Caught By The Out Of Network Deductible

We got a bill last week for $397 from the company that provided Jay’s crutches, knee brace, and ice machine when he had knee surgery in January. The surgery was done at the Vail Valley Medical Center in Vail, Colorado, by Dr. Steadman; both the hospital and the doctor are on our Humana PPO network. Jay called the claims department prior to the surgery and got everything pre-certified. After the surgery, Jay needed weekly physical therapy, and our health insurance policy covers 20 visits/year. I’ve been carefully keeping track of his visits, making sure we don’t go over 20. We got bills from the hospital, the surgeon, the radiology department, and the anesthesiologist, and paid for the anti-inflammatory meds and pain meds that were prescribed after surgery. I kept careful track of all the bills we paid, and they came to exactly $3000, which is the amount of our deductible. All is well.

Then last week, we got the $397 bill for the medical equipment. The bill said that the amount had been applied to our deductible, so I called Humana to see what was going on, since we had already met the deductible. Turns out that the medical equipment supplier that the hospital used is not on the Humana network. So we have to meet an out-of-network deductible, which means we have to pay the $397 ourselves, even though we’ve already paid $3000 for Jay’s surgery (the in-network deductible).

Things like this are what frustrate people so much about our medical system. Even when you have health insurance, get things pre-certified, verify your health insurance coverage levels, and confirm that your doctor and hospital are in-network for your plan, you can’t account for everything. The hospital in Vail didn’t give us another option for getting the crutches, brace, and ice machine. They had Jay in the brace as soon as the surgery was complete, and on the crutches as soon as he was awake. The ice machine was hooked up to his knee by the time I was called in to the recovery room to see him. There’s no medical equipment store where you can compare options and make sure that the supplier is in network – each hospital works with a particular supplier, and that’s that. And honestly, even if we had known at the time that the medical equipment was being billed through a third party that was not on our health insurance network, we would have had to take it anyway. Without the ice machine that we still use all night, every night, Jay’s knee would not have had anywhere near the amount of cold therapy that it’s gotten so far. And obviously he had to have the crutches and knee brace just to get out to the car in the hospital parking lot. But it’s frustrating to find out 10 weeks after the fact that you owe $400 for something you thought was covered by your health insurance and had no choice but to accept.

Our system is just too complicated. There’s not enough transparency, and too many private suppliers in the mix – all on different PPO networks with different pricing arrangements. Even those of us who are in the health insurance industry and know to do our homework before seeking treatment get stuck with bills like this we didn’t expect.

About Louise Norris

Louise Norris has been writing about health insurance and healthcare reform since 2006. In addition to the Colorado Health Insurance Insider, she also writes for healthinsurance.org, medicareresources.org, Verywell, Spark by ADP, and Boost by ADP. Follow on twitter and facebook.

Comments

  1. Yes, our system is messed up and way too complicated. I just paid a $260 doctor’s bill for the same reason. The doctor was out of my PPO network, so I knew all of it wouldn’t be covered, but none of it was covered because it was applied to my $1000 out of network deductible (I met my in-network deductible months ago).

    I switched from my father’s insurance to my own, but assumed I would be fine because both were PPOs, and both from the same reputable company. But my employer’s plan has this $1000 out of network deductible, and I’m stuck. I love this doctor, she is the only endocrinologist I have ever liked/found helpful. I’ve been having a lot of complex, frustrating diabetes issues and continuity of care seems very important. I can’t see throwing a new doctor into the mix doing anything other than making my diabetes issues more difficult, stressful, and harder to control.

  2. And yet there are people viciously defending this system and promising to wreak vengeance on anyone that tries to change it for the better. It’s stories like this that make me pray that Congress gets their act together.

Speak Your Mind

*