“High performance network” health insurance plans leave patients with unexpected medical debt

A Tennessee family faced a potentially catastrophic situation when Joe Smith – a husband and father of four – was diagnosed with a brain aneurysm. Smith, of Chattanooga, had health insurance through his job at Blue Cross Blue Shield of Illinois, but the insurance company refused to pay for the surgery needed to prevent a life-threatening tear.

“We knew he had some kind of time bomb in his head,” said Stacey Smith, Joe’s wife.

The insurer claimed the neurosurgeon the Smith family chose was out-of-network and the plan had no coverage for out-of-network doctors and hospitals.

So the family looked for another neurosurgeon in the area who was in the high-performance network, but couldn’t find one. Smith eventually underwent surgery, but only after emergency treatment at the hospital.

The Smiths’ health plan, known as a “high-performance network” (HPN), only covers in-network doctors and hospitals. This type of coverage offers cheaper premiums for employers and employees, but no out-of-network options.

A KFF study revealed that 100 million Americans are burdened with health care debt, including those with health insurance coverage. One reason for this may be the growing popularity of closed network plans, which are cheaper for employers and employees.

Sabrina Corlett, a professor at Georgetown University who studies health insurance reforms, said that “some employers are increasingly introducing these closed-network plans or narrow-network plans as a way to reduce their health care costs.”

For the Smiths, even a month after the surgery, they weren’t sure if their insurance company would pay for the procedure.

“I think I spent the whole day on Monday in tears on the phone with anyone who would listen, the insurance company saying, look, he needs this surgery now. What should we do?” said Stacey Smith.

The day after the canceled surgery, the couple said Joe Smith developed a persistent headache and went to the emergency room. In the end, Joe Smith received emergency surgery from Dr. Maishan Gyasi, who was out of network. The couple did not know if their insurance company would cover the costs, which could have been hundreds of thousands of dollars.

Nearly a month after Joe Smith’s surgery, and after CBS News contacted the company, Blue Cross Blue Shield of Illinois later sent the Smith family a letter stating that their request for Ghiassi to perform the surgery was “denied in error ” and now it will be approved. The company declined to comment on Joe Smith’s case, but said “in some situations where an in-network provider is not available … a member may receive services from an out-of-network provider.”

“It speaks to the need for some basic standards, because you know how quickly a plan has to review and act on a request to allow this kind of service.” But right now, unfortunately, a lot of these insurance companies think they can save a little money by dragging their feet in a way,” Corlett said.

In March — the same month Joe Smith was awaiting surgery — Blue Cross Blue Shield of Illinois was fined more than $600,000 by the state of Illinois for violating state laws. Violations include improperly applying maximum driving time and distance standards to reflect the actual number of providers available. The insurance company said it is committed to helping its members get access to the care they need, where and when they need it.

However, Joe Smith, an appliance and air conditioning repair specialist, expressed his displeasure with the situation.

“I don’t like that they have such power over people’s lives. They should not interfere in people’s lives and push them away. Deny, deny.”

Joe Smith is back at work full time after recovering from surgery. In addition to hospital costs, the Smiths were concerned about follow-up care costs, which they now expect to be covered by their in-network billing.

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