Insurance Policy Anxiety Over Sarasota Memorial and Blue Cross Health Insurance
Sarasota area residents with Blue Cross Blue Shield insurance faced uncertainty earlier this year while the insurance giant negotiated a contract renewal with Sarasota Memorial Hospital. Although the insurer and hospital eventually reached an agreement that prevented the hospital from becoming an out-of-network facility, many patients decided to delay medical treatment during the negotiations out of fear that a lack of coverage would result in crushing expenses.
The battle between Sarasota Memorial and Blue Cross Blue Shield sounds a wake-up call to policyholders to learn more about where and what their health insurance covers.
Sarasota Memorial vs. Blue Cross Blue Shield: What Happened
One key element of any insurance plan is its in-network coverage. Most health insurance plans cover medical services such as doctor’s visits, tests, and hospital stays as long as a patient uses an in-network healthcare provider. Patients who go to an out-of-network provider face claim denials or larger out-of-pocket costs.
But, as CNBC reported in 2016, a New England Journal of Medicine study found that the in-network vs. out-of-network issue becomes especially confusing when out-of-network doctors work in an in-network hospital emergency department. Patients seeking acute and emergency care rarely think to ask whether the doctors caring for them are in their insurance networks. That thought only dawns on many of them later, when large out-of-network medical bills arrive in the mail.
The negotiations between Sarasota Memorial and Blue Cross Blue Shield mirrored similar negotiations throughout the United States. Healthcare providers participate with insurance companies as in-network partners for several reasons, chief among them the access insurers give to potential customers. In exchange for that access, providers commonly agree with the insurer to accept lower payment rates than they would for out-of-network patients.
In its negotiations with Blue Cross Blue Shield, Sarasota Memorial Hospital also pushed for concessions on the following issues, according to MySuncoast.com:
- Protection from claim denials and disputes
- Prompt payment for services rendered
- A small rate increase for the hospital’s physicians
A successful agreement came down to the wire with contract expiration set for March 31 and new contract implementation set for April 1. The uncertainty of resolving the issue was so great that many Blue Cross Blue Shield policyholders received letters from providers directing them to other hospitals. Fortunately, the two sides reached a deal, but not without causing extra stress to patients with already stressful medical conditions.
Understanding Your Health Insurance
Knowing you have health insurance is one thing-understanding your policy is entirely different. If this describes you—you’re not alone. A 2017 survey conducted by insurance industry clearinghouse Policygenius and Radius Global Research discovered that a majority of Americans think they know more about health insurance than they actually do. This overconfidence results in huge wake-up calls when it’s time for an important medical procedure or treatment.
Surveys on Health Insurance Understanding
Policygenius and Radius Global Research surveyed more than 2,000 people in 10 of America’s largest cities, and asked participants if they could define four key insurance terms: “deductible,” “co-insurance,” “co-pay” and “out of pocket maximum.”
The results: Only four percent of Americans could correctly define all four terms. Especially eye-opening was the amount of confidence those surveyed had regarding their knowledge. Participant’s confidence—as in, “I definitely understand” these terms—was an astounding 68 percent. Overall comprehension—as in, “I can correctly identify” these terms—was 42 percent.
Millennials (ages 25 to 34) had the lowest overall understanding of health insurance terms: On average, only 36 percent correctly identified any terms. They, too, thought they knew more than they did—65 percent responded they “definitely” knew what the four terms meant. In fairness, millennials may lack understanding due to just coming off their parent’s plans and their unfamiliarity of health insurance policies. In comparison, 71 percent of baby boomers (age 55 to 64) said they “definitely” knew the four terms meaning, while only 47 percent actually did.
The Policygenius report concluded that “[t]he low percentage of people understanding their coverage demonstrates the need for better awareness around policy details,” particularly considering that insurance companies don’t do a very good job of writing policies that are easy to understand.
Insurance Companies are All About Profit
Its important to remember that the bottom line of all insurance companies is to make a profit. The only way that an insurance company can increase their profit is by decreasing the money that they expend on policy claims. With the full weight of multi-billion dollar enterprise behind them, insurance companies have all the resources they need to take advantage of any possible ways they can reduce the cost of a claim or even outright deny it. Keep this in mind whenever you revise a policy or find yourself needing to make a claim.
Protecting Your Rights
Overconfidence is a bad thing when it comes to your and your family’s health care insurance. It can lead to unexpected costs and claim denials. But, even when consumers do grasp their coverage terms, they still often find it confusing and difficult to navigate the healthcare system.
To begin with, being sick or otherwise needing medical care is stressful in its own right. It can feel overwhelming just to make good, informed choices about the kind of care you need, let alone whether particular doctors, drugs, or treatment options are covered by your health insurance.
Worse, claim denials and other insurance issues usually only crop up after you’ve received medical care, placing you in an impossible position. After all, it’s not as if you can return your knee replacement for a refund, or un-take expensive medication. Sometimes, procedures require pre-approval, which can eliminate surprises after-the-fact, but even then, insurance companies often drag their feet in responding to the approval request, or try to play hardball with their clients and provider.
When an insurance company denies a claim that your policy covers, it can help to have an attorney by your side who has experience pushing back on insurers. Not only can skilled attorneys protect your legal rights, they can also protect your health by making sure that you receive the care you need and that your insurer has an obligation to reimburse.
The Dolman Law Group
If your health insurance company has denied an insurance claim for medical care you’ve received, or preventing or denying you coverage for the treatment you need, call the Dolman Law Group today at (941) 210-7586 or contact us online. We proudly represent clients in the Sarasota area who have fallen victim to complicated and confusing health insurance issues. Discussing your situation with our experienced lawyers during a free consultation is the first step to achieving the peace-of-mind you need during an already stressful time.
Dolman Law Group
8039 Cooper Creek Blvd
University Park, FL 34201-3007