People often ask this question. And with just cause. After all, it seems pretty straightforward to go online, click a few boxes, and purchase health insurance. Or, if your employer offers group coverage, you simply read the employee handout and make your selection.
But, without professional advice, can the average person really understand all of the provisions of an insurance plan and navigate an often-complicated claims process? Sometimes, it takes a medical “event” to reveal the details in your coverage.
Consider this real-life example:
A teenage boy was injured in a sports accident at about 5:00 pm on a Monday. The boy was seen in the emergency room (ER) at about 6:00 pm. At 7:00 pm, a CT scan showed that his jaw had been broken. The ER contacted the on-call oral surgeon who arrived at the hospital at about 8:30 pm. The surgeon reviewed the scan and determined that immediate surgery would be required to reset the jaw. Since the operating room was booked for the evening, the surgeon sent the boy home for the night (with lots of pain meds!) and scheduled surgery for the earliest possible time the following day.
The surgery took place at 2:00 pm on Tuesday. The boy spent Tuesday night in the hospital and was sent home the next day.
Here are some key facts about the family’s insurance:
- The family was covered under a high-deductible insurance plan, with a Health Savings Account (HSA) that allowed them to put aside funds for medical care
- The out-of-network deductible was 2 times the in-network deductible, with out-of-network totals accumulating separately from in-network
- The hospital was an in-network provider
- The on-call oral surgeon was an out-of-network provider (note the family did not select the oral surgeon, but was assigned the on-call doc for an immediate evaluation)
The charges for the ER visit, surgery, and stay at the hospital were applied to the family’s in-network deductible, causing the deductible to be met. So far, so good: the insurance was working as intended — the financial impact of this major incident would hit a ceiling at the deductible.
However, the surgeon’s fees were billed as out-of-network, even though the boy’s treatment had been at an in-network hospital. Yup, the in-network hospital called an out-of-network on-call provider for this boy’s emergency treatment. Because the out-of-network deductible is separate from the in-network deductible AND twice as much, the family was responsible for the entire bill — several thousand dollars. This was not something the family ever anticipated since their intent was to always choose in-network providers.
Alarmed, they called their agent who explained that emergency treatment should be billed as in-network. The agent called the insurer to explain the situation, but the insurance company was adamant that since the patient had been sent home from the ER, the surgery was not an emergency, and the surgeon’s fees were therefore out-of-network.
At the agent’s instruction, the patient’s parents wrote a letter to the insurance company documenting the incident, complete with a detailed timeline showing that the surgery occurred less than 24 hours from the accident and, indeed, constituted emergency care.
The insurance company reversed its decision, and the oral surgeon’s fees were billed in-network. Since the in-network deductible had been met, the charges were fully covered. This family was saved literally thousands of dollars, due in no small part to the agent’s assistance in understanding the coverage and communicating with the insurance company.
At Virginia Medical Plans, we are often called by our clients when something does not go as planned. We represent our clients’ interests in these stressful situations.
So, if you’re looking for a reason to use the services of an agent, look no further. In addition to guiding you in choosing the right coverage, an experienced agent can help when you need it the most! Give us a call!
