Avoiding Insurance Problems Can Be Easy

April 27, 2004 -- Posted at 5:53 p.m. CDT

JONESBORO -- According to the US Census Bureau, 61% of Americans were covered by employment-based health insurance in 2002, the last year for which figures are available. Many of those insurance providers have in-network and out-of-network providers.

But what happens when your in-network doctor refers you to an out-of-network facility? It's no secret that health care is expensive. Having heath insurance can be hard to figure out...there can be a big difference in out-of-network and in-network.

"When a patient goes in network, they are usually responsible for a smaller portion of that bill, and they are also protected from any additional costs that their health care has agreed to pay," said Dr. Connie Meeks, Medical Director for the Northeast Region of Blue Cross Blue Shield.

Deniseia Mayhan is a KAIT employee who just resolved a dispute with the American Life Care Insurance Company.

When her husband needed a procedure last October, their in-network doctor recommended the Jonesboro Surgical Hospital.

"They contacted my insurance company to make sure that facility was covered and they were given pre-cert numbers assuming that ment the facility was covered and it was not," said Mayhan.

And when Mayhan got the bill from the out-of-network facility, she was shocked.

"I got a $2,000 dollar bill that the insurance company would not pay," said Mayhan.

Having networks help control health care costs. Dr. Meeks says it's both the doctor's and the patient's responsibility to know which network they are in.

"It's very important for the patient to insist on finding out whether or not a facility or another provider is actually in the network," said Dr. Meeks.

"We were getting threatening letters all the time saying your going to be turned over and sending them back letters saying, I've spoke to this person on this date who told me it was taken care of, I spoke to this person on this date, you know here's all the numbers you gave me," said Mayhan.

Mayhan's paper trail and her persistence paid off, but still at a price.

"They eventually wrote off 80% of it. I had to pay 20%, which was twice what I would have had to pay if it was in-network," said Mayhan.

So what should you do if you find yourself in the same situation?

Dr. Meeks said, "It's real important for patients to take responsibility to know what their health benefits are and what their contract with their health plan actually says."

And having that knowledge can save you lots of time and trouble. If you have a dispute with your insurance company, make sure you keep a record of all your correspondence with the company.