Soap Box

To the editor,

Current system:

1) Find a doctor: visit your insurance company’s website for a list of “preferred providers” in network. Locate a doctor, hopefully near you. Call your insurance company, be placed on hold, then find out if that provider is still in network. Call that doctor (as instructed by the insurance company) to ensure that she is in network.

2) Make an appointment with the network doctor, or an out-of-network doctor if no network doctors are available soon or near enough.

3) Call your previous doctor to have your medical information forwarded to your new doctor. Call your new doctor’s office to make sure it received your information. Expect to be placed on hold twice.

4) Show up at your new doctor appointment, fill out forms and HIPAA statement.

5) Is this doctor one you want to continue seeing? If not, repeat steps 1-4.

6) If your doctor recommends a line of treatment, call your insurance company to find out if it covers the treatment, and to what extent. You will be given an “estimate” of coverage, together with a disclaimer that what you are being told does not bind your insurance company to actual payment.

7) If the estimate would deplete your savings, return to your doctor to find out about optional treatment, and repeat step 6.

8) If you decide on a course of treatment, you will need “pre-authorization” by your insurance company. Groove to the hold music, which you know well by now. Pre-authorization does not ensure actual payment for your procedure. If your treatment is expensive, consider your odds of getting the “coverage denial run-around,” as frequently happens. (See “bankruptcies,” step 11).

9) Receiving treatment may involve locating a specialist or surgeon, which will require repeating steps 1-4.

10) If you need surgery, or any procedure requiring anesthesia, you must ensure that both the facility and all other specialists involved such as anesthesiologists are also in network. If they are not, good luck lining up a full team that is covered by your provider. Your costs can easily be many thousands, even for preventive check-ups like a colonoscopy.

11) After your procedure, office visit or check-up, expect to receive bills months later with only obscure codes explaining what the bill is for. Search “surprise medical bill” when your coverage “didn’t happen.” Call your insurance company, be placed on hold, request information about the charges, then endure the multi-step process of appealing your lack of coverage. Your wages could be garnished, leading to one of America’s 500,000 “medical bankruptcies.”

12) During “open season” your policy will almost certainly change its details. To learn about your new coverage limits, you’ll have to read through a thick brochure of obscure terms, qualifications and exclusions. Your option is to read other similar obtuse brochures of competing plans. Better coverage costs more; bring your wallet & magnifying glass.

NIMA - National Improved Medicare for All (Bernie Sander’s bill S.1129):

1) Since you are covered from birth by comprehensive benefits, you will never have to forward your information from one doctor to another or fill out legal documents. All facilities will have your entire family’s complete medical history, greatly reducing medical error or fraud. All facilities will still be privately run; NIMA only pays costs, like Medicare.

2) Since all medical personnel, hospitals and clinics will be “in network,” you can simply make an appointment anywhere throughout the country. Planning a procedure requiring anesthesia will take one step, not 20. You can sleep well at night: your children, spouse, siblings and parents will have life-long coverage.

3) No confusion will exist about coverage for any medical intervention or procedure. One comprehensive plan will cover everything – far more than Medicare does now. Your sole out-of-pocket cost – for drugs – will be capped at $200/person annually. You will never need separate insurance. Ambulance services, prosthetics, mental health, long term care, vision, dental, hearing and more will be covered.

4) Providers will not be juggling the details of 60+ different insurance policies that change every year. Nor will they repeatedly have to submit payment requests to insurance companies or wrestle for authorization for best-practices treatment, as they do currently.

5) Say goodbye to “open season.” Coverage benefits will remain comprehensive despite your financial situation. You can find employment anywhere, not based on benefits offered. Your costs in taxes will be substantially lower than now and based on your income. No one will be excluded for any reason.

– Kirby McLaurin, Durango

To the editor,

This is the second installment of my double billing saga with Centura Health, the supposedly nonprofit corporate overlords for Mercy Medical Center. Last fall, I and Medicare were double billed for a routine office visit on Sept. 9 to a provider with an office in the hospital complex.

The top line charge to see the provider was $387, and the second charge was $308.92, bringing the top line charge for a routine office visit to almost $700!! I called Centura and was advised the second charge was a “facility fee” for the privilege of setting foot in their hospital. This is a new charge that looks like basic corporate price gouging.

While I and Medicare didn’t pay the top line charge, people with high-deductible health insurance might, I’ve been told.

On Dec. 12, I had another routine visit with the same provider in the hospital building. I just got the bill for that. More double billing to me and Medicare. It’s $387 to see the provider and $189.82 for what’s called “clinic – general classification.” I called Centura again and confirmed that is indeed another “facility charge.” So this time the top line bill for a routine visit is only $576.92, a screamin’ deal, right?

Interestingly, my co-pay after Medicare is the same as the Sept. 9 visit - $24.72 for the facility charge and $13.70 to see the provider. Also interesting – both charges were on one bill instead of two separate bills for the earlier visit. Is that so the patient and Medicare might be less likely to notice the double billing? Or if it’s on the same piece of paper, it’s not double billing?

The Jan. 30 Telegraph had an article from Colorado Public Radio about the role of hospitals in our state’s above the national average health care costs. The story cited a Denver Metro woman who spent two hours in the ER and was hit with facility fees of $650 and $7,000. It doesn’t say if this was a Centura hospital. Do other hospitals do this? 

The article ended with comments by Centura president and CEO Peter Banko. “Price is only one small part of the equation,” he said. “We’ve been able to partner with health plans and deliver greater savings and more affordability.” How do these facility fees fit in there?

Because of this corporate rip off, I’ve suggested people should schedule their health care with someone other than Mercy if an alternative is available. Is it true that the facility charge is only applied when there is no local alternative? I had an office visit with another provider located in the Mercy complex in late fall. I got the bill for that visit, but so far no facility fee bill. There are local alternatives to that provider.

Fortunately, an alternative is available for a test I need, and I’ll be doing that at Animas Surgical Hospital. 

– Carole McWilliams, Bayfield