The Hidden Traps of Health Insurance - Expert Edition Episode 47

In this eye-opening episode, I dive deep into the frustrating world of health insurance and medical billing. As a nurse and a healthcare administrator, I thought I knew it all, but a recent experience with my daughter's asthma attack and the ensuing insurance debacle proved otherwise. I'll share the shocking details of my encounter with insurance tiers, unexpected copays, and a battle to avoid unfair charges. My story not only exposes the hidden complexities of healthcare coverage but also offers vital insights and advice on how to navigate these challenges. Join me as we unravel these complexities, fight for our rights, and learn to question every charge on our medical bills.

Mentioned Episode:

• Beyond the Benefits: Finding the Right Health Insurance for You w/ Oxana Parfenova - Episode 24

• This Nurse Is On A Mission To Make A Difference In The World w/ Angel Cellucci - Ep. 93
  

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TRANSCRIPT:

[00:00:00] Naseema McElroy: You guys, let's just say I am absolutely pissed after going back and forth with my insurance company for the last few months and actually medical debt going to collections. I I want to share with you because we all need to know this. So let me start with the story. So my kids have asthma and I'm a nurse at a hospital and my healthcare coverage for my family is through that hospital and It's always been a given that if you get treated at the hospital, you don't typically have to pay any copays, anything like that, because everything is within house.

All right. So my daughter's having an asthma attack. And for me being budget conscious, we drive the hour to my job for her to get seen at the emergency room. Okay. She gets seen. She's okay. Boom. Okay. Months later, I get this bill in the mail from the medical group saying that she owes this money.

And I'm writing them back no, this doctor was at the hospital that I work at, that I've worked at for 13 years. I've never gotten a bill from the hospital. And so going back and forth with the insurance company, they're like, it should be covered then they just send my debt to collections. And I'm telling the collection agency no, I've been disputing this.

And so one good thing I learned it. There's a couple of good things I learned about this, but they were able to put my collection on like this. Holds that it was being disputed. And so it didn't like, hit my credit or anything like that, but I'm still bothered that I have a medical data collection company.

Anyway, so I'm going back and forth back and forth. And so I have a pile on my desk of stuff that needs to get handled, and this is perpetually been sitting on my desk for the last few months. And finally, I had the time. Last week to call the insurance company and actually spoke to the right person that knew what the heck was going on.

And so it ends up that there's this tier structure that the way that my insurance works. I have a PPO. I'm very fortunate. I pay less than 15 a pay period to cover me and my 3 girls. So I'm very blessed about that. But this is supposed to be top tier insurance. Let me tell you how they play me though.

Okay. There's tears, right? So tier 1 is anything that I get done in the hospital and tier 1 is usually covered at 100%. Then there's tier 2. There is, places that I can go outside of the hospital that are within my insurance network, which is a blue shield insurance network. That is tier 2.

but when I go to those visits, I'm subject to copayments and I have to meet my deductible before they started paying out. And then there's tier 3, which is out of network, which is, you covered most of the things it's your deductible and all these kinds of things. Basically, you're paying a lot out of pocket.

So I'm tier 1, I'm taking my daughter to this to the emergency room and my job is my people, whatever, whatever. So the customer service lady is like looking deep and digging. Deep into it. And she's okay, yes, everything with your hospital is covered. Like the visit is covered. However, the medical group gets billed separately.

And this doctor is not employed by your hospital. This doctor is employed. It was a like a locum doctor. So it was a doctor that came in on a contractual basis to work at the hospital. But she said, but the good news is the doctor is a blue shield provider. That means that the doctor falls under tier two.

And because that doctor is the one that you seeing now you're subject to the co pay for seeing that doctor. Now, mind you, this is an emergency room visit. So I. I am not, I don't have the privilege of selecting who the doctor is, right? So I'm just like, so this doctor basically selected me. So now I already drove an hour from my daughter who's having an asthma attack to make sure that I don't incur any extra costs.

But now you're telling me, but just because the luck of the draw, I show up and it's this one doctor that's there that I don't have any choice of now I have to pay because he does not fall under tier 1. I was like, that's some BS. I was like, so if this is a situation where I don't have a choice in the matter of the doctor, shouldn't it be covered?

And she was like, technically. Yes. However, it's not automatically covered. I was like is there a way to appeal it? She was like, yes, but the appeals process. Is 180 days after the service now, this happened in April last year. So we're far out of that 100 and 80 day window. Now, she said what she has seen happen is that if a lot of people start appealing it, they might move this doctor into tier 1 status, or the hospital will make an exception for these doctors where.

They're covered, right? They fall under tier one. And but the bottom line is most people don't understand this. Number one, most people do not read their insurance bills. Either they just pay them or they just let them pile up. They let them go to collections. They don't care. I read all of my insurance bills and in past episodes, I've had Angel Salucci on talking about medical errors with insurance billing.

I'll link that in the episode. I also had on Oksana Performa, who is an insurance agent, an independent insurance agent that finds private insurance for people. If you're employed or not, but she knows all of these rules as well. But those are some things to go back on, but I, like I said. I'm not an average consumer, right?

First of all, I'm a nurse, so I work in health care, right? But I also have a master's degree in health care administration, meaning that I've worked on the back end in insurance companies. And for me not to understand this is freaking annoying. So I know your average everyday consumer isn't digging deep into Their bills.

And so that's why I wanted to make this episode so I can tell you guys like how important it is for you to look into your bill. And if something like this were to happen, where you have no choice in your provider appeal that so you don't have to pay now in full transparency, it was only 77, but the bottom line is I don't want to have to pay that if I'm driving an hour with my sick daughter to a hospital to avoid a copayment, I don't want to pay a copayment.

Okay, and I don't think you should have to either. We pay enough for insurance, even though my deductible is very low. The insurance cost itself is very high. I'm just fortunate enough that my job occurs and just covers those costs. The bottom line is read your insurance, know your rights, stand up, question everything on your bill.

Nine times out of 10, they're wrong. Review those podcast episodes that I have with Oksana and Angel. So you understand that you are paying for what you only, what you need to pay for, stop overpaying these insurance companies. They get paid enough. They don't reimburse us enough, but that's a story for another day.

But yeah, I just wanted you. To make you aware of this, like little loophole is annoying AF, but you do have some recourse. And hopefully if this happens to you, you know what to do.

Hey there I’m Naseema

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