Choosing wisely

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

the plan!

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 protected]


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