Dr. Marc answers readers’ question every other week. To send a query, click here.
Dear Dr. Marc,
I recently had my first need for emergency medical care. I referred to the insurance plan book given to me by my employer, and picked an “in-network” hospital. In the emergency room, I signed the “conditions of services” required for treatment. One clause stated that certain services in the emergency were provided by “independent contractors.” That proved to be true for most everything I was treated with. Ultimately, from that emergency room visit, I was billed separately for the lab, the X-ray, the physician and the CAT-scan. Despite my diligence, virtually everything except the hospital stay itself proved to be “out-of-network” and at a cost considerably higher than the promised coverage.
Who is to blame: my insurer for failing to make certain that “in-network” hospitals use “in-network” subcontractors or the hospital for circumventing the promised maximum fee for services by subcontracting and then benefiting by receiving a share of the profits as a fee from the sub-contractor?
This, in essence, negated much of the security I had thought I had with health insurance. I believe there should be legislation to protect health consumers, especially if this travesty is done with a wink-and-a-nod when contracts are negotiated between hospital and insurance companies.
JOAN H. LEONARD
Sherman Oaks, CA
Your questions are very important but hard to answer. You’d be surprised how much that emergency room visit actually does cost at today’s technological prices. ER visits are very poorly covered by many HMOs, without great documentation and even, as you experienced, with all the right paperwork in order. But HMO’s are not the patient’s advocate, they are businesses, they don’t want to have to pay for what costs the most, or even, here I cringe, what is potentially the most lifesaving. The best practical option for the middle class is to get the most comprehensive coverage possible without spending a fortune for it (easy to say, I know). I’ve said for sometime now that it should be the role of the government to work at getting these costs reduced–though much of our government is otherwise motivated. Not a completely satisfying answer, I know. But it’s critical to make every effort to demand that our elected officials take the nation’s healthcare crisis more seriously.