HEALTH CARE/Joan Retsinas

Playing Gotcha: The Medical Version

We are all used to playing “gotcha;” and we are used to losing. Our opponents, who designed the game, are too skilled for us amateurs. So we muddle on, forced to play, expecting to lose.

We play “Gotcha” with all the Bigs, starting with the megaliths who supply our cell phones and computers. Their indecipherable bills dun us for services we didn’t know we asked for, services we don’t want; yet the mechanized voice on the phone tells us we can’t back out of the deal. For every day late, we accrue penalties. So we pay up.

Mortgages take “Gotcha” to a higher level. Even attorneys muddle through the codicils, the conditions, the multi-page gobblydook that tie homeowners not just to domiciles, but to cyberspace usurers. Whatever the stated costs of the mortgage, our monthly tab is more. Again, we agreed to the terms; we must have. “They” won.

We American consumers expect to be taken – the game is rigged. Even Solomons who read all the prospectuses, all the fine print, who google-search for wisdom end up “taken.”

Yet the cruelest opponent – and victor – is Big Medicine. We expected the Affordable Care Act to outlaw the egregious “Gotcha” insurance gimmicks, like exclusions for pre-existing conditions, low ceilings for expensive procedures, gigantic deductibles. It did. Yet some physicians saw the Affordable Care Act as a challenge: how to continue the game, build in more traps? Gotcha is a win-lose game: if patients lose, physicians win. And Big Money, befitting Big Medicine, is at stake.

Here are a few hints for patients, to help them limit their losses.

• Networks. These are the sand traps of “Gotcha.” Typically a patient goes to a primary care physician, one who belongs to “the network.” The patient’s insurer has been paying those “in network” bills, minus a co-pay. All is well. Then comes the referral to a specialist. The specialist is probably part of a network. But is it the patient’s insurer’s network? If not, the insurer may refuse to pay. Verify the specialist’s status before making an appointment. Check with the insurer, as well as with the specialist. If you can’t verify, ask your primary care physician for a referral to somebody else. Then verify all over again.

• Don’t limit the verification to physicians. Verify the status of the laboratory, the diagnostic imaging department, the therapists.

• In the hospital, the sand trap is hidden. Consider a plausible scenario: you are on the operating table, anesthetized. A slew of physicians surrounds you. Are they all in network? Don’t assume so. The key surgeon may be in network, but maybe not the one who stitches you up. The non-network physician will bill much more. For a muscle and skin graft, a “network” surgeon might bill $1,781; an out-of-network surgeon, $150,500. A gall bladder surgery in network will cost $1,892; an out-of-network surgery, $44,000.

Sometimes the insurer will pay part; sometimes the patient can negotiate a lower fee; sometimes the patient just admits defeat. Admittedly, patients are hard-pressed to verify in advance the network status of everybody, including the “consultants” and “assistants,” who will be taking care of them. That is why New York State, sated with patient complaints, passed legislation protecting patients: If a patient receives a “surprise” bill, the insurer and the physician must battle it out before an arbitrator. Urge your state to consider similar legislation.

• Parse “covered” services for the fine-print distinctions. Policies list the services covered. But is it covered only in an outpatient clinic, not in the hospital? If so, insist on being an outpatient. Is only one part of the bill covered (the surgeon, but not the anesthesiologist, the hospital room, or medications)? Is a preventive service covered, but not a subsequent procedure (a colonoscopy is covered, but is removal of a polyp?) One adviser suggests that patients talk, in advance, to their physicians’ billing departments, to see what will be covered, what won’t be covered, what will fall under the deductible, what the final bill will be.

The patient-players come to this version of “Gotcha” at a distinct disadvantage. Many are ill, focusing on survival. They trust their physicians – those heirs of Hippocrates – to take care of them, not to fleece them.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email retsinas@verizon.net.

From The Progressive Populist, December 1, 2014