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“High performance network” health care insurance plans to leave patients with unexpected medical debt

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A Tennessee family faced a potentially catastrophic situation when Joe Smith — a husband and father of four — was diagnosed with a brain aneurysm. Smith, of Chattanooga, had health insurance through his job with Blue Cross Blue Shield of Illinois, but the insurance company refused to pay for the surgery necessary to prevent a life-threatening rupture.

“We knew that he kind of had this ticking time bomb in his head,” Stacie Smith, Joe’s wife, said.

The insurer claimed that the neurosurgeon that Smith’s family had chosen was out of the network, and the plan had no coverage for out-of-network doctors and hospitals.

So the family searched for another neurosurgeon in the area who was in the high-performance network, but couldn’t find one. Smith eventually underwent surgery, but only after emergency treatment at the hospital.

The Smiths’ health insurance plan, known as a “high-performance network” (HPN), only covers in-network doctors and hospitals. This type of coverage offers cheaper premiums for employers and employees but no out-of-network options.

A KFF study revealed that 100 million Americans are burdened with health care debt, including those with health insurance coverage. One reason for this could be the growing popularity of closed network plans, which are cheaper for employers and employees.

Sabrina Corlette, a professor at Georgetown University who studies health insurance reforms, said, “some employers are increasingly introducing these closed network plans or narrow network plans as a way to cut back on their healthcare costs.”

For the Smith family, even a month after the surgery, they were unsure whether their insurance company would pay for the procedure.

“I spent all day Monday, I think, in tears on the phone with anybody who would listen to me, the insurance company said, look, he needs this surgery now. What do we do?” Stacie Smith said.

The day after the canceled surgery, the couple said Joe Smith developed a persistent headache and went to the emergency room. Joe Smith eventually received emergency surgery by Dr. Mayshan Ghiassi, who was out of network. The couple did not know whether their insurance company would cover the cost, which could have been hundreds of thousands of dollars.

Nearly a month after Joe Smith’s surgery and after CBS News contacted the company, Blue Cross Blue Shield of Illinois later sent the Smiths a letter stating that their request for Ghiassi to perform the surgery had been “denied in error” and would now be approved. The company declined to comment on Joe Smith’s case, but said that “in some situations where an in-network provider is not available…a member may receive services from an out-of-network provider.”

“This speaks to the need for some basic standards, for you know how quickly a plan has to review and act on a request for authorizing this kind of service. But right now, unfortunately, a lot of these insurance companies think that they can save some money by dragging their feet in manner,” Corlette said.

In March — the same month Joe Smith was awaiting surgery — Blue Cross Blue Shield of Illinois was fined over $600,000 by the state of Illinois for violating state laws. The violations include failure to properly apply maximum driving time and distance standards to reflect the actual number of providers available. The insurance company stated that it is committed to helping its members access the care they need, where and when they need it.

However, Joe Smith, an appliance and air conditioner repairman, expressed his discontent with the situation.

“I don’t like them having that kind of power over people’s lives. They shouldn’t mess around with people’s lives and push it off. Deny, deny.”

Joe Smith has returned to working full-time after recovering from surgery. Apart from hospital expenses, the Smiths were concerned about the cost of follow-up care, which they now anticipated would be covered under their “in-network” billing.