Continuing my effort to keep people updated on Seattle’s emergency rooms, the ER physicians and insurance coverage, I thought I’d let you know that Premera announced the following in their July 2009 Producer Bulliten (PDF here, bolding mine.)
Ballard Emergency Physicians Rejoin Network
Ballard Emergency Physicians have signed an agreement to be part of the Premera Blue Cross provider network, effective August 1. The physician group provides emergency room services for Swedish Medical Center in Ballard.
Please note that Swedish Emergency Physicians (SEP), the physician group providing emergency room services for Swedish Medical Center on First Hill, is not in the Premera provider network. As a result, members seeking emergency care at Swedish Medical Center on First Hill may experience higher out-of-pocket costs for emergency physician services. Swedish Medical Center is a contracted facility, so facility charges and services received from physicians and providers other than SEP are considered in-network and will be paid accordingly.
See previously under the Ballard Emergency Physicians tag.
Tags: ballard, ballard emergency physicians, health care, medical, premera, seattle, swedish medical center, washington state
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Franz Kafka would feel right at home.
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I am hoping you can help me. I found out the hard way that the ER physicians at Swedish are not part of my Premera network; although when my daughter went to the ER in February 08 they were in the network; June 09 – not in the network. So, what I am trying to find out is – where is this published when they make these changes? I didn’t recieve anything from Premera and when we checked in there was no mention of it when I presented my insurance information. So, how does a Premera consumer know when the change is made? Looks like you know – any help would be great.
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Hi Margaret – thanks for your note. First, I know the most about Swedish Ballard and the Ballard Emergency Physicians – as far as I know, the BEP were out of network with Premera for a few years, and just as of August 1 are back in-network. I don’t know as much about Swedish’s other locations, but do know that First Hill is still out of network for Premera. What Premera has told me is that initially, when the ER physicians became no longer in-network, they sent out bulletins to the subscribers letting them know. The thing is, in my case, we weren’t with Premera when the change happened at Swedish Ballard, so we found out the hard way. The telephone representatives at Premera were also not able to tell me where I could go that had in-network physicians, but it seems that might have changed more recently. The dirty thing about all of this is that there just isn’t a good way for people to know about these things!! When I met with Premera’s representatives face-to-face, they admitted that this was an ongoing issue, and they do make it known in the policy that the insured may be responsible for out-of-network costs at in-network facilities… but that’s it. I let Premera know that I believe there needs to be a policy change. I also wrote letters to the state legislature, Congress, WA Attorney General’s office and WA Department of Health. My legislators were the most responsive, and actually did some work on my behalf! I highly recommend letting your representatives know what is going on with your case! Also, I recommend contacting Premera and appealing their decision, if you’re within the time period allowed. I would additionally recommend talking to the billing office of the ER physicians, they may ultimately lower your overall bill.
I can only believe that this stuff continues to go on because too many people accept our current system as-is, and don’t realize that a few letters can drive down some of their out-of-pocket costs, if not for them – for others.
Thanks again – and best of luck. I’ve outlined my process of taking care of my own bills here in my blog. Feel free to look under the tags section for the relevant information!
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I too am dealing with the same Premera issue. It’s good to not feel so alone in my fight. I went to St. John’s Hospital in Longview, WA and the ER doctors were not contracted. Of course my Level 1 was denied, today I had a phone interview for my Level 2, which I am guessing will be politely denied.
Their website shows only 13 Emergency medicine PPO specialists in the entire state and none within 75 miles of my home. Their toll free number told me only 1 ER physician was within 75 miles of my home, they knew his name, but not what hospital he practiced at! They have refused to provide me with info. stating what other ER doctors in my area are contracted at. It’s truly amazing that they are getting away with this.
After they refuse my Level 2 appeal I am going to request an IRO. They have to pay outsiders to consider my case. I find it amazing that they will waste so much time and effort on such a small amount of money. I’m sure by now they have wasted much more money in correspondence and employee time then they would have by paying the remainder of my bill!
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I am with the rest of you on this; I found out the hard way when I visited the Swedish ER at their First Hill facility in both July and August for middle-of-the-night kidney stones. While the majority of the hospital bill was covered, the Seattle Emergency Physicians bill was not. An in-network amount was paid by Premera toward those bills, but the rest was left to me.
Despite the ER + radiology total costs being 7-10 times higher than the a physician charges, my out of pocket expense is now about 2x more as a result of paying the uncovered portion of the out of network physician than it would’ve been if I need only pay my ER co-pay, coinsurance, and meeting my deductible. My insurance plan’s “out-of-pocket maximum” is $1800 per year, but because of the out-of-network physician technicality I’ve paid over that much out of pocket while only about 1/3 of what I have paid actually counts toward it.
I work for a different kind of insurance company, we do auto, home, life, etc. While our contracts can in some regards be hard to decipher — any document that needs to be legally concise will suffer from this — it’s not difficult to know what is and isn’t covered and what the out of pocket cost will be if it is or isn’t covered. Health insurance is a big mystery though, with providers not knowing what a person’s insurance will or will not cover and the insurer not being able to aptly help their customers find providers and facilities that would have coverage all around.
When I visited in July I did not even notice that the several hundred dollar bill from Seattle Emergency Physicians was something not covered. I had actually assumed it was just part of meeting my deductible, coinsurance, and co-pay, so I went ahead and paid it. It wasn’t until my visit in August, which lasted an hour or two longer and thus incurred higher expenses, that I realized I had even larger bills the second time around despite having met my deductible from the first visit a month earlier.
I called the insurance company who suggested that I call the physician to see if they’ll reduce the bill. I thought this was odd since I couldn’t imagine a doctor reducing their price knowing full well they can ruin my credit if I don’t pay what they ask; this proved to be true, as the physician’s billing flat out told me they don’t reduce their fees. They recommend I speak with Premera again and file an appeal.
I sent a written appeal explaining how I had kidney stones unexpectedly at 6am and the following month at 3am and Swedish was the closest hospital ER I knew to go to, and since I knew Swedish to be a “preferred provider” for Premera I thought it a safe bet. I told them I was laid up for several hours at the hospital, during which time I have no idea what person that came into the room was even the doctor, and had no choice in the doctor overseeing my care. They responded about a week or two ago with a denial of my appeal. Their contract language does state that out-of-network provider costs may be left to me, but I have to be honest that I had no idea the hospital would have doctors that aren’t in the network that the hospital is in. After having kidney stones in 2001 and 2005 while insured with Aetna I was probably also a bit jaded because in those cases I simply paid a $50 ER co-pay and never saw another bill (though that was admittedly before the awful bloat of our healthcare system started turning into the higher rates and reduced coverages of health insurance plans we see today).
Should I continue to appeal? Should I forward a copy of my appeal to my congressman/woman?
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Thanks for your comment! I really believe that aside from keeping all documentation, it is best to continue to appeal, and let your legislators know. I say legislators, because while I believe that our representatives on the federal level should be aware of our individual struggles, the legislators in our state capitol have a role in insurance regulation and state law which effects us more directly. Also, I’ve gotten a very good response from my state legislators. My recommendation in all communications is to try to be concise about the facts, and stick to the facts. The emotional part is important, but the facts are even more important in this matter.
The people at Premera, though they scheduled my second appeal to be IN PERSON did not expect me to show up to the point that they didn’t even book the room or have the members of the panel ready. While it didn’t help my case, it did take them by surprise, and I believe if more people get directly involved, it will make a difference. I can only believe that all the people involved, doctor’s offices, insurance companies, etc. are banking on people not standing up for themselves and being passive consumers. It costs them time and money to deal with appeals.
Best of luck to you, and again, thanks for the response.
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Thank you for your advice. As I have never written a legislator before, can you point me in the right direction?
I found that I am in the 37th Legislative District. The website says Adam Kline is the senator while Sharon Tomoko Santos and Eric Pettigrew are representatives. Do I handwrite a letter to one or each of them?
Thank you!
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I did all my contacts to my representatives through their websites using their email addresses. I recall that with the legislators, I could actually choose to cc my other legislators in the message. It makes it much easier. I got email responses in return, which was also really nice.
Good luck!
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