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<blockquote data-quote="Ricochet1a" data-source="post: 877752" data-attributes="member: 22880"><p>One of the things most people don't realize is the "reasonable and customary" limits that are placed on out of network coverage. </p><p></p><p>I managed to find the 2009 benefits book (knew I kept it), but I obvously don't have the 2011. </p><p></p><p>When looking at the 2009 coverage of Premier Plus, for in-network care there was an annual $1,000 maximum out of pocket per individual, and an annual $5,500 maximum out of pocket per individual for out-of-network care. On the face of it, not too bad. I know the deductables are higher now. </p><p></p><p>But there is something which this casual observation doesn't reveal. Most of the talented health care providers didn't sign the contract CIGNA offered at the time (even fewer have signed the contracts offered by CIGNA or Anthem now). </p><p></p><p>So when one is admitted for an urgent issue, one will indeed receive care, but they will inevitably receive care from out of network providers. </p><p></p><p>This is when the system begins to "burn". </p><p></p><p>There is that "reasonable and customary" clause in the insurance. Quoting out of page 81 of the 2009 benefits book:</p><p></p><p><em>The Plan will not pay any charges that are more than the R&C limit. You must pay the amount that exceeds the R&C limit according to CIGNA HealthCare's guidelines. Charges over the R&C limit do not apply to the out-of-network deductible or out-of-pocket maximum. Expenses for in-network care are based on a negotiated fee schedule and you are not responsible for charges in exess of the negotiated rate. </em></p><p><em></em></p><p><em></em></p><p><em></em>So, if you are in-network, you're covered - any "excess" billing is wiped clean by the provider, they can't demand payment for that amount as part of the terms of their accepting the contract with CIGNA. </p><p></p><p>If you are out-of-network, <u>you</u> are personally liable for any charges over the R&C limit, these charges DON'T apply to the out of pocket maximum. </p><p></p><p>So if a neurosurgeon provides care (which will inevitably be out of network, no neurosurgeon is going to accept the rates CIGNA offered 2 years ago), they will charge their fee which NO ONE actually pays in full. Let's say it is $15,000 in this case. </p><p></p><p>The insurance will look at the actual procedure done by the neurosurgeon, and claim that the task's R&C fee is actually $7,000 - which is true, that is the average amount this procedure would collect. The insurance will then compensate the out of network provider at 70% of the R&C amount - which would be $4,900 in this case (assuming the annual maximum out of pocket hasn't already been paid). The patient would be thinking that they would only be liable for the other 30% of the R&C ($2,100 in this case), and if they had already reached their annual maximum out of pocket, the insurance - CIGNA - would then pick up this amount. </p><p></p><p>What happens is that the billing for the neurosurgeon will then come after the patient and claim that they are owed the remaining $8,000 or $10,100 (depending on the circumstances). This is when the whole thing goes to collections and a mess starts. </p><p></p><p>This is where having dual coverage comes in, the other insurance would battle with the billing department, and make a settlement of the final amount payable - the patient only receives the statements in the mail reporting the progress of how the billing is being whittled down. </p><p></p><p>Given the very low rates of compensation being offered by the current CIGNA and Anthem plans, most providers aren't signing contracts with the plans - meaning they are by default out-of-network. </p><p></p><p>The EXACT same thing is happening to Medicare and Medicaid - in order to cut costs, the government in these instances is offering less and less compensation for services rendered - so providers are refusing new patients and some outright refusing to provide care for those with these insurance plans. So people have these "plans", but are finding there are no providers who will accept them - and those providers who do accept them, have real issues with quality of care. There is a de facto two-tiered heatth care system developing. </p><p></p><p>Guess which "tier" Express health insurance is moving into. You (current employee) are paying more and more each year for your coverage - and it covers less and less while the selection of heath care providers keeps on getting narrower and narrower.</p></blockquote><p></p>
[QUOTE="Ricochet1a, post: 877752, member: 22880"] One of the things most people don't realize is the "reasonable and customary" limits that are placed on out of network coverage. I managed to find the 2009 benefits book (knew I kept it), but I obvously don't have the 2011. When looking at the 2009 coverage of Premier Plus, for in-network care there was an annual $1,000 maximum out of pocket per individual, and an annual $5,500 maximum out of pocket per individual for out-of-network care. On the face of it, not too bad. I know the deductables are higher now. But there is something which this casual observation doesn't reveal. Most of the talented health care providers didn't sign the contract CIGNA offered at the time (even fewer have signed the contracts offered by CIGNA or Anthem now). So when one is admitted for an urgent issue, one will indeed receive care, but they will inevitably receive care from out of network providers. This is when the system begins to "burn". There is that "reasonable and customary" clause in the insurance. Quoting out of page 81 of the 2009 benefits book: [I]The Plan will not pay any charges that are more than the R&C limit. You must pay the amount that exceeds the R&C limit according to CIGNA HealthCare's guidelines. Charges over the R&C limit do not apply to the out-of-network deductible or out-of-pocket maximum. Expenses for in-network care are based on a negotiated fee schedule and you are not responsible for charges in exess of the negotiated rate. [/I]So, if you are in-network, you're covered - any "excess" billing is wiped clean by the provider, they can't demand payment for that amount as part of the terms of their accepting the contract with CIGNA. If you are out-of-network, [U]you[/U] are personally liable for any charges over the R&C limit, these charges DON'T apply to the out of pocket maximum. So if a neurosurgeon provides care (which will inevitably be out of network, no neurosurgeon is going to accept the rates CIGNA offered 2 years ago), they will charge their fee which NO ONE actually pays in full. Let's say it is $15,000 in this case. The insurance will look at the actual procedure done by the neurosurgeon, and claim that the task's R&C fee is actually $7,000 - which is true, that is the average amount this procedure would collect. The insurance will then compensate the out of network provider at 70% of the R&C amount - which would be $4,900 in this case (assuming the annual maximum out of pocket hasn't already been paid). The patient would be thinking that they would only be liable for the other 30% of the R&C ($2,100 in this case), and if they had already reached their annual maximum out of pocket, the insurance - CIGNA - would then pick up this amount. What happens is that the billing for the neurosurgeon will then come after the patient and claim that they are owed the remaining $8,000 or $10,100 (depending on the circumstances). This is when the whole thing goes to collections and a mess starts. This is where having dual coverage comes in, the other insurance would battle with the billing department, and make a settlement of the final amount payable - the patient only receives the statements in the mail reporting the progress of how the billing is being whittled down. Given the very low rates of compensation being offered by the current CIGNA and Anthem plans, most providers aren't signing contracts with the plans - meaning they are by default out-of-network. The EXACT same thing is happening to Medicare and Medicaid - in order to cut costs, the government in these instances is offering less and less compensation for services rendered - so providers are refusing new patients and some outright refusing to provide care for those with these insurance plans. So people have these "plans", but are finding there are no providers who will accept them - and those providers who do accept them, have real issues with quality of care. There is a de facto two-tiered heatth care system developing. Guess which "tier" Express health insurance is moving into. You (current employee) are paying more and more each year for your coverage - and it covers less and less while the selection of heath care providers keeps on getting narrower and narrower. [/QUOTE]
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