Transition of Care

[nancyfer]

I am currently undergoing chemo treatments. When these treatments began in August my health insurance coverage was with Cigna thru my husband's employer. In January the insurance coverage was changed to Aetna. We were told that our transition would be painless and that our benefits would not change. We were told that any on going plan of care for such illnesses as cancer would be covered. A transition of care form was filled out by my oncologist and approved by Aetna. Under our Cigna plan we had a $2000 deductible. After the deductible was paid we owed very little. Last year I had four surgeries and four cycles of chemo. My out of pocket expense was less than $5000. So far this year according to Aetna my out of pocket expense is over $60,000. I have the same deductible!!!!! They say they are paying my claims at 100% of the fees that are considered by Aetna to be normal for the treatment that I am recieving. How can they do this??? I have not changed doctors, hospitals, labs or anything else. The only difference is the insurance coverage. My doctor is not a PPO provider but he was approved by Aetna to continue my treatments. I have filed a complaint with the Commissioner of Insurance. What recourse do I have in this matter? There is no way that I can pay that kind of medical expense. That is what I have insurance for. Anyone out there ever heard of this happening before? Any suggestion?? Please help!!!!

[tranquility]

When an employer says benefits will not change, they don't mean they will be equal, but equivilant. Insurance contracts are different and the specifics will never be exactly the same. Without reading the contracts it is impossible to see what your costs should be.

I understand the issues you are going through and feel your pain. Believe me. But, you will not have a recourse against your employer or the insurance company. I suggest you review your policy and see what you can do to reduce costs as much as possible.

[SBillock]

What you also have to understand is that when Aetna says they are paying 100% of the fees considered by them they mean they are pay 100% of what they feel is a resonable and customary charge based on their own internal fee schedule, not what the provider is billing. In my many dealings with Aetna I have found that their internal fee schedule can be far less than what other carriers pay and/or what providers are charging. There may also be a difference in the fact that your providers are not PPO providers and do not participate with Aetna but they did particpate with Cigna. The fact that Aetna approved them makes no difference.

I would try filing appeals with Aetna and try and get them to reprocess your claims and pay a higher amount. You can site such things as switching doctors (just because your coverage changed) in the middle of cancer treatment is not a good thing to do. Ask them where you could have gone to receive the same service for the price they feel is a reasonable fee. Also, get your husband's employer involved. They are the ones paying the premiums and in many cases when they squeak, the carriers listen.

Hope some of this helps

[ecmst12]

Sounds like your doctor was contracted with Cigna but not Aetna. Aetna can't force a non-contracted doctor to write off any portion of his bill, but they don't have to pay more then the reasonable and customary amount. You might want to consider switching to an in-network oncologist. You can work with your current doctor to make the switch as smooth as possible, and I'm sure he will understand your reasoning. If you were seeing a network doctor, they wouldn't be able to bill you for more then your deductible or copays.

[momm2500]

contact a social worker at the hospital and see if there are any govt programs available to you for your insurance issues. normally if classified as a terminal illness, there are programs out there to help you.

[lkc15507]

Okay, I am basically agreeing with all of the above that you have found yourself in an untenable situation where you are likely out of network with your providers. All of the above are good suggestions. Try them. Before I get into my speel, I am sorry that it seems you have misinformation about the transition, but that ultimately will more than likely fail as a defense.

What troubles me is the extremely large amount ($60,000) out of pocket that would appear to be from UCR (usual, customary, reasonable) provisions of your plan. I suggest that you read your plan document carefully regarding those provisions. There could be a wide range to define UCR. But, I also propose that you may be able to attack the dollar amount with hard work and research. Plans must have a method of establishing UCR charges. If you can make calls, do reasearch of similar services at similar treating institutions, and CHALLENGE THE UCR DATABASE, you might find that the $60,000 could be significantly reduced. But, USE YOUR PLAN's APPEAL PROCEDURERS in order to make that claim. If this doesn't make sense, please read your plan document page for page, word for word and then ask questions about the things you may not understand.

As an example, I sucdessfully challenged the UCR charges of a specialized type of radiation therapy on behalf of a client. The therapy was called IMRT and not available within her network. However, it was billed with standard radiation therapy codes available within the CPT coding manual. Using the standard method of UCR database by code, she was out over $20,000 in UCR charges. However, we polled providers of the service, (only 3 within a 200 mile radius of her) and learned that the charges for this specialized service far exceeded the billing / coding capabilities. NEW TECHNOLOGIES do not have distinct billing codes!!! What I mean by 'successfully challenged' is that we established that providers of IMRT were few nationwide (much less within a zip code), polled them regarding their charges for the specific service rather than the non-specific, new technology, miscellaneous billing code. This is an example, but there may be many other bases for challenging an UCR database. Read your plan, be knowledgeable, prepared, and informed.

Are the services offered available within your provided network? How many providers of the service are available within your network. IE, if one provider of a specialized service within a zip code, they set the rate in the zip code (a common method of establishing UCR). However, since only one provider of the specialized service in the zip code, not a true indicator of the UCR for the SERVICE when and where available. You would need to locate and quiz all providers of the service as to their charges.

Again, your best offense and defense is to read and understand your group health plan document to understand where and why you have incurred these charges. Even if NOT UCR, there is an explanation provided to you. If you do not agree, use your plan's appeal process!!! lkc15507

FYI, in my example above, my client's $20,000 debt was reduced to $0. My last suggestion--if you have incurred these charges because you are out-of-network, get yourself in-netowrk. I am a nurse, I understand continuity of care, but I also understand that continuity of care lasts about one day. Care is easily transitioned among healthcare professionals. IE, it is a valid, but very short lived excuse to remain out of network in the eyes of a heathcare plan. And, rightly so. lkc15507