Bamboozled: Read the fine print

While politicians in Washington started their slug-fest over health care costs, Anthony and Jucelia Correia were involved in theirBB branding own health care money brawl.

Recent transplants to New Jersey from Queens, they both visited a new primary care physician for routine annual physicals in March. The Springfield couple, insured by Empire Blue Cross Blue Shield, went to an in-network doctor. When the doctor ordered blood work for both Anthony, 37, and Jucelia, 35, the couple went to an in-network hospital, Overlook Hospital in Summit, to have the work done.

They presented their insurance cards and their veins for a little withdrawal, and they went home.

A few weeks later, they received a bill for more than $1,700.

”If I had known that the two bills would total a little more than a monthly mortgage payment, we would not have gone to the hospital at all,” Anthony Correia said.

That can’t be right

Correia figured there must have been a mistake, so he called his insurer. That’s when he learned that even though he visited an in-network hospital, his blood work was sent to an out-of-network lab.

80411”How am I supposed to know that an in-network hospital would send our blood work to a third party out-of-network lab?” Anthony Correia said. ”I feel that I did my due diligence by going to an in-network doctor and an in-network hospital for services.”

Correia said he and his wife identified themselves as Empire Blue Cross Blue Shield members when they registered at the hospital for the blood work, so he assumed the hospital would send the blood work to an in-network lab.

So began three months of phone calls. He called Overlook’s customer service manager, that person’s supervisor, the patient advocate, billing reps and others. He was told time and time again that it’s his responsibility to know his insurance coverage. That he should have verified that the hospital used an in-network lab.

Then the family started to receive collection calls.

Thinking he was in the right, Correia didn’t pay the bill and kept trying to get the hospital to listen to reason. He again called Empire Blue Cross Blue Shield. The rep suggested Correia tell Overlook to resubmit the claims with an itemized bill that shows the labs were done in-house. He called the billing representative at the hospital, who resubmitted the two claims.

Soon, the Correias got news Empire Blue Cross Blue Shield paid the re-submitted claims. The Correias owed nothing. Not a co-pay, not a deductible. Nothing.

”Now that is a resounding relief,” Anthony Correia said.

Making sense of that which doesn’t make sense

Of course it was the responsibility of the Correias to understand their insurance coverage. They went to an in-network doctor. A no-brainer. They then went to an in-network hospital for blood work. That makes complete sense.

But why would an in-network hospital’s lab be out-of-network? That makes no sense at all. Overlook Hospital referred us to Empire Blue Cross Blue Shield for an answer.

It’s not uncommon for an in-network hospital to have out-of-network providers, said Craig Andrews, spokesman for Empire.

Andrews explained an insurer will negotiate a contract for payment with a hospital or other provider, and it’s not uncommon for a hospital to have a lab within its walls that operates as a separate entity. That separate lab would have to negotiate its own contract with an insurer, and in this case, it seems the lab and Empire never reached an agreement. That’s why the lab was out-of-network, even though it’s inside an in-network facility.

Any why did the insurer, after denying the claim twice, change its mind the third time around?
It’s most likely there was an honest mistake and the blood should have gone to an in-network lab. In a case like that, Empire would pay the claim, Andrews said (speaking hypothetically), and then inform the provider of the proper procedure for the future.

But a person, not a computer program, would have to review the claim to see there was an error, and many claims are processed by computer.

Andrews said sometimes if the system rejects a claim, it could be approved upon further review by a human.

That further review may not happen unless a patient or a doctor asks about a rejected claim.

Review your benefits and your bills

As a customer, it’s essential that you question every rejected insurance claim.

While it’s possible you were rightly rejected because a benefit is not covered under your plan, it’s also possible that you may identify an error.

To protect yourself, make sure you know your plan and your benefits, and if you’re not sure or something doesn’t seem right, call your insurer to ask. You can never know too much.

”Some people take more time researching a new car than they do their health benefits,” Andrews said.

That’s a lesson Anthony Correia takes to heart.

”The one thing I am certain to do from now on is to make sure that I verify that lab work will be performed in-house, at an in-network lab,” Correia said.

”Save yourself some aggravation and check, then double and maybe triple check. Ask questions. Don’t assume anything.”

Well said.