- By Milt x_Zall
- Jun 19, 2000
A recent experience at the doctor's office makes me wonder what's become
of my health plan.
The largest plan in the Federal Employees Health Benefits Program and
the one that I belong to is the indemnity benefit plan, run by Blue Cross/Blue
Shield. This is supposed to be a fee-for-service plan, which means its members
can choose the doctor or health care provider of their choice. In years
past, that's exactly how this plan operated.
Then, at the urging of the Office of Personnel Management, the fee-for-service
plans introduced the concept of "preferred provider." Each plan contracted
with various health care providers who agreed to provide services to feds
at reduced rates. I have no problem with that, so long as the cost differential
isn't too great. For example, if it costs $12 to see a preferred provider
and $20 to see a nonpreferred provider, that's OK. "You pays your money,
you takes your choice."
In time, however, the cost differential between seeing a preferred provider
and a nonpreferred provider spread. For example, my wife went to see a doctor
who doesn't participate in the service indemnity plan. He charged her $65.
The plan said $38.63 was a reasonable charge for this visit and that it
would pay 75 percent — or $29 — of that. It cost my wife $36 to see him.
I think that's too much of a spread. If I wanted to join a health maintenance
organization, I would have done so during open season. I decided not to
join an HMO, so why am I being coerced into using "company" doctors?
On top of that, the doctor ordered blood tests for my wife. He charged
more than $200 for them. Guess how much my plan reimbursed me? About $55.
Why? Because that's what they pay preferred providers. So I'm out of pocket
more than $200 for this visit. If my wife had gone to a preferred provider,
it would have cost me about $25. Theoretically, I do have a choice. My plan
allows me to use any doctor I want. But look at the cost of going outside
When I called my plan and asked how they arrived at their paltry allowance,
they told me they didn't have that specific information. Maybe OPM did.
Right! Then I asked, "Can I see what you pay your participating providers
for lab work?" I was told, "No, that's confidential." I then pointed out
that without that information, I had no assurance that my claim was processed
correctly. I asked if they would review the claim. "Sure," I was told. "All
you have to do is file for a reconsideration in writing." I asked why, and
they said they needed it because they needed it! Get it? I asked if I could
fax it in, and they said no because "we use our fax for emergencies." Like
what? A traffic jam on the route home?
I'm not happy with the way fee-for-service plans are evolving. They
resemble HMOs more and more each day. The only thing missing is the designation
of a primary care physician. Maybe that's what lies ahead. All I can tell
you is, it stinks. n
—Zall is a retired federal employee who since 1987 has written the Bureaucratus
column for Federal Computer Week. He can be reached at email@example.com.