Angry Doc and in network vs out network question

[tonymoo]

What is the name of your state? NY

Looking for any advice or suggestions. Thanks in advance.
(omitting lots of details for brevity and privacy but happy to share more if needed)

My wife developed breast cancer last year. As part of the prep for treatment she was sent of gyn oncology consult. She had a very poor experience wit that consult and ended up filing written complaints against the MD with both the hospital he is affiliated with and the state.

Now, a year later, she needs gyn onc surgery.

We live in a county where one mega hospital dominates about half the county and a lot of docs including him have practices attached to it.

None of the docs is his practice will see her (which I find understandable) and none of the other docs in that specialty affiliated with the same hospital will see her (they say it is policy not to see a patient who has already seen another affiliated doc in that specialty).

We have a good BCBS policy with a pretty big network and great in network coverage, but not so great out of network. But those are the only docs in that specialty within 30 or so miles who are in network.

My wife found an out of network doctor nearby who she likes, but it will cost us about 6K in deductible and coinsurance.

My employer provides a free Health Advocate service who we have reached out to. The health advocate and BCBS are discussing the situation.

The BCBS policy says they will treat an out of network doctor as in network if there are no in network docs within a reasonable distance.

The nearest in network doc is probably 50 miles away in NYC (there might be a possibility 35 miles way but it isn't clear if the specialty matches).

Thoughts or suggestions? Is it worth appealing to the hospital admins? Hope for the best with BCBS? Are the other docs acting ethically? Justpay the 6K?

 

[cbg]

I'm not quite sure what you're looking for, but I have more than 40 years direct experience working with employer sponsored benefits so I know a lot about health insurance.

Something that a lot of people don't understand; the insurance policy is a contract. They are liable to pay for what it says they will pay for; they are not obligated to pay anything that they are not obligated to pay for.

Legally, you are entitled to be paid whatever the insurance policy says they will pay for. No more, no less.

Often, a hospital and an insurance company will work with you to help you minimize your costs; they may offer a discount or pay an out of network doc as in-network when there are extenuating circumstances. However, the out of network doc has no obligation to accept the insurance company payment as full payment the way an in network doc would. They are not legally obligated to do so. Nor is the hospital or insurance carrier obligated to provide discounts or to increase payments OON.

Certainly you can appeal the costs. Certainly you can ask admin for assistance. There's absolutely no reason not to. But it's their opt whether to cooperate or not.

As I said, I'm not quite sure what you're looking for. If you're looking for a legal way you can make them pay the OON doc as in network, there isn't one; nor is there a way you can force the OON doc to accept as full the insurance carrier payment.

If that's not what you are looking for, maybe you can clarify your question.

 

[tonymoo]

Thanks for replying.

Looking for advice and opinion and you gave some.

I guess I was asking for opinions on the following strategies:
1) Pushing the hospital administration to try get one of the other affiliated practices to agree to treat her. Basically 10 or so doctors have blackballed her. And was wondering if that violated medical ethics or their contract with BCBS?
2) Trying to squeeze the fact that no in network doctor within a reasonable distance will treat her as meeting the no in network within a reasonable distance clause to get BCBS to pay for the out of network doctor.
3) If neither of those is viable, is it ever done that I could get BCBS an dthe OON doc and I on thephone and work something out or is everything hard and fast? The doctor is somewhat flexible.

 

[cbg]

1.) The hospital administration does not have the authority to force any practice to treat your wife. There is nothing unethical about refusing to treat someone who has made a complaint about one of their members. I have not read their contract with BCBS but I would be very surprised if they were under a legal obligation through that contract to treat anyone who is covered under the policy regardless of past history.
2.) They undoubtedly have their own definition of what is and is not reasonable distance but there's no reason you can't try to convince them of it. They may or may not be willing to listen to your explanation; they may or may not agree with you. There is nothing you can do that will force them to agree, but that doesn't mean you can't try.
3.) If you can convince them to try it, that's fine. Whether or not they will agree, and whether or not any such agreement will be legally binding, is not something I'm prepared to say.

The bottom line here is that you are free to use whatever means you want to, to try to get them to agree to cut your costs. There is no law you can invoke that will force them to do so, or that will force the OON doc to accept BCBS's payment as full payment.

 

[quincy]

tonymoo, first I want to say how sorry I am that your wife was diagnosed with breast cancer and is now facing surgery. How scary this must be for both of you.

If the need for surgery is urgent, I suggest you worry about the cost of the surgery second and deal with the medical need for surgery first.

Even if you cannot get a concession from your insurer and the hospital, there are other resources available to help pay any outstanding medical costs (e.g., GoFundMe). No one should ever feel the need to compromise their health because of the cost.

Good luck.

 

[cbg]

BTW, I don't want it to sound as if I'm unsympathetic. Believe me, I wish you all the luck in the world. No one knows better than I do how broken the system is. I'm just doing what my boss's boss calls "managing expectations".

As you move forward with this, please do not hesitate to ask any questions; I'll be happy to help as best I can.

 

[tonymoo]

Thanks, both.

I am lucky enough that I can pay if need be bu things are looking up financially.

We are proceeding with OON doctor. She has agreed today to just accept the 60% that BCBS will pay (we will just need to cover the 1000 OON deductible if we can't convince BCBS to treat as in network - still bouncing around there - they haven't said no at least).

For cbg, just one clarification. I had no issue with docs in the same practice refusing to see her. My issue was with docs in other practices refusing simply because the practices are both affiliated with the same hospital ( and basically using some kind of anti-patient poaching as the reason)

 

[quincy]

I am happy to hear that your wife found a doctor who is willing to provide a discount.

Best wishes to your wife.

 

[ajkroy]

Keep pressing BCBS to cover OON benefits for that one doctor as in-network. It doesn't matter if there are a hundred clinics within walking distance of your house if none of those providers will agree to treat her. There are no contracted providers available to her.

Did the complaints result in any disciplinary action? Has she filed complaints against other doctors in the past? If so, expect that to work against her (regardless of whether or not the allegation is factual).

I hope for a long-lasting remission for your wife.

 

[cbg]

Just to answer your remaining ethical issue; the only time any medical provider is obligated to accept a patient is if that patient is currently in an emergency situation where lack of immediate care could be life threatening. They are allowed to use whatever criteria they like, short of illegal discrimination, to determine what patients they will accept. And if (I do not know if it is or not; I say IF) their across the board, regular policy is to refuse to accept patients who have previously been patients of (Dr. Smith and his associates) then is is not outside the realm of possibility that accepting your wife as a patient is what could be seen as illegally discriminatory (to others).

Agree with ajkroy - while you can't force them to cover the OON doc as in-network, there's absolutely no reason not to make your best case for it.

 

[tonymoo]

Keep pressing BCBS to cover OON benefits for that one doctor as in-network. It doesn't matter if there are a hundred clinics within walking distance of your house if none of those providers will agree to treat her. There are no contracted providers available to her.

Did the complaints result in any disciplinary action? Has she filed complaints against other doctors in the past? If so, expect that to work against her (regardless of whether or not the allegation is factual).

I hope for a long-lasting remission for your wife.

Thanks.

No, this was the first time she ever filed a complaint against a doctor and he was punished really severely : they (the hospital) made him take a 2 hour sensitivity/ patient rights class (end sarcasm). Though she wasn't expecting more.

 

[quincy]

Thanks.

No, this was the first time she ever filed a complaint against a doctor and he was punished really severly : they made him take a 2 hour sensitivity/ patient rights class (end sarcasm). Though she wasn't expecting more.

The doctor probably learned more from your wife’s complaint than what was taught him in the sensitivity/patient rights class.

He probably learned that he places his license in jeopardy if he isn’t careful. And he is, with luck and hopefully, a better doctor now because of the complaint made by your wife.