Wednesday, September 13, 2006

First You Are In, Then You Are Out . . .

Irene Greco knew she would have to pay from her own pocket to use the surgeon she wanted, rather than one in her insurer’s network, but she thought she knew how much the additional cost would be. She was wrong — by almost $5,000.

She had her operation at a hospital that was in Oxford Health Plans’ network. But Oxford, her insurer, says that because the surgeon was outside its network of doctors, the hospital bill as a whole would also be considered out of network, and therefore subject to less coverage

I have to admit, this is a new one on me. Hidden providers are a frequent occurrence, but have not (yet) experienced a claim where a network facility was adjudicated as non-par simply because you used a non-par physician.

Ms. Greco said, “It’s an unreasonable policy that an in-network hospital suddenly becomes an out-of-network hospital just because you use a different doctor.”

Officials at the hospital and the Healthcare Association said they had never heard of such a practice until she complained to them. They say they have since learned of a few insurance policies with similar provisions, but that in those cases, the rules are more clearly stated.

This deserves more research.
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