Healthnet of CA - Advice Needed

[somarco]

I appreciate your comments, pipedream.

I was discussing your situation (in generalities) with another carrier today. We both agree that carriers don't always do a good job of customer service. Sadly, the economics of client service don't allow CSR's to spend much time on the phone with clients. All calls are recorded and timed. The idea is to get the problem solved in (something like) 3 minutes or less.

Granted, some calls don't take that long while others could take much longer. If the CSR doesn't meet their quota for X number of calls per shift they are written up. If it continues, they lose their job.

As we discussed your situation, and trying to play devil's advocate, chances are the questions your brother posed were answered correctly, but not completely.

It is not unusual at all for treatment by a non-par provider to be subject to an additional deductible. Reimbursement will usually be lower as well, say 70% vs 80% for in network. And so forth.

So the $1500 figure may have been adequate as far as an additional deductible but obviously there is more to the OON penalty than just $1500.

On the other end, as indicated before, the billing clerk at the hospital probably verified coverage but never bothered to get into details about in network vs out.

I have been involved in a few claim issues myself on behalf of clients, so I know what can happen early on.

It is also my experience that the claim is usually paid according to the letter of the contract. Sometimes a situation comes along where the carrier will go beyond the bounds of the policy language and waive any OON penalties.

Hopefully HN will do that in this case which will help considerably.

The docs may or may not be willing to discount their services. Hopefully they will which will help even more.

While I am sure this is difficult to go through, this thread is a learning experience for you and others who read this. Maybe it will inspire some agents to take more care with their clients, and maybe a few consumers will come away with enough education as to avoid some of the pitfalls of going out of network.

We all wish the best for your brother and he is fortunate to have family support through all of this.

 

[Guest]

Maybe it will inspire some agents to take more care with their clients, and maybe a few consumers will come away with enough education as to avoid some of the pitfalls of going out of network.

Maybe this guy's story and the tens of thousands of stories like it will get us a one-payor, no-network, easy-to-understand health care FINANCING system.

Of course there won't be any agents needed to "sell" it, nor will there be any insurance company execs making obscene salaries.

It's got to be the worst nightmare for most of you health agents.

I've read the thread and except for one or two of you the vast majority don't have a bit of sympathy for this guy's brother. I'm not surprised. Follow the money. This is the financing system that feeds you, which is congruent with your conservative ideology of Social Darwinism and self-centered avarice and which I have no doubt you will defend (here in this venue) until the moon turns blue.

Whatever comes out of Congress I can only hope it puts the whole lot of you out of the health business because I don't think most of you give a damn about the clients or what is best for your community, state, or nation. It's all about how much commission you can make on a private insurance system based on the same greed an avarice that is the political hallmark of the majority in this venue.

I go to bed each night and wake up each morning truly thankful that most of you see me as the anti-Christ.

 

[somarco]

I am not excusing HN, but merely offering some insight into how these things work.

Keep in mind, we are discussing an intangible product governed by the laws of the state and contract language. Most states, and CA is no exception, require readable contracts.

I understand most folks would rather have a root canal than read their policy, but if you want to maximize your benefits it is incumbent on the individual (and their agent) to understand what is covered, what is not, and how benefits are determined.

Some 20 years ago pure indemnity contracts were abandoned for managed care policies. The resulting savings was tremendous (and still is) which results in lower premiums and/or greater benefits for the same dollar. Like it or not, everyone has two insurance policies. One for network providers who have agreed to accept a "reduced" fee in exchange for increased patient load (steerage) and prompt payment.

The other policy is for providers who choose not to negotiate rates and do not join any networks.

The very nature of the dual policy is such that in network (par) benefits are significantly higher and there is less OOP than for non-par benefits.

I am not making excuses or casting blame, just telling it like it is.

I think it is admirable that HN and the providers in PA are willing to make concessions and try to work things out. I would be curious to hear what Brad from HN has done as well.

Even though you took exception to my comment about hospital billing clerks, the same applies to those in the doctors office. Providers have no way of knowing what the benefit levels are unless they ask. Often on a large claim they will do so but then will only get a summary, not the full policy.

Providers also have no way of knowing if the claim will be deemed par or non-par until it is submitted and adjudicated.

Like it or not, that is the system. When you assign benefits to a provider no one really knows what their exposure is until the claim is filed and adjudicated.

Much has been said about transparency, and no doubt we could be, and should be further along in this regard. Transparency does work well for routine things such as primary care, lab and Rx. But more complex procedures are impossible to price out before hand.

Even if they were, how many people, especially those with insurance, will shop around and look for the lowest bidder when it comes to their health?

I submit no one will do that.

If you think that single payer is any better, then you really need to get acquainted with the problems other countries are having with that approach. You really don't have to venture beyond the borders of the 57 states to find out. Just look at Medicare and Medicaid.

Both programs are severely underfunded and broke. At best, half the docs will accept Medicare patients and even fewer take Medicaid. Those that do accept M/M patients will limit their patient load in order to avoid taking too big a hit in the shorts due to the low reimbursement levels from M/M.

If you think M/M pay for everything you are mistaken.

But this is not about the future of funding health care, this is about your brother. Hopefully this information helps you understand and gives you some insight into how to better negotiate not only on past bills but those in the future as well.

No one wins in litigation. Sometimes people feel that is their only recourse but there are easier, less expensive, and better ways to reach middle ground.

 

[somarco]

I am not excusing HN, but merely offering some insight into how these things work.

Keep in mind, we are discussing an intangible product governed by the laws of the state and contract language. Most states, and CA is no exception, require readable contracts.

I understand most folks would rather have a root canal than read their policy, but if you want to maximize your benefits it is incumbent on the individual (and their agent) to understand what is covered, what is not, and how benefits are determined.

Some 20 years ago pure indemnity contracts were abandoned for managed care policies. The resulting savings was tremendous (and still is) which results in lower premiums and/or greater benefits for the same dollar. Like it or not, everyone has two insurance policies. One for network providers who have agreed to accept a "reduced" fee in exchange for increased patient load (steerage) and prompt payment.

The other policy is for providers who choose not to negotiate rates and do not join any networks.

The very nature of the dual policy is such that in network (par) benefits are significantly higher and there is less OOP than for non-par benefits.

I am not making excuses or casting blame, just telling it like it is.

I think it is admirable that HN and the providers in PA are willing to make concessions and try to work things out. I would be curious to hear what Brad from HN has done as well.

Even though you took exception to my comment about hospital billing clerks, the same applies to those in the doctors office. Providers have no way of knowing what the benefit levels are unless they ask. Often on a large claim they will do so but then will only get a summary, not the full policy.

Providers also have no way of knowing if the claim will be deemed par or non-par until it is submitted and adjudicated.

Like it or not, that is the system. When you assign benefits to a provider no one really knows what their exposure is until the claim is filed and adjudicated.

Much has been said about transparency, and no doubt we could be, and should be further along in this regard. Transparency does work well for routine things such as primary care, lab and Rx. But more complex procedures are impossible to price out before hand.

Even if they were, how many people, especially those with insurance, will shop around and look for the lowest bidder when it comes to their health?

I submit no one will do that.

If you think that single payer is any better, then you really need to get acquainted with the problems other countries are having with that approach. You really don't have to venture beyond the borders of the 57 states to find out. Just look at Medicare and Medicaid.

Both programs are severely underfunded and broke. At best, half the docs will accept Medicare patients and even fewer take Medicaid. Those that do accept M/M patients will limit their patient load in order to avoid taking too big a hit in the shorts due to the low reimbursement levels from M/M.

If you think M/M pay for everything you are mistaken.

But this is not about the future of funding health care, this is about your brother. Hopefully this information helps you understand and gives you some insight into how to better negotiate not only on past bills but those in the future as well.

No one wins in litigation. Sometimes people feel that is their only recourse but there are easier, less expensive, and better ways to reach middle ground.

 

[pipedream]

I appreciate your comments, pipedream.

I was discussing your situation (in generalities) with another carrier today. We both agree that carriers don't always do a good job of customer service. Sadly, the economics of client service don't allow CSR's to spend much time on the phone with clients. All calls are recorded and timed. The idea is to get the problem solved in (something like) 3 minutes or less.

Granted, some calls don't take that long while others could take much longer. If the CSR doesn't meet their quota for X number of calls per shift they are written up. If it continues, they lose their job.

I assure you my brother spent HOURS on the phone with Health Net attempting to get answers in order to insure that he understood exactly the ramifications of going out of network - including the initial 38 minute phone call noted in his quote earlier in the thread.

I can't imagine any other industry surviving with the abysmal customer service exhibited by Health Net in this instance. IF the company's employees are unable to provide accurate, straightforward information, how can the policy holder (away from home, sans policy) be expected to act in any way other than to take the company's representatives word for what they are saying.

A person diagnosed with an aggressive form of cancer does not have all the time in the world to weigh his options....to say nothing of the shock and trauma he experiences from the diagnosis. Under the circumstances, I don't think anyone can blame my brother for relying on information provided by his insurance carrier. This type of "bait and switch" is happening too often with too many companies to be deemed inadvertent.

As we discussed your situation, and trying to play devil's advocate, chances are the questions your brother posed were answered correctly, but not completely.

It is not unusual at all for treatment by a non-par provider to be subject to an additional deductible. Reimbursement will usually be lower as well, say 70% vs 80% for in network. And so forth.

So the $1500 figure may have been adequate as far as an additional deductible but obviously there is more to the OON penalty than just $1500.

It is not obvious to me, nor was it obvious to the Health Net customer service representative, nor to my brother that there was more to the OON penalty than an addtional $1,500 deductible.

Note that UPMC has agreed to accept Health Net's ordinary and customary reimbursement for the services and procedures they provided AS IF they were in-network. No one is questioning the appropriateness of the services rendered. SO there is no more being asked of Health Net than IF the same services had been provided in network. The patient was covered, the condition is a covered condition, the services and procedures have been deemed medically necessary and appropriate, the provider has agreed to accept payment at the level acceptable to and as determined by Health Net.....what more could Health Net want? Health Net was happy to accept 10 years of increasing premium payments; now is doing its best to avoid providing the benefits for which they were paid handsomely over the years.

On the other end, as indicated before, the billing clerk at the hospital probably verified coverage but never bothered to get into details about in network vs out.

Well, this would involve more than one "billing clerk" - billing personnel at the surgeon's office, the hospital, the local cancer center, the pharmacy....hmmmm, all were fooled into believing the services they provided my brother were covered by Health Net. All of them collected the required co-pay....according to directions from Health Net. The myriad phone calls back and forth between their offices and Health Net to clarify coverage and benefits apparently meant nothing.


I have to agree with al3 that it is circumstances like this that will eventually usher the USA into a single-payer system. I am against socialized medicine but I am also against people who have faithfully insured themselves through a decade of health with one company, find themselves hit with a medical catastrophe only to have the heath insurance company do everything possible to deny coverage.

It is also my experience that the claim is usually paid according to the letter of the contract. Sometimes a situation comes along where the carrier will go beyond the bounds of the policy language and waive any OON penalties.

Hopefully HN will do that in this case which will help considerably.

The docs may or may not be willing to discount their services. Hopefully they will which will help even more.

It is my understanding that the UPMC docs & hospitals have already agreed to accept HN's pay rates. HN does not want to pay for what they absolutely would have had to pay for had they but given my brother and his service providers accurate information when queried.

While I am sure this is difficult to go through, this thread is a learning experience for you and others who read this. Maybe it will inspire some agents to take more care with their clients, and maybe a few consumers will come away with enough education as to avoid some of the pitfalls of going out of network.

We all wish the best for your brother and he is fortunate to have family support through all of this.

Thank you. I'll keep you informed. I hope there is a positive outcome to this and litigation can be avoided.

 

[pipedream]

I am not excusing HN, but merely offering some insight into how these things work.

And for that I thank you. I appreciate the time you have taken to explain things.

I understand most folks would rather have a root canal than read their policy, but if you want to maximize your benefits it is incumbent on the individual (and their agent) to understand what is covered, what is not, and how benefits are determined.

Granted, in ideal circumstances that'd be great...read the policy and know. But please, someone tell me how this could have been handled differently from the onset considering these facts:

1) the patient is hundred of miles from home on a prolonged RV trip
2) he is diagnosed with an aggressive form of bladder cancer
3) he is single and has no one to help him through surgery and treatment in CA
4) he calls his carrier, HN, to determine if they will cover his treatment if he travels to PA in order to have the support and care of his family
5) he is told the only down-side is that his deductible will rise from $3,500/year to $5,000/year
6) he opts to come to PA, has two surgeries and months of chemo (I learned today that the chemo was covered as it was done in a local cancer center that is in the HN network....who knew?), only to find himself on the collection end of $65,000 in medical bills when HN denies coverage.

Some 20 years ago pure indemnity contracts were abandoned for managed care policies. The resulting savings was tremendous (and still is) which results in lower premiums and/or greater benefits for the same dollar. Like it or not, everyone has two insurance policies. One for network providers who have agreed to accept a "reduced" fee in exchange for increased patient load (steerage) and prompt payment.

The other policy is for providers who choose not to negotiate rates and do not join any networks.

The very nature of the dual policy is such that in network (par) benefits are significantly higher and there is less OOP than for non-par benefits.

All well and good except the argument in this instance doesn't hold water....as UPMC has agreed to accept the "reduced" fee...they are willing to be treated exactly as if they were in network and they are willing to negotiate. HN is not.

I am not making excuses or casting blame, just telling it like it is.

I think it is admirable that HN and the providers in PA are willing to make concessions and try to work things out. I would be curious to hear what Brad from HN has done as well.

Well, I heard from Brad today. It was a call I'm sure he didn't want to make cause it was all bad news. I'm afraid he was subjected to some serious venting against HN. The more I think about this, the more likely seems that HN deliberately misled my brother so that they could deny coverage. I do not believe that his situation is all that unique or rare - I think it is an industry pattern.

After looking into the situation, it turned out that there is nothing that can be done - though Brad was sympathetic to what had happened (that and 50 cents....). The final denial letter has been issued by HN - case closed. I recovered my composure enough to thank Brad for taking time to look into the situation.

Brad said that the insurance commission in CA may have another take on the situation once they have evaluated the complaint that has been filed. We shall see.

Even though you took exception to my comment about hospital billing clerks, the same applies to those in the doctors office. Providers have no way of knowing what the benefit levels are unless they ask. Often on a large claim they will do so but then will only get a summary, not the full policy.

Providers also have no way of knowing if the claim will be deemed par or non-par until it is submitted and adjudicated.

I didn't take exception to what you said. I just found it beyond belief that the health industry can operate this way. That numerous billing clerks whose job it is to make sure the patient is covered, were unable to determine actual benefits from so many "know nothing" HN CSRs". Why have billing clerks or CSRs when it is a crap shoot at best?

No one wins in litigation. Sometimes people feel that is their only recourse but there are easier, less expensive, and better ways to reach middle ground.

I would love to be enlightened as to the easier, less expensive, and better ways to reach middle ground besides litigation. At this point, unless the insurance commission causes HN to rethink their stance, I don't believe John sees any alternative to litigation.

 

[Guest]

After looking into the situation, it turned out that there is nothing that can be done

There is plenty that can be done.

- though Brad was sympathetic to what had happened

And you believe that?

The final denial letter has been issued by HN - case closed.

F--k that s--t. Open a new case... a legal case.

I recovered my composure enough to thank Brad for taking time to look into the situation.

You got played.

Brad said that the insurance commission in CA may have another take on the situation once they have evaluated the complaint that has been filed. We shall see.

The CA DOI could care less and probably won't do diddly. You want to take this to the Dept. of Managed Heath Care in Sacramento. Cindy Ennis, Ellen Bradley. I once worked there. You have a good shot at getting them to be your advocate.

I just found it beyond belief that the health industry can operate this way.

Most of the agents here are happy it works that way. They don't want to see a one-payor system because while it will negate the problem your brother is facing, it will also eliminate their 6-figure commission income. Given the choice of seeing your brother (or anyone else) lose everything vs. the agents getting paid, screw your brother!

That numerous billing clerks whose job it is to make sure the patient is covered, were unable to determine actual benefits from so many "know nothing" HN CSRs". Why have billing clerks or CSRs when it is a crap shoot at best?

There are a lot of big claims. A private insurance carrier has to have lots of people to handle the screwing of lots of people. Those people don't care about you... they care about the company that pays them. They are about the same as agents.

I would love to be enlightened as to the easier, less expensive, and better ways to reach middle ground besides litigation.

I told you earlier, take this to the media. Hire a PR person if you can to handle your campaign.

At this point, unless the insurance commission causes HN to rethink their stance, I don't believe John sees any alternative to litigation.

Do them both. Find a lawyer who will sue the s--t out of HN... or file the papers yourself (tons of books on how to do this.) At the same time take this to the media.

HN is counting on you to roll over and die. They know they will lose in the media and probably in court. If you make enough of a stink about this they will settle. Otherwise they will clink their martini glasses together and say to each other "Looks like we screwed another poor slob. Good for us!"

I would not write HN if it were free! If the rest of you had a smidgen of conscience neither would you... but you are all ruled by greed, in my opinion.

 

[somarco]

Contact the CA DOI and lodge a formal complaint. HN is already on their "list" due to some past transgressions. One more won't hurt.

With your permission, I will post your story in InsureBlog. This blog get's a lot of traffic and sometimes pressure from the blogosphere helps.

You might also look for patient advocates. They may or may not help but a few hundred dollars to have them review the details is cheaper than a lawyer.

The news media is another resource. The MSM is nutso about claim issues right now, and especially in CA. You can probably get someone to take up your cause without too much trouble.

Carriers record all phone calls involving patient matters. If need be, those records can be subpoenaed to support your case.

Contact me direct if you want to discuss in more detail.

 

[pipedream]

HN is counting on you to roll over and die. They know they will lose in the media and probably in court. If you make enough of a stink about this they will settle. Otherwise they will clink their martini glasses together and say to each other "Looks like we screwed another poor slob. Good for us!"

Well they can forget about us rolling over and dying....ain't gonna happen. We have duly noted your suggestions and have not ruled out doing "all of the above".

I would not write HN if it were free! If the rest of you had a smidgen of conscience neither would you... but you are all ruled by greed, in my opinion.

Being from Pennsylvania, I had not heard of HN until this situation. It sounds as if you are saying they are a known bad entity within the health insurance industry, would that be accurate?

 

[Guest]

Being from Pennsylvania, I had not heard of HN until this situation. It sounds as if you are saying they are a known bad entity within the health insurance industry, would that be accurate?

I don't know about the "industry" but they have had a multitude of issues with the CA regulators over the past number of years. You might check this one out. I will sound somewhat familiar to your own case.