Gair says she should have been told this beforehand and is refusing to pay. Blue Shield is considering her appeal. Gair is holding off on follow-up surgery to remove the plate until the dispute is resolved.
"I think the whole system is messed up and needs to be changed," Gair said. "I regularly paid my insurance, but even when I had an accident I get stuck with a bill."
Physicians are fighting the insurance giants in court. In class-action lawsuits, thousands of doctors alleged that the nation's largest insurers, including WellPoint, Aetna, Cigna and Humana Inc., were involved in a "conspiracy. . . . to deny, delay and diminish payments to healthcare providers."
The suits accused insurers of systematic efforts to shortchange doctors, including reclassifying treatments to reduce payments, arbitrarily rejecting claims and purposely delaying reimbursements while earning interest on the money.
To settle the litigation, insurers set aside hundreds of millions of dollars to pay doctors who successfully challenge disputed bills in arbitration. WellPoint and Aetna alone committed $235 million to the recovery fund. Several smaller groups of doctors have similar lawsuits pending.
Insurer reimburses after being sued
Doctors and patients in New Jersey sued Woodland Hills-based Health Net Inc. over out-of-network fees. Without admitting liability, the insurer agreed to reimburse as many as 2 million people who complained of inadequate insurance payments from September 1997 through July 2007.
U.S. District Judge Faith Hochberg ruled that Health Net used a database that set out-of-network payments too low. Most health insurers use the same database, produced by Ingenix, a subsidiary of UnitedHealth Group. Doctors, patients' rights groups and some state regulators are trying to get the system overhauled.
In February, New York Atty. Gen. Andrew M. Cuomo announced that his office was investigating UnitedHealth and Ingenix. He accused them of cheating patients by using faulty data to reduce out-of-network payments. Cuomo said the case could affect 70% of Americans with private health insurance.
UnitedHealth defended the Ingenix data, saying it was "rigorously developed, geographically specific, comprehensive and organized using a transparent methodology that is very common in the healthcare industry."
