Released: September 11, 2006

When choice of doctor drives up other bills

Source: By Richard Pérez-Pena, New York Times (Free Registration)

Irene Greco knew she would have to pay from her own pocket to use the surgeon she wanted, rather than one in her insurer’s network, but she thought she knew how much the additional cost would be. She was wrong — by almost $5,000.

She had her operation at a hospital that was in Oxford Health Plans’ network. But Oxford, her insurer, says that because the surgeon was outside its network of doctors, the hospital bill as a whole would also be considered out of network, and therefore subject to less coverage.

Oxford says its coverage policy is straightforward and properly communicated to its customers. But some health care experts say this policy is so unusual that they have never seen it before, and the hospital industry calls it the latest in a string of unfair practices by Oxford and its parent company, UnitedHealth Group, that are designed to avoid paying what is owed.

The Healthcare Association of New York State, the main lobbying group for the state’s hospitals, has filed a complaint over Ms. Greco’s case with Attorney General Eliot Spitzer’s office, which is looking into the matter. The group’s leaders say they cannot recall ever making such a complaint against an insurer.

Oxford, one of the largest insurers in the metropolitan area, insists that everyone involved should have understood in advance how it would handle Ms. Greco’s bills. It was spelled out “in the certificate of coverage the member receives when they sign up for the plan,” said Maria Gordon-Shydlo, a spokeswoman for Oxford.

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