my son, etc. It has been exactly as advertised. And all the EOBs, patient visit paperwork, test results, are all readily available online. We've even avoided a few doctors visits by emailing our docs.
This still doesn't address the issue of an illness that occurs when you are away from home and outside of an area with Kaiser facilities and it isn't an emergency.

On several occasions when I was traveling, I needed to see a doctor but it didn't merit a visit to an emergency room. On one occasion I was visiting family and they got me an appointment at their primary care doctor's practice and on another I was traveling with a tour group and the local tour guide arranged for me to visit a local doctor. On both occasions my PPO tried to charge it as OON, but I was able to get them to cover it as in-network since there were no in-network providers within an 8-hour drive of where I was located. Had they continued to dispute the charge, they still would have paid albeit at a lesser rate - a higher co-pay for the doctor's visit and a lower cost-share on other services. But I never would have gotten stuck for the entire bill.

However, It doesn't sound like this is an option with Kaiser HMO. And I would imagine they would crack down on anyone using the emergency room when it wasn't merited.
User avatar
dm200
Posts: 23214
Joined: Mon Feb 26, 2007 1:21 pm
Location: Washington DC area

Re: Out of network care

Post by dm200 »

This still doesn't address the issue of an illness that occurs when you are away from home and outside of an area with Kaiser facilities and it isn't an emergency.

On several occasions when I was traveling, I needed to see a doctor but it didn't merit a visit to an emergency room. On one occasion I was visiting family and they got me an appointment at their primary care doctor's practice and on another I was traveling with a tour group and the local tour guide arranged for me to visit a local doctor. On both occasions my PPO tried to charge it as OON, but I was able to get them to cover it as in-network since there were no in-network providers within an 8-hour drive of where I was located. Had they continued to dispute the charge, they still would have paid albeit at a lesser rate - a higher co-pay for the doctor's visit and a lower cost-share on other services. But I never would have gotten stuck for the entire bill.

However, It doesn't sound like this is an option with Kaiser HMO. And I would imagine they would crack down on anyone using the emergency room when it wasn't merited.
Fortunately, while with Kaiser, we have not encountered such a situation - so I cannot relate an actual experience. Since such situations seem to be more "urgent" than "emergency", I would call the Kaiser advice line (24 hours a day, seven days a week) and ask for guidance. My guess would be that they would either: 1. authorize being seen (and authorize payment) by a local provider (maybe the ER); 2. provide sound and credible advice (to the patient's satisfaction) that the condition could wait until returning home. My experience with the Kaiser advice line in recent years is that they advice nurses tend to lean more strongly to the patient being seen. The other option that Kaiser has (depending on details) is a virtual housecall with a Kaiser physician and a smartphone (video both directions).

If you were traveling in an area of the country where there is a Kaiser presence, a call to the Kaiser advice nurse line might merit a referral to a local Kaiser facility.
2015
Posts: 2906
Joined: Mon Feb 10, 2014 1:32 pm

Re: Out of network care

Post by 2015 »

toofache32 wrote: Sat Nov 04, 2017 8:26 pm
2015 wrote: Sat Nov 04, 2017 8:09 pm
toofache32 wrote: Sat Nov 04, 2017 7:48 pm
2015 wrote: Sat Nov 04, 2017 8:55 am
toofache32 wrote: Fri Nov 03, 2017 9:13 am

You are correct, but almost nobody understands the plan they signed up for. You are probably the rare exception.
http://www.pbs.org/wgbh/pages/frontline ... ation.html

http://www.investopedia.com/terms/c/cap ... ntract.asp
I agree with the above that your former characterization of HMO's is unfair. Having only used HMO's, I have had nothing but positive experiences.
It might be unfair for your HMO, but I think my experience with multiple HMOs is just as valid as yours.
My experience is with multiple HMO's spans almost two decades. Your post was a generalization. The negative extrapolation to all HMO's implied in your post is invalid.
Huh? You posted opinion, I posted fact. My original post was a factual description of the HMO business model supported by the links I provided. This is their HMO business model.
I am keenly aware of the HMO business model (which was in fact why I chose it in the first place), but you missed the point. Upthread you stated: "At best, they will pay as little as possible...They are in the business of NOT paying claims. Every claim paid is counted as a loss on their books...Be very careful with HMOs. They profit by offering as little care as possible." You also posted a couple of links to substantiate. In doing so, you generalized that all individuals who choose HMO's will have a negative experience and extrapolated the links content to veil this generalization as fact. The generalization is untrue and the extrapolation is simply invalid. What I stated was not at all an opinion, but the reality of what I've experienced. Again, to summarize that reality (or fact, if you will), for almost two decades, I have had outstanding care using only HMO networks, and have had absolutely no issues with multiple HMO's paying claims on everything from surgeries, to tests, to x-rays, to all kinds of preventative care. I have even had my latest HMO pick up the tab voluntarily after I had a dispute with the provider.

Where one must be very careful is how one takes in information when making choices.
Post Reply