[Posted by Henry Stern, LUTCF and Bob Vineyard, CLU]
Part One exposed things carriers do not want you to know about your rights under an insurance policy. We have concentrated on the HDHP (High Deductible Plans), but this issue really extends to all health insurance policies with a network component.
Well, almost all: as Joe Paduda has pointed out (and Bob has confirmed with his own TPA), self-funded plans often include a provision which extends network pricing to non-covered expenses. This makes sense, of course, since a self-funded plan can cover pretty much anything the employer chooses.
Benefits which are excluded by contract are not necessarily going to receive favorable pricing.
"Not necessarily," because the marketing literature, and the policy itself, is mute on this point. Sadly, it seems many company reps and even those in higher positions in the carrier are unwilling, or unable to address this issue.
Or maybe they just don’t know the answer . . .
At least one carrier has said the re-priced fee is made available but the provider is not obligated to accept the lower fee as payment in full and may in fact balance bill the patient.
The disparity (at least in our minds) comes when you explain to a client:
■ Your annual GYN exams are a covered item and are re-priced. Your pre-natal & delivery charges are not a covered item and are not subject to repricing, even when it’s the same doctor.
■ You are eligible for coverage and repricing on corrective cosmetic surgery as would follow a mastectomy. You are not covered for, or eligible for repricing on breast augmentation surgery, even when it’s the same doctor.
■ You are eligible for coverage and repricing for well check up or even a sick visit . . . as long as it is not for treatment or follow up of a condition excluded by contract such as hypertension or hyperlipidemia. If the visit is prompted by a condition that is excluded by contract there is no repricing, even when it’s the same doctor.
So what is the solution?
Until the carriers are willing to step up to the plate the most logical solution is for the insured to purchase a separate PPO discount membership completely independent of the health insurance policy.
Try and follow this:
Many carriers use the PHCS network as their PPO of choice. The access fee -- which allows you as an insured to use their providers and receive lower, re-priced charges -- is INCLUDED in your health insurance premium.
You can also purchase access to the PHCS network completely independent of your insurance policy through companies such as Careington. For $25 per month you can have access to the same providers (and more) as are available under your insurance plan.
Your policy ID card bears the PHCS logo, as does your discount medical card.
Same fee schedule.
One will allow you to benefit from repricing on some claims, the other will allow the re-priced benefits on ALL claims.
MORE: Joe Paduda examines Why This Matters.