Health insurance bait and switch--any recourse?
May 25, 2018 10:24 AM   Subscribe

I have health insurance through my spouse's job. There are two choices of PPO-type plan. Plan A has a higher premium and lower copays/deductible. Plan B has a lower premium and higher copays/deductible. Both offer the same level of reimbursement for out-of-network costs, 70%. Or at least that's what the benefits sheets say. This year, we switched from Plan A to Plan B. After doing the math, we figured we'd save some money. Nope.

We see some out-of-network providers regularly, and all of a sudden, the reimbursements dropped to practically nothing. Yes, the reimbursement is still "70%," but it's 70% of an "allowable amount" that's laughably small. So 70% reimbursement is a complete fabrication. I mean, I'm familiar with the games insurance companies play with "reasonable and customary charges" and so forth, but this is beyond the pale. Here are some fake sample numbers to give you an idea:

Out-of-network provider charges $200/visit.
Last year's reimbursement: 70% of $200, or $140. Our old cost: $60.
This year's reimbursement for the same provider: 70% of $50, or $35. Our new cost: $165.

Is it possible to find a provider who charges $50? Of course not, not even close. And these are providers we see a few times per month, so the bills have quickly put us in real trouble. There are in-network providers for these services, but good ones are rare, and making the switch is difficult. I have had to cut back on appointments instead, which is harming my health.

There's no way we could have known about the change in allowable amounts before making this decision. In the past, I've tried to find out reimbursement amounts ahead of time, but the insurance company won't tell me, because we live in a different state than where my spouse's company is based. I have been told over the phone that I'll just have to submit the claim to find out what the reimbursement will be. In this case, we figured we knew the amounts already, since we'd been seeing these providers for some time. We have appealed, but of course our appeal has been denied.

I'm so angry and frustrated, because we made a decision based on the information we were given, but that information was a lie. I can't believe (except, sadly, I can believe) this kind of misinformation is even legal. Do we have any other recourse?
posted by the_blizz to Work & Money (10 answers total) 3 users marked this as a favorite
This is in New York State, if it matters.
posted by the_blizz at 10:30 AM on May 25, 2018

Unfortunately this kind of obfuscation is very common in the health insurance arena. And yes it is legal. Most people don't have the patience to go over a policy line by line, much less know that the burden is on them to do so.
Is it possible for you to change your plan back in the next open enrollment?
posted by jtexman at 10:31 AM on May 25, 2018

I would start by talking to whoever arranges these benefits in the HR department. They should want to know about it and can use this information in negotiations in the future. If they use a broker to arrange their insurance, the broker may be able to do something about it too? Maybe?
posted by purple_bird at 10:32 AM on May 25, 2018 [4 favorites]

1-800-428-9071 is the NYAG's Health Care bureau consumer hotline number. I don't know what they can do for you, but it's worth a call.
posted by praemunire at 10:34 AM on May 25, 2018 [4 favorites]

Most people don't have the patience to go over a policy line by line,

It's worse than that. Even if you could get a copy of both policies without purchasing them and went over both line by line, this issue would likely not become apparent beforehand. Furthermore, this can change from one year to the next when using the exact same policy.

Much of how insurance claims are processed is done by internal policies that aren't necessarily officially written down anywhere and can change at the drop of a hat when the actuarials get miffed and decide a policy is costing too much. They send the policy to legal and legal "discovers" they have been "paying the policy incorrectly" the entire time it has existed and then the claims department gets retrained to "pay the policy correctly." So, in other words, they come up with a legally defensible argument for changing how they pay the policy before they start paying it differently so as to prepare for possible law suits ahead of time and how they will justify fucking over their clients on a whim/ to pad their bottom line a bit more.

It's truly puke worthy (and one of the reasons I no longer work in insurance).

Some practical suggestions:

Talk to your primary care physician about getting an official referral to the out of network providers you need and a Letter of Medical Necessity signed by your physician that spells out why you absolutely need to see these particular providers and there is no acceptable in network provider for your needs. Keep the original for your records and fax the insurance company a copy.

Call the insurance company and ask if they have a social worker on staff or other patient advocate or team that deals with problem files or special cases. Sometimes there are people within the company who can cut through the red tape on your behalf. (A lot of claims are being processed by entry level workers who are not super knowledgeable and not being well paid and they have to make quota to keep their job. This directly causes a lot of problems for people like you, not because of willful malice, but because they are just trying to get through the damn day themselves and doing right by some total stranger who happens to own a policy and have special needs is not going to make their radar in most cases. In some cases, this can be remedied by getting hold of the right person.)

You may be able to switch policies if you have a Qualifying Life Event. Here is a list of such:

If you aren't already doing this, you may be able to seek out online support groups that can help you pursue diet and lifestyle based approaches to managing your health issue. This may mitigate some of the harm being done to you by having fewer doctor's appointments.

Contact your state's Insurance Commissioner: Map of US with contact info for all states. They are a consumer advocate. This should be free. If you have any recourse, they will likely know what it is.
posted by DoreenMichele at 11:04 AM on May 25, 2018 [10 favorites]

I would definitely talk to your husband's HR department and see if they can help. I realize some HR departments are fairly useless, but I know a lot of HR professionals who are wonderful and awesome at this sort of problem solving, and who really love to try to help employees in this way.

As others have said, too, it may not be that Plan A and Plan B have different definitions but perhaps that all the insurance company's plans changed their definition of "allowable amounts." But if you can get HR to fight the insurance company about what they're paying for, that's likely going to work better than you fighting it.
posted by lazuli at 11:25 AM on May 25, 2018 [1 favorite]

If you are seeing out-of-network providers because there are no local providers in the network you may have recourse. When we were with Carefirst (BC/BS of DC) there were no endocrinologists within 30 miles accepting new patients, so they had to let us go out-of-network at in-network rates. However, that was top secret info that only was surfaced when we complained loudly and persistently and got an actual nurse to work with us. The front line customer service folks were clueless. It may have also helped that I did file a complaint (and won) with the DC Insurance Commissioner when they wouldn't cover something that was clearly covered by the language in the policy. For a while, BC/BS, or more likely their PR firm, was monitoring my blog and calling me anything I posted about them.

But it totally sucks that you have to have a pHD in health insurance fuckery to figure out how to work the system.
posted by COD at 12:21 PM on May 25, 2018 [7 favorites]

I second praemunire's recommendation to contact the New York State Attorney General's Health Care Bureau. I have dealt with them on other health-insurance issues, and they have been very helpful.

Also, COD: truer words were never spoken: "But it totally sucks that you have to have a pHD in health insurance fuckery to figure out how to work the system."
posted by merejane at 5:28 PM on May 25, 2018 [1 favorite]

Here is what happened:

I was all set to contact the NYSAG, but we went to HR. (They were firmly on our side, and were frankly appalled at the situation.) HR spoke with the insurance company, and...they are letting us switch to our old plan effective May 1. Yes, without a qualifying life event. Effective January 1 would have been better, but I'm pretty happy with this outcome.
posted by the_blizz at 4:32 PM on May 31, 2018 [3 favorites]

YAY! So glad they were able to help.
posted by lazuli at 7:27 PM on May 31, 2018

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