Care Outside Insurer's Network Proves Costly, Despite Approval

Here's a form letter for the ages.

"We're sorry to learn you need hospitalization," Anthem Blue Cross Blue Shield wrote to Joshua Lemacks, a patient needing heart surgery. "We know that when you need to be in the hospital the last thing you want to worry about is your health care coverage."

The catch: at the time Lemacks was two months old. The letter went on to inform the boy that the insurer would be reviewing the care he'd received to make sure it was appropriate, but to rest assured, "you can count on us to pay for this hospitalization...."

 

As detailed in Tuesday's Washington Post, the faux pas was the least of worries for Lemacks' parents, Jodi and Mark. Not only were they preparing for a second surgery on their infant son, who had a congenital heart defect, but they had found out that Anthem wouldn't pay the specialists their going rate because they weren't part of the insurer's network.

You can read the letter here.

That decision ultimately left the Lamackses on the hook for $85,000 in bills. Anthem says everyone's premium rates would rise if it paid out-of-network doctors all they billed.

While advocates for the health care overhaul say it would protect people from overwhelming financial burdens should they fall ill, the Post story, reported by Kaiser Health News, shows that both the House and Senate bills wouldn't protect people from such charges, known as "balance billing."

Today, the Lemacks still owe more than $40,000 to their doctors.

Rau is a reporter for Kaiser Health News, a nonprofit news service.