Friday, June 24, 2011

Anthem Blue Cross Open Enrollment

As a final reminder, Anthem Blue Cross is offering open enrollment during the month of June for those who might want to change their health plan. This open enrollment ends on June 30th. If you want to take advantage of this, send me a pm or visit and enter your information to check out your various options.

Sunday, June 19, 2011

Health Insurance Out of Network Rates

This is a very good article written by Anna Wilde Mathews in the Wall Street Journal.

Consumers know they will have to pay out of their pockets if they use medical providers outside their insurers' networks. But because of a little-noticed change, they may find themselves with even bigger bills than they expect.

Several major insurers are now using rates based on Medicare fees to calculate payments for out-of-network providers. Those amounts are often a lot lower than what doctors and hospitals actually charge. The upshot: Providers may bill patients for the difference. What's more, that bill comes on top of whatever patients owe in deductibles or co-payments.

New York entertainment attorney Mark D. Sendroff says he knew he'd get a bill when he went to an out-of-network surgeon for a shoulder operation last summer. But he was shocked when his Aetna health-insurance plan paid only around $1,000 of the surgeon's approximately $30,000 charge -- and part of the payment was his deductible. "It was absolutely crazy," he says.

Mr. Sendroff thought the plan was going to pay his doctor based on a "usual and customary" rate that's supposed to represent a typical charge for his area. Instead, the insurer pegged the doctor's reimbursement to 110% of the fee paid by Medicare. Mr. Sendroff appealed the decision, and after he contacted the New York attorney general's office, Aetna agreed to pay more, he says.

Aetna says some of its plans began basing out-of-network payments on Medicare rates in late 2009, and typically they pay a percentage above the government program's fees. In New York, the company says it warned insurance brokers the new system might generate bigger out-of-pockets, and mentioned the issue in a summary for potential customers. Aetna declined to comment on Mr. Sendroff's case, citing privacy rules, but said $30,000 was "well above the average charge" for such surgeries.

Health Care Service, the nonprofit parent of Blue Cross and Blue Shield plans in Illinois and Texas among other states, began phasing in Medicare-based fees last year. Cigna says employers are increasingly opting for plans that pay a set percentage above Medicare.

Insurers say Medicare is a reasonable basis for reimbursement. An Aetna spokeswoman says the Medicare-based payments are a "more consistent way of paying and keeping the premium down." Health Care Service says the Medicare method helps "increase transparency for providers and members."

For patients, the safest financial path is to use insurers' networks. When this isn't possible, they need to do their homework before getting treatment by talking to their providers and insurers. It's best to get billing codes for each service and run them past the health plan, says Ida Schnipper of Health Champion, a patient-advocacy firm.

Patients also should watch for unexpected out-of-network providers. For instance, an in-network hospital might have out-of-network anesthesiologists. If they do get stuck with a charge they didn't see coming, they can appeal to the insurer and also try turning to a state regulator for help. Providers also sometimes negotiate discounts with patients.

Starting in August, consumers can turn to a new usual-and-customary medical charge database operated by Fair Health, which will be available at Currently, the site only has dental fees. The nonprofit says it expects a growing number of insurers to use its data.

Write to Anna Wilde Mathews at

Thursday, June 9, 2011

The Problems with Obamacare

Healthcare reform has been a hot topic of debate ever since the 2008 Presidential election. Much rhetoric has passed back and forth between the two political parties, the insurance industry and other parties involved in the healthcare industry. It is this blogger's opinion that everyone is missing the most important issues which are controlling the spiralling costs of healthcare and health insurance premiums. Until these two issues are resolved, everything else is secondary.

The current political party that controls the final votes on any legislation believes that health insurance should be a right rather than a privilege and that the government should play a major part in executing the healthcare and health insurance in this country. The major problem with this is that our government is facing a trillion dollar deficit balance at a time when millions of "baby boomers" are set to enter the age of Medicare. Medicare will not be able to financially support this new infusion of "retirees" and is already in dire straits financially. The question here is how can a government with a huge deficit balance in a poor economy take on such an arduous task.

As important as finding a way to execute affordable health insurance for the majority of Americans is finding a way to control the costs of healthcare. There is no transparency to costs, and something has to be done in order to create affordability. There are no easy solutions to these problems, however it would be a major step in the right direction if the politicians, the insurance executives, the pharmaceutical companies and the medical practitioners could sit at the same table working out solutions rather than continually sniping at each other as adversaries. The U.S. is facing a major financial crises in health care, and steps need to be taken toward compromise and execution of plans and programs that have a realistic chance of working. Unfortunately, this is not happening as I write today.