Chicago, IL – You may think you have great insurance. But what if you are treated in an emergency situation by a doctor or hospital not approved by your insurer. Mark Saxenmeyer has a case in point.
Dave Shafer’s been an avid athlete his entire life. His main passion, his bike.
weekend, he used to be on his wheels until a collision with another
cyclist got him wheeled to the e-r. Shafer now says "There are no bones
from my eye over to my cheek, that’s been pieced together with metal."
businessman’s head-on accident also led to some huge insurance
headaches. He adds: "The paperwork that I’m getting from medical
providers, health insurance providers, is quite frankly, mind boggling."
after he was pieced back together by a plastic surgeon and long after
his insurance company had settled up, Shafer started receiving new
bills. The staggering total: nearly $12-thousand dollars.
brought into the hospital in an e-r situation, barely conscious, life
threatening injuries, the last thing you as the patient are thinking
about is," Shafer says, "Is this a participating provider?"
years, Shafer had paid high monthly premiums for what he thought was a
first-rate health insurance plan only to find out that there’s a gaping
hole in the system.
Judy Dugan is the Director of Research for Consumer Watchdog.
says: "It’s a real dirty secret of our medical system that you can make
sure you’ve gone to a network hospital, that the main doctor who’s
treating you is in network, but then even if you’re unconscious and
can’t make a decision, you can get an out of network surgeon."
Out of network" and non-participating member. Those are the key terms in this doctor drama, according to Dugan.
adds: "It’s a very easy business decision and it has nothing to do with
health care or a rational health care system. Some specialists can make
more money by staying out of network and billing directly to patients."
called "balance billing," doctors who happen to be out of the patient’s
insurance network sending bills directly to the patients to pick up the
portion their insurance won’t pay.
Earlier this year, the California Supreme Court ruled that practice unconstitutional for emergency cases.
late for Dave Shafer. But Dr. Howard Krauss, a health care reform
advocate, says it’s still a mess, adding: "The Supreme Court decision
took the patients off the hook, but it’s given a free ride to the
insurance companies and the hmos."
With health care reform
topping President Obama’s to-do list, we asked him to weigh in on the
balance billing controversy. A spokesman for the White House tells us:
"We all know about the millions of people who suffer without health
care insurance, but this shows just how broken the system is."
Walsh is a lawyer for C-Bol Corporation, an aerospace exporter paying
top dollar for employee health care. When she discovered multiple
employees were on the brink of bankruptcy because of "out of network"
medical costs, she went to bat for them.
"We have insured people
who are rendered uninsured by a loophole in the system and it needs to
be fixed," she says. "We had an employee who had an er situation. The
surgeon and the anesthesiologist were out of network and the employee
was left with close to a $40,000 bill."
Walsh spent months
fighting for her colleagues and managed to get the bills lowered but
not erased. Walsh admits: "I don’t have a solution, i just know this is
Dugan adds: "It’s a nasty fight for the patient, and it shouldn’t happen at all but don’t give up without a fight."
Shafer’s still fighting his bills, but more than anything, he just
wants people to be aware, saying: "There is this gap, this imperfection
in the hospital system, you gotta, one way or the other, you gotta look
out for yourself."
You can check your health plan’s website or
annual handout book to see every doctor that’s in network and what
percentage of costs are covered.
It’s also important prior to an emergency to designate someone close to you be an advocate in an emergency situation.