News and Tribune


January 19, 2013

DODD: We deserve disclosure

“Never go to a doctor whose office plants have died!” — Erma Bombeck

If you have to see a medical provider and ask one simple question, it can cost you a lot of money. I mean a boatload of money.

That simple question is what I would suppose many people ask when they hand the person at the front desk: “Do you take this insurance?”

If the answer is a reassuring, “Yes, we do.” Your troubles might just beginning. The question you should have asked is, “Are you an in network provider?”

Simply by not asking the question the right way, my wife Kim and I are on the hook for $4,000 in out-of-pocket expenses from two different medical providers last year who although they accepted the insurance, failed to mention that they were not in the network.

I should have known better. I have a CPCU, which is graduate level study in the insurance field, and worked in the insurance industry for 20 years. I was a health care subrogation specialist and even wrote legal contentions for binding arbitration for a year. So if I can get hooked for over $2,500 I didn’t have had to pay, what chance does the average person who knows nothing about insurance except how to pay the monthly premium have?

And yes, I feel pretty stupid by simply asking if they took my insurance instead of if they were an in network provider. Of course, when I was referred by the emergency room doctor at the hospital who took my insurance and the provider was located in the parking lot of the hospital, I simply made a huge assumption. I would think most people my age remember the old saying about when we assume anything and how that makes a-you-know-what- out of you and me!

Kim had to visit a chiropractor when she suffered a painful back injury last year. She handed the lady her card and again simply asked, “Do you take my insurance?” and was assured they did. She now owes $1,500 her insurance wouldn’t pay for an out-of-network provider.

I had thought about writing about this earlier but it wasn’t until this past Wednesday that a co-worker of mine told me their story. They had a colonoscopy at the same place they had with the same insurance three years ago. When their explanation of benefits arrived in the mail they were shocked to learn that they owed $3,000 because this medical provider was no longer in network.

Insurance is now a very difficult thing to understand for a lay person. There are multiple plans and each has specific benefits, different in-network provider lists and varying deductibles. I have listened to agents trying to explain benefits who got confused on more than one occasion and they sell the stuff every day.

What’s more, I almost consider any provider billing representative who doesn’t inform you they are not in a major provider’s network to be partaking in a deceptive business practice. After all, before accepting your insurance, they usually are required to get a procedure preapproved. Between the professional medical billing specialist and the actual health insurance professional, why shouldn’t someone feel a moral obligation to inform the patient about the major cost they will incur by using an out-of-network provider?

I know in the past, State Rep. Steve Stemler and State Sen. Ron Grooms have admitted to reading my column. If they do this week or if not if someone would send it to them, I am curious if this might not be a situation where a requirement to disclose such information to the patient might be something to investigate. I obviously don’t know how widespread an issue this might be in Indiana.

While I have egg on my face, I certainly wouldn’t expect the elderly, the poorly educated and the even above average intelligent but noninsurance person to be able to fully understand the difference between asking if their insurance is good or if they are in the insurance company’s provider network.

As for our household, we will be out about $350 per month that we probably shouldn’t owe this year had we simply asked the proper question. I accept that I should have known better. However, I simply ask that any medical professional feel some type of responsibility for disclosure to their patients before they incur a bill in the thousands, of which insurance will pay only a small percentage. In my case a bill was for around $4,100 and the insurance company paid a little more than $1,400.

And in closing, I feel that I should make one statement about the treatment we received. It was adequate and the results were successful in both of our cases. I in no way wish to disparage the providers for their expertise and their help in alleviating the discomfort we both suffered before the help was rendered.

For me, this is simply a matter of a live and learn moment. For anyone else who reads this, I simply don’t want you to make my mistake. Some lessons in life are more expensive than others.

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