Health Insurance benefit that cannot be accessed easily?

I commute 1.5I hours to work (I work 12 hour shifts to cut down on communting time). All the health care plans offered by my job (that 50%/$1600. is deducted from my paycheck annually for) have particiapting healthcare facilities local to my job and if I seek care near my home, it is called out of service and I must pay a higher percentage of a non-negociated rate. Also my local hosptial does balance billing so in actuality the money recieved from my insurance plan is just a bonus to my hospital in addition to what I must pay out of pocket. I.E my son's appendix was rupturing and he had surgery- he has a four inch scar from the open surgery. My insurance stated they pay 70% of their negociated rate of $3000.00 that included a 24 hour stay. My insurance company paid $2100.00. My hospital stated they charge $6800.00 for this service, they deducted the $2100.00 and demanded I pay $4700.00. I did pay it, but I am confused as to way I pay for health insurance that I cannot use to the fullest potential, and how can my insurance company determine a negociated rate that does not apply to the balance I must pay? (In other words, they don't really pay 70%, and my hospital won't state a rate for a simple appy so no matter what my insurance pays, it seems that they will charge me what ever they can get out of me.) Am I looking at this wrong, missing something here, or is my insurance company and local hospital both cheating me?

I think some of the other people who have answered your question were confused, because you called the $3,000 a "negotiated rate." Based on the fact that you specifically stated that your local hospital is not participating with your insurer, I'm guessing that you meant that the $3,000 was your insurer's "usual and customary rate."

(And yes, it is correct that a non-participating hospital can balance bill you. And, unfortunately, the insurer is allowed to pay what they determine to be the "usual and customary" rate to the hospital. Which, as you've learned, leaves you in a bad position.)

There may be a solution in this for you...here's what I would ask about if I were in your situation:

Does your insurance company use a "travel" or "out of area" network? The vast majority of group insurance policies have access to a network for when a member is out of the normal service area. Whether that member is on vacation out of the area, or whether they live out of the area, as in your case.

Normally, there would be a logo for this travel network somewhere on your insurance card. Examples of some common, national networks are First Health, Beech Street, Multiplan, and PHCS. Those networks contract with providers all across the country. (The hospital system I work for has contracts with all of the ones I mentioned.) Your insurance company still pays your claims, and any provider who is contracted with your travel network (if you have one) should be considered "in-network" for you.

Its possible that your plan doesn't have a "travel network," but I would be extremely surprised if it didn't. That's a very common thing. The hospital system I work for has several hospitals that are near the border between 2 states, and our hospitals frequently get patients from across the state line, because they access us as "in-network" through their travel network.

(Also, I used to work for a large health insurer in Ohio, and all of our members had coverage in other states by using one of the "travel networks" that I mentioned above. Even though the insurance company I worked for didn't have direct contracts with any providers outside Ohio.)

If I were in your position, that would be the first thing I'd ask about! And if you do have access to a travel network, find out which one it is and whether any hospitals closer to your home are contracted with them.

If it turns out that you truly don't have access to an "out of area" or "travel" network, then you will have to make the determination whether you want to keep your insurance through your employer or drop it at open enrollment. That's a very personal choice for you. (Personally, I would still keep the insurance, because I'd hate to take the risk of getting a pre-existing condition and not being able to get any insurance. But that's a decision only you can make.)

If your son't condition was a true emergency (and a ruptured appendix would be one), does your plan then allow you to use an out of network hospital and get paid at an in-network rate? That might be something you could check in to.

~~What the hospital did is illegal. They aren't allowed to balance bill the patient if they have a negotiated rate. You need to contact your insurance company an get their assistance in helping you to have the hospital refund you the difference you paid. If you don't get help, contact your state's insurance commissioner. Insurance companies have the right to have their contracted doctors located wherever they choose. Your insurance is the first one I have heard of to set the radius from your job, it's usually within the subscriber's address. Have you contacted the insurance company yourself to be sure you can't get one in your home area yourself. I would to be sure you were given correct information. Hope they refund your money promptly. They certainly took advantage of you!~~

The hospital is correct. If you are out of network they can balance bill. The insurance company does not have a negotiated rate with out of network hospitals but apparently your policy states it will only pay 70% the negotiated rate whether you are in or out of network and you are responsible for the balance. This is not unusual so the insurance company is not cheating you.

You should look into getting an individual plan that has networks in your hometown, at least for your family, since you said all the plans offered at work are local to your job. Talk to the HR department or someone at work to find out when the open enrollment period is, which is the only time you can drop the work plan. Talk with a local agent that works with all the major companies in your hometown to find the best plan for your situation and be sure to get approved for a plan prior to canceling your work plan. Depending on your job some employers will offer to pay part of the premium for someone in your position so also be sure to talk with your boss.

Something seems rotten here.

It seems to me that the hospital is incorrectly charging you the balance. If they have negotiated a rate of $3000 with your insurer then that is all they are permitted to charge, period. That means you'd only owe $900. If, however, the $3000 is not a negotiated rate and just the maximum your insurance will pay (some insurers have scheduled maximums they will pay for specific procedures), then it's simply that you have a not-so-great policy and would be liable for the difference, though most hospitals will allow you to negotiate a lower rate.

My advice would be to sit with your Human Resources Director and have them go over and explain the policy, what it covers, etc. I'd also call the insurance company and check to see if that $3000 is a negotiated rate or simply the most they will pay. If it is a negotiated rate then your insurer should help you deal with the hospital to get back what you overpaid.

Also, check to make sure that there are no doctors local to your home that are on the plan. That would be a pretty small network if there's no doctor near you! Also, some plans will charge in-network fees if there are no in-network doctors within x amount of miles from you, so ask your insurer if they have a similar program that no one has told you about. If there aren't find out if your doctor can apply to be considered on the plan. Nothing ventured, nothing gained!

If you still don't have answers then call your state's department of insurance. They can help you get answers from your insurer if your insurer isn't helpful.

Best of luck!

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