National Consumers League

Health care experience triggers quality of coverage questions


By Sally Greenberg, NCL Executive Director I recently experienced the health care system’s shortcomings while seeking out treatment for a condition known as “trigger finger.” That’s when one of your fingers locks up and won’t straighten without much effort – and pain. Though I live in Washington DC, my first consult occurred while visiting my father, a doctor, in Minnesota. He sent me to see his friend, a hand surgeon, to have a look. The hand doctor gave me a shot of cortisone, saying that, while that only works 50 percent of the time with trigger finger, it was the first step before surgery. The cortisone worked for a few days but soon enough the finger locked up again. So I decided to seek out the surgery option and made an appointment to see a doctor back home in Washington, DC. He was “out of network” for my insurance, but his offices are far closer to me than any of the “in network” doctors on my insurer’s list, and he came highly recommended. This physician sized up the finger, asked about the cortisone option, and recommended minor surgery, which is apparently very routine. I made arrangements to have the surgery at a local hospital where this doctor is on staff. The whole procedure would take 30 minutes and would be outpatient and, thank goodness, I could go home immediately after its completion. The doctor said his fee for this procedure was $2,000, plus the cost of the hospital. This sounded high for such a minor procedure, but what do I know? Before I proceeded, I wanted to find out how much coverage my insurance would provide. Believe it or not, my health insurance coverage amounted to only $296 for the doctor’s fee, of which they would pay only 70 percent, and that’s after an annual deductible of $300. In other words, I would receive nothing from my health insurance to cover the cost of this procedure if I went outside their network. However, the facility cost would be covered at 100 percent. Then I called the doc in Minnesota. His fee for this procedure is between $800 and $1,300. A lot less than $2,000 but a lot higher than the $296 my insurance pays. This experience prompted so many questions for me. First, if the in-network doctors are making little or nothing on this procedure, how can they even cover their own costs? Also, what standards are insurance companies using to determine what a “usual and customary” charge for procedures? If the DC doc charges $2,000 and the Minnesota doc charges between $800 and $1,300, certainly, what should insurance cover? And what about the quality of my insurance coverage? Does this put my insurance company into that loathed category of “junk health insurers” who take your premiums each month but they cover little of your actual health care expenses? Why such a difference between in-network and out-of-network coverage? What are the actual costs of these procedures? I’m a professional consumer advocate, and I found the experience overwhelming. What’s a patient – who’s lucky enough to HAVE health insurance -- to do? I called my dad’s friend and asked for advice. He said his practice would do the surgery for a fee somewhere between what my insurance says it’s worth and what his practice charges. I figured he was willing to negotiate because of our family connection. But when I called the DC doctor to say I was putting off the surgery, his assistant said they wouldn’t expect me to pay the whole fee out of pocket either and we could come to some arrangement. The lesson learned here is that for those of us lucky enough to have health insurance, it does pay to check into coverage before you move forward with treatment. Actually, it was a pain to wait on hold for 30 minutes while the insurance looked for the amount of coverage they’d provide for this very routine procedure and even then, I wasn’t sure she’d gotten it right. To me, this experience brings home how fraught this system is with pitfalls and traps for consumers. And this was a simple, common, and fairly inexpensive procedure. I feel for those with chronic or life threatening conditions or illnesses who have to deal with this system every day. I honestly don’t know how they do it.