United Healthcare of Colorado on Out-of-Network Policy

I’ve been getting a few calls from people asking me about the article “When Choice of Doctor Drives Up Other Bills” in the New York Times yesterday. The article is about Irene Greco’s health insurance claim, who is insured by Oxford Health Plans in New York.

She had her operation at a hospital that was in Oxford Health Plans’ network. But Oxford, her insurer, says that because the surgeon was outside its network of doctors, the hospital bill as a whole would also be considered out of network, and therefore subject to less coverage.

Oxford says its coverage policy is straightforward and properly communicated to its customers. But some health care experts say this policy is so unusual that they have never seen it before, and the hospital industry calls it the latest in a string of unfair practices by Oxford and its parent company, UnitedHealth Group, that are designed to avoid paying what is owed.

Ms. Greco, 45, had surgery at Mercy Medical Center in Rockville Centre, N.Y., a hospital in Oxford’s network, so she expected everything except the surgeon’s fee to be completely covered. Instead, she learned months later that she was being charged a $1,000 deductible and 30 percent of all remaining costs, more than $4,700 in all.

Officials at the hospital and the Healthcare Association said they had never heard of such a practice until she complained to them. They say they have since learned of a few insurance policies with similar provisions, but that in those cases, the rules are more clearly stated.

Chris Hendriks, spokeswoman for Catholic Health Services of Long Island, Mercy’s parent company, said the hospital went through the usual steps to verify the service would be covered, and got no hint that Oxford would pay anything less than the full bill. “Our finance people say they have never encountered this before,” she said.

Ms. Greco appealed her bill to an Oxford review board and lost. She said when she asked Oxford for an explanation, it cited a single passage in her handbook dealing with out-of-network coverage: “When you receive covered services from network providers but not in accordance with the H.M.O.’s guidelines, those covered services will be covered under this certificate in accordance with its terms and provisions.”

Ms. Gordon-Shydlo pointed to that line and two others. One says that if a patient is treated by an in-network provider, but in a way that does not follow Oxford’s rules, “the covered services will be treated as if they were delivered by a nonnetwork provider.” Another line says Oxford pays on an out-of-network basis for seeing doctors without its approval, but it does not mention services like hospital stays.

Although this story stems from a policy made by Oxford, an HMO in New York, people insured through United/ Golden Rule in Colorado are concerned because of the statement in the article saying “Many hospitals and doctors in the region say that while they clash constantly with insurers, Oxford is more severe than its competitors, particularly since UnitedHealth took it over in 2004.

To get the correct answer to this question, I called the claims department at United Healthcare/ Golden Rule to ask them if this situation would happen with United Healthcare in Colorado. I spoke to Karen F. who told me that this situation would not happen with a United Healthcare claim in Colorado… “If the hospital is participating with the network on the plan, the charges received from the hospital would be processed with in-network repricing.

About Jay Norris

Jay operates a health insurance brokerage in Colorado, where he helps individuals and small groups obtain and maintain health insurance coverage.
Complimenting his work as a health insurance broker, Jay also provides data analysis and creates visualizations that are easily understood by consumers and other stakeholders in Colorado’s health insurance market.

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