My six-digit mistake with a new health insurer

November 2, 2015

My story begins last fall when I went through the process of signing up for health insurance through my practice. As I trust insurance companies about as much as I trust the government, I took what I thought were reasonable precautions.

Henry Rosevear, MDI considered titling this blog, “How a conservative physician learned the appeal of Bernie Sander’s health care plan.” But I am getting ahead of myself; more on Sen. Sanders’ plan later.  

My story begins last fall when I went through the process of signing up for health insurance through my practice. As I trust insurance companies about as much as I trust the government, I took what I thought were reasonable precautions. I called every doctor my family sees and ensured they were in-network physicians. I verified that both of the hospitals in the town that I live in were in-network. I even went so far as to see if I myself was in-network, thinking that I should probably sign up for a plan that my own business does business with.

Also read: Winning at EHRs and meaningful use is ‘Mission: Impossible’

I also made the conscious decision to have a high-deductible plan. I looked at the tax advantages of health savings accounts (HSAs) and was impressed. If you aren’t aware of these accounts, for people with high-deductible plans, you can put away pre-tax money, let it grow tax-free, and then use the money tax-free on health care-related investment costs. This page on the U.S. Treasury’s website describes these accounts.

Having done my due diligence, I signed up for an HSA-eligible plan with a company I’ll name “Banana.” A month after making that decision, I learned that my wife was pregnant-with twins. And no, they don’t run in the family, and there was no medical assistance with the conception. These are identical twins and, as such, are simply good luck.

The pregnancy went well but not perfectly, and my wife ended up spending the last 3 weeks admitted with pre-term labor. After some heroic efforts to stay pregnant, she delivered two (reasonably) healthy baby girls at 32 weeks gestation. The girls each spent just over a month in the NICU before being discharged. I’ll concede that I did think about the cost of the hospital stay, but I assumed that my exposure was limited by the in-network out-of-pocket maximum listed in my plan, given that all of the care was at an in-network facility.

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I was wrong. I was wrong for an amount that will take me a significant amount of time to pay off and which would very likely have bankrupted most families.

NEXT: What did I do wrong?

 

What did I do wrong? It turns out that the physicians that run the NICU to which my two beautiful little girls were admitted are out-of-network doctors. Yes, this is the same NICU that is physically located next to the labor and delivery unit where my wife delivered and that resides in one of the in-network hospitals in the town where I live. To compound the situation, these physicians who work at this in-network facility charge about six times the normal and customary amount and when I called their billing company to inquire about the cost, they informed me that their policy is to balance bill the patient 100% of costs not covered by insurance.

I called Banana to inquire about my options. A very polite, if entirely unhelpful, representative explained that the plan I signed up for doesn’t have any neonatologists in my city of over 500,000. She continued with a very libertarian tone to her voice that in the future, I should think about this before signing up for a health care plan.

That’s right, her solution was for me to predict every type of doctor I would need and then ensure that there was an in-network physician available at the time I chose my health insurance.

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Hence, the momentary appeal of Sen. Sanders’ wildly expensive and totally unworkable-yet elegantly simple solution-to the problem; namely, single-payer health care with Medicare for everyone. If I, as a reasonably educated physician, can be stuck with a hospital bill that exceeds the value of my house despite having “good” private insurance, I am unsure how the average person with no exposure to the health care system could possibly reasonably be expected to be able to ask the appropriate questions.

Currently, I have my practice’s biller, a health care lawyer, and the principle at the national company that sold my practice our health insurance plan working with (against?) Banana to attempt to resolve the question. I am hopeful that some compromise will eventually be reached, but this event has at the very least changed the way I think about health insurance coverage.

In the long run, I now have two healthy baby girls, and I am lucky enough that while this bill will significantly change my financial situation, I’ll survive. But I’m acutely aware that I am in the minority of people who could make that statement. I also recognize that this type of hyper-capitalism where insurance companies like Banana spend their time devising ways to maximize their profits at patients’ expense is not a sustainable solution.

Further, while I owe a debt both figuratively and literally to the skilled NICU practitioners without whose help my beautiful little girls would likely not be here, through this experience I gained an appreciation for the responsibility that all practitioners have to ensure that the rates they charge are grounded in reality.