Health Insurance Quagmire

Last October I had my annual mammogram at a location approved by my Humana Medicare Advantage plan. Imagine my surprise when while they paid for the mammogram, they declined paying the radiologist who read the mammogram. Evidently, Memorial Hermann Hospital Outpatient Radiology (where the mammogram is OK to have done) has contracted with MD Anderson Cancer Hospital's radiologists to read their mammograms. And they are not approved. It makes you kind of wonder if I have blood work done, will they pay for drawing the blood but not reading the results. Do I need to bring my own syringes?:(

I have never heard about such a thing. That is terrible.

That is terrible. Surely someone knows how to fight this ruling on part of insurance co, that they won't pay? You did not contract with the MD Anderson guy.

This happened to me 12 years ago with my hospitalization but I fought it and finally won, but had to contact State Attorney general's office to get any results.

Things have changed so much since then, I would not know what to do.

When my hubby had cancer our HMo didn't have a doc on staff that could perform the services he needed so they contracted with another provider but never sent the paperwork to them for them to sign that they would do it at a reduced price. WE were notified we were approved and for a year fought with both companies to get the bills paid. Our insurance finally realized it was their fault and paid the other hospital in full because they failed to have them sign they would do it a t a reduced price. I made tons of calls to both but in the end was lucky that our provider had a local office and took all my paperwork in person and got a supervisor to straighten it out. WE were talking 20K they wanted from us so I was motivated to spend the time to work it out.

It's a nightmare. My dentist refered me to an oral surgeon. I never thought to question if he was a participant in my network because my wife had gone to him previously. I got through the primary exam, panoramic X-rays, mouth mold etc. Went to the receptionist and was handed a $1700 estimate for services to sign. Turned out it was his brother next door, also an oral surgeon, who participates. Same last name of course. I settled for about $400 and never had the procedure done.

I have been screwed over enough times that I won't do anything without calling my insurance first.

FEAR of stuff like this is why I always choose the PPO rather than HMO plans, even though they are way too expensive. So if I'm ever hospitalized and someone out of network does something at least the out of network rates will kick in, rather than not being covered at all, and some ridiculous bill being 100% my responsibility to go backrupt over :~).

There have been a lot of articles lately about patients being screwed in this way. You go in thinking you have checked everything out but don't realize until afterwards that some of your procedures or tests are done by out of network providers. I wish I wish I wish that our healthcare system would become a top priority but it just gets worse.

The most common scenario like this I've heard about are patients having surgery and their surgeon is in network, but the anesthesiologist isn't. I wish I could offer more than just agreeing with you that it sucks.

I never thought I would be here at 45 with a good job and insurance scared to go to the DR like when I was 25 and struggling with jobs and insurance. Seems like we need at least a consumer protection regulation where they have to tell the patient/consumer everything and who is doing it so we can make sure we are covered. It seems a lot of people are paying a lot for their healthcare.

Single payer.

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Originally Posted by oldhat

Single payer.

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Amen to that!

I wish I could believe in single payer but my cynical self believes in greed in all systems so that somewhere somehow....the little guy will always get screwed. But hey, at least it will be in a different orifice.

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Originally Posted by jp1

The most common scenario like this I've heard about are patients having surgery and their surgeon is in network, but the anesthesiologist isn't. I wish I could offer more than just agreeing with you that it sucks.

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this happened to my patients over and over, it's disgusting. The only time this didn't happen to me was when I had an EPO, I could only use services the hospital system I worked for provided. Out of network pay was zero, so you tripled checked everything to make sure the services were all covered by the hospital plan and you were set. I paid so little for what I thought was top notch care. Until I got sick, then sicker and multiple tests could not be done because my hospital simply did not do them, I could not go to the best specialists in the area that were recommended. Amazingly, Cobra let me switch to the PPO in open enrollment for $20 more, if I had switched to the PPO while working it would've cost me $200 more a month. So this is a huge gift. Even though I cannot get anyone to issue me the new PPO card, I've called every single week. They say it's the same number but I don't want to take the chance handing docs the EPO card that I still have and getting bills. Insurance is such a cluster****.

what are the odds of this? I just finished typing and received a call from my insurer is mailing the new card today.

I am all for single payer