Hello, family and friends of Paul and Kimberly, and welcome to another episode of Fun with Medical Billing. Perhaps you thought that our show had been cancelled due to a lack of new material; that’s certainly what I thought. As it turns out, that assumption was incorrect. Sadly incorrect. Frustratingly incorrect. And so I’m here to tell you all about it.
But first, a little back story: Our firm’s medical insurance policy comes up for renewal each year on the first of October. In early September, I learned that the folks at Group Health Uncooperative were going to make changes to their insurance plans, and that the plan under which we had been covered would no longer exist. Instead, they had several new plans from which we could choose. Our office manager reviewed plan benefits and premiums with a GH minion, and found that there was a policy that was very similar to the one that we had. And the monthly premiums would be lower! But wait, the out-of-pocket limit (OOPL) would be higher. In network, we would pay $500/year more before reaching the OOPL. For out-of-network providers, such as Dr. Futran and the UWMC team, the OOPL would be $1000/year higher than the old OOPL. (Lower premiums and higher limits are a way of adjusting coverage so that those who need lots of health care pay more than those who don’t. But the politics of health care are not my topic for today.)
For the first nine months of the year, Paul and I had paid for the old medical insurance policy. We paid the higher premiums, and, as you saw in a previous episode, we hit the $4000 out-of-network OOPL before the end of February. What, I wondered, would happen when we switched to the new policy, which had an additional $1000 dollars of OOPL? Given Paul’s CAT scans, doctor appointments, physical therapy and such, he might incur an additional $1000 in payments by the end of the year. (With 60% out-of-network coverage from Group Health, it would take only $2500 of medical charges to reach that point… and it’s amazing how quickly one can rack up that amount.)
I asked our office manager to contact Group Health and discuss this issue with them. She did, and was told that this would not be a problem, as the payments that we had made for the previous “plan year” (October to September) would be applied to this calendar year (January to December). Does that sound a little odd to you? It did to me, too, but that’s what she had been told, and I accepted it. OK, now we’re all caught up.
So, imagine my surprise when, a couple of days ago, we received an Explanation of Benefits form for one of Paul’s physical therapy appointments, and it showed an out-of-network OOPL of $5000. And $100.20 was shown as “your total responsibility”. Better yet, $10 was indicated as a copay, because, oh, I forgot to tell you, the new plan has copays… and copays are not applied to the OOPL.
You will have to imagine for yourselves the words… no, the epithets… no, the flat-out cursing that was heard in our house on top of Queen Anne hill, because this is family programming and I don’t say those words here (here being in cyberspace, at PvTSM, not here where I am physically). Well, I use them only very occasionally, and today is not one of those occasions. However, that day was one of those occasions.
I have yet to contact my friend… what was her name?… Marcie! my friend Marcie at Group Health Uncooperative to discuss this, as I have not yet had a chance to discuss it with our office manager. (I hope that she has the name of the GH minion with whom she discussed this.) And I’ve been trying to figure out exactly what to tell Marcie that I expect, what makes sense, what is “fair.”
For the first 3/4 of the year, we paid higher premiums, and had the lower OOPL. For the last 1/4 of the year, we’ve paid lower premiums. If we are going to have a higher OOPL for the last 1/4 of the year, it seems to me that the increase should be prorated for the percentage of the year in which the new plan has been in effect. Rather than raising Paul’s OOPL by $1000 to $5000, I would be willing to accept their raising it by only 1/4 of that, or $250. Barring that, I want a refund for nine months of the difference between our current premiums and our old premiums: $52.64 x 9 = $473.76.
Before I mention to anyone at Group Health that we’re willing to consider paying anything more for Paul’s health care this year, I want a letter from Group Health stating their policy regarding changes in health plans (and premiums and benefits) during the middle of a calendar year. On the letter, I want the signature of a person who has sufficient rank to do something about this, and the direct line at which I can reach that person. I also want a pony, delivered personally by Santa Claus. However, Santa Claus probably won’t care if I send him a letter stating that my attorney will be in touch if he doesn’t deliver.
Well, folks, the resolution will have to wait, as we’re out of time for tonight. Tune in again next… well, who knows when. That’s part of the hilarity of Fun with Medical Billing. Thanks for watching our show.