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Considering Your Options When The Insurance Company Stops Paying

Blue Cross just advised a twenty-six-year old woman I know that it will cut off payments for the physical therapy that was making it possible for her to sit at a keyboard for eleven hours a day.  Her thirty sessions were up.

The young woman has an overuse injury to both of her arms that causes so much pain she can’t even mix up a salad dressing.  “I am not getting any better,” she said.  “To do that I would have to stop working or scale back the number of hours required by my job.”  Those physical therapy sessions offer strengthening exercises that reduce swelling and inflammation and make it possible for her to keep working.

Shifting Medical Costs to Patients

One cannot entirely fault insurance companies for trying to clamp down on medical costs, but rather than actually lowering the underlying costs of medical services, their solution is to shift costs to the patient—a cost control method that is accelerating with dubious results because if patients can’t pay, many simply will stop going to the doctor even when they need to.

A recently released study from RAND Corp. showed that when people had high deductible policies and other kinds of cost-sharing, they cut back on doctor visits and put off needed care.  What a surprise!  From the insurance companies’ point of view, the cost-shifting solution is more acceptable because it does not bring up the nasty subject of lowering provider payments that would anger the health system’s big powerful stakeholders—the doctor, hospitals, and drug companies.

Paying Out-of-Pocket Medical Costs

So what are patients to do when they are cut off from services they believe not only makes them feel better but also keeps them employed?

Pay for the service out-of-pocket is the first thing that comes to mind.  That may be easier said than done.  The “retail” charge for a month’s worth of physical therapy for this young lady comes to $370.   How many young adults just starting out have that kind of spare cash?   The young lady had been paying a $15 copayment for each visit plus $360 each month—her share of her health insurance premium, already barely doable on an income of about $40,000 a year in New York City.

Negotiating a Discount

She could try negotiating a deal with the physical therapist who might be interested in the business even if she will rake in less money.  After all, we are being told health care is a market and in a market, buyers and sellers negotiate with each other.  Right?  The young lady also asked about other lower-priced options the physical therapist had available.  It turns out that she could buy a package of four visits at a cost of $70 per visit, or a package of eight visits for $60 a visit.  Let’s see, if she takes two eight- visit packages, that comes to $960, which should get her to the beginning of next year when she is again eligible for another thirty visits—unless Blue Cross cuts back the number of approved visits.  She also wondered about inquiring about options like participating in “group” physical therapy sessions (if such exists), which would clearly reduce her treatment costs.  But the provider would have to agree to that, and maybe the session would not be as clinically effective as a one-on-one.

When Your Job is On the Line

But here’s the larger question.  Aren’t these kinds of arbitrary limits on care counterproductive and could end up costing society even more in the long run?  What if she couldn’t work and had to go on disability or welfare—if she could qualify.   In the end, some people become so disabled from workplace injuries they have no choice.  “I am not going to let that be an option,” she vowed.

We rarely take a big picture look at all health care costs and how they relate to what we spend on other social services.  And health insurance and worker’s comp coverage are seldom if ever looked at as a package designed to keep us active and working…what a shame that connecting those dots is solely left up to patients.

P.S. My young friend, fortunately with help from her family, opted for the discounted package of therapy visits.  With her job on the line, all agreed this was her best option.

*This blog post was originally published at Prepared Patient Forum: What It Takes Blog*

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One Response to “Considering Your Options When The Insurance Company Stops Paying”

  1. Erica says:

    This too happened to me recently. And it is BCBS. They blamed it on my policy holder saying they wouldn’t approve more than 30 visits per year, which we all know is bunk. Yet they will allow me to continue getting steroids injections, which the reimburse at the rate of $700 (plus I pay 10% of that) to the orthopedist because it’s considered a “surgical” procedure even though it’s done in his office. That $700 would cover reimbursement for seven PT visits. And since steroid injections merely mask the symptoms, I am eating $75 out of pocket four times a month. Health insurance in the US is sheer insanity.

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