Should you choose to utilize the services of a non-designated or non-participating facility, you may want to check in with the Plan beforehand to see if the Plan can negotiate a “one-off” agreement to help mitigate any large out of pocket expense to which you may be liable.
The key word in the aforementioned paragraph is “negotiate”. Negotiating takes time. Calling the Plan up three days prior to a surgery and expecting the Plan to get an agreement negotiated is unrealistic. Why? For the reason that it can takes weeks of work to find the “decision maker” in these institutions. Once located, it can take weeks to come to a mutual agreeable understanding and to get a document signed.
Furthermore, participants are advised that one-off-agreements cannot always be made. Equally important to understand is that negotiating with an out of network provider after services were rendered will not occur because once services are rendered the Plan can only treat (pay) your out of network claim in accordance with the out-of-network rules of the Plan. Additionally, the Plan cannot treat your out-of-network claim differently than it treats (pays) the out-of-network claims of other participants
While participants can choose any hospital that they wish, they are kindly reminded that facility benefits are greater when those services are provided within a participating designated facility. As a reminder there are two levels of participating hospitals and facilities. They are:
In-network Level “A” Designated Hospital Facilities
Franciscan St. Anthony Health - Crown Point, IN
Franciscan St. Anthony Health - Michigan City, IN
Franciscan Healthcare - Munster, IN
Franciscan St. Margaret Health - Dyer, IN
Franciscan St. Margaret Health - Hammond, IN
In-network Level B Designated Hospital Facilities
Community Hospital - Munster, IN
Community Stroke and Rehabilitation Center – Crown Point IN
Methodist Hospital - Gary, IN
Methodist Hospital - Merrillville, IN
Pinnacle Hospital - Crown Point, IN
Portage Hospital - Portage, IN
Porter Regional Hospital - Valparaiso, IN
St. Mary Medical Center - Hobart, IN
St. Catherine’s Hospital - East Chicago, IN
University of Chicago - Chicago, IN
The Fund’s contract with the aforementioned facilities only covers the facility fees and charges for covered services provided by those employees on their payroll. If a medical provider is neither on the hospital’s payroll nor participates with the Funds selected network, then they are considered non-participating or an out-of-network provider.
Be advised that similar to emergency room physicians, radiologists, anesthesiologists, and pathologists are typically not employees of the hospital. Consequently, if any of these professionals do not participate within the Plans network, then the bills that they submit will be paid in accordance with the out-of-network provisions of the Plan.
Like you, the Plan has no choice in the matter as to who is on call and treats you at the time you receive services in the emergency room.
Further, many of these facilities have sub-contracted out these departments to independent contractors whose business model is not to accept any insurance. This business decision, specifically and again, to subcontract out the services of these departments to independent contractors, is the hospitals to make. Meaning; it is out of the control and influence of the Fund.
Therefore, and as stated earlier, anyone working for these independent contractors would not be covered under any of the contracts with the aforementioned designated facilities. That does not mean that they will not be paid. They will. However, they will get paid in accordance with the out-of-network provisions of the Plan.
To change this requires the American medical industrial complex to change. That takes votes. So, get involved. Tell your elected representative that you need legislation that states that if your tax dollars are subsidizing these institutions then there should exist a law that in emergent situations, these physicians and facilities should be mandated to accept the Medicare allowable payment for a covered service provided to a non-Medicare covered patient by a non-participating physician. If nothing else, there should be a national conversation about this. This is not only important, but necessary to get citizens to understand the American medical system and to create a vision of a system that is better, fairer and the best in the world.