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Navigating Healthcare with Health Insurance Purchased on the Healthcare Exchange - Part 1

A few days ago I got a phone call informing me that my husband was ok, but he fell off a ladder while working on our rental property in Denver and I needed to get to him ASAP. Within a few seconds there were endless questions along the lines of, what did he hurt and how bad? How far up did he fall from? Did he hit his head? How did this happen? What insurance company do we have anyway? How much was this going to cost? Over the next few hours many of these questions were answered, but one that could not easily be answered was related to cost. It will likely take weeks or months to determine the total cost of this ladder mishap.

As a physical therapist I have seen many ladder injuries involving nearly every body part. There is usually a story to go along with any ladder or roof injury, some are funny, others unlucky, or sometimes they are just silly accidents. No matter the story, most involve treatment and sometimes an extended recovery. Often times ladder accidents can be prevented (i.e. don't stand on the top of the ladder or don't wear slippers) but sometimes accidents just happen and there is no way to prevent or predict them. That is what insurance is for - you hope you don't need to use it, but when you do need it, you are happy that you have it. Or are you?

My husband and I are both self-employed so we purchase our health insurance on the marketplace/healthcare exchange. This year we had 175 choices for health insurance plans! After a lot of consideration, I chose a Bronze level, $0 deductible plan, $8600/person out of pocket max with Bright Healthcare, a "discount" healthcare provider in Colorado. Since we are both fairly young (30s, 40s), generally healthy, and active, I view our plan as a "catastrophic plan"...if something catastrophic happens, our out of pocket max is an amount that is manageable enough that it won't bankrupt us. Even with health insurance, for most of our predictable healthcare needs we opt to pay out of pocket with our preferred providers, a strategy that generally gets us better, quicker, and more convenient care.

After a quick assessment of my husband's injuries, it was clear that his left wrist was broken and an x-ray was essential. We immediately made a plan to go to Urgent Care, with the goal of getting an x-ray and anticipating a cast application. But turns out our "in-network" urgent care centers (Concentra) are only open weekdays 8am-5pm. Since it was 6pm on a Friday we had no other option but to go somewhere else. A quick call to Bright Healthcare indicated CareNow Urgent Care was also an in-network facility and was open until 8pm. Except when we got there, we were told CareNow is not in-network. I'm still unsure how this was miscommunicated with my insurance representative, but at the time I was willing to pay the out-of-pocket/out of network cost of $211 for a consult and x-rays (versus a $50 copay). Unfortunately, the x-rays showed a complex fracture that required reduction ("resetting") the emergency room. That also meant another co-pay ($1000 with our current plan for an ER visit), image fees, and provider fees. A quick internet search for in-network hospitals led us to Porter, just a few minutes down the road.

After getting situated at the ER, it was time to fill out more paperwork, including acknowledgement of the federal and state mandated "No Surprises Billing Act". Starting this year, this act mandates transparent billing practices for healthcare providers. Or course I asked for an estimate of cost; the response I received was: "it depends on what they do". At this point we knew it was a broken wrist. An appropriate (and legal!) response would involve estimated costs for an ER visit, physician fees, x-rays, reduction/manipulation, and casting. We did not receive any information regarding any of these costs before, during or after our ER visit.

Read more about the "No Surprise Billing Act" bill here:

After a few hours in the ER, racking up $$$, it was determined that the facture could not be fully reduced and a visit to a hand surgeon would be required. More co-pays, images, and fees. We left the ER late Friday night with my husband in a cast, a referral to a hand surgeon, and assurances that the images would be forwarded. No thanks, we'll wait for a copy of the x-rays.

I believe that anytime surgery is involved, at least 2 surgical opinions are prudent. I was feeling lucky when I determined that my favorite hand surgeon in Denver is in-network with BrightHealth! A call on Monday morning to schedule a consult confirmed that he is in fact in-network, but unfortunately the practice is self-determined "maxed out" on their Bright Healthcare clients right now, so they would not be taking my husband's broken radius on as a new client. This is not ideal, but I still wanted a consult with this particular doctor, so we asked to self-pay. Turns out, it is illegal to see a client at a self-pay rate if they have an insurance plan that is actively contracted with the clinic (this same rule applies to Medicare and Medicaid). So we can't see the provider we want because we can't self-pay and we also can't use the insurance they take. A completely unfair practice leading to frustration and regret in regards to choosing Bright Healthcare as our insurance. Who is this health insurance rule protecting anyway?

Luckily, we were able to find 2 other hand surgeons that are actively taking our insurance and we were able to see them both within a day. Both presented very similar surgical solutions and the choice between the two of them was easy - Dr. G got us scheduled for surgery within 48 hours. BUT it would have been 24 hours if the doctors preferred surgical center was in-network with our insurance! I obviously come back to the question: "Why did I choose this insurance carrier"?

So far our estimated surgical costs: $947 MD fee & $1700 facility fee. The hardware for the open reduction, internal fixation (OR IF) surgery at the radius and 4th metacarpal is still TBD. Add the ER visit, 2 specialist consults, MD follow-up, and post-op custom splint fabrication...are we going to hit the $8600 out of pocket max? If not, we will certainly be close!

Through this whole process, my husband has expressed multiple times how lucky he feels to have me helping him navigate this process. Healthcare coverage is confusing and frustrating, and it will likely stay that way for the foreseeable future.

Helpful Hints for navigating your health insurance and healthcare journey:

  • Always ask for copies of your images/notes/referrals. HIPAA protects your healthcare information, but it also makes it very difficult for multiple providers to communicate with each other. You always have access to your own healthcare information and can share it with anyone that you choose.

  • Double check your health insurance benefits. In-network vs. out-of-network fees can be extraordinarily different and often times out-of-network payments do not count towards your deductible or out of pocket max.

  • The healthcare exchange/marketplace is amazing for self-employed people. But the options can be overwhelming. Understanding the difference between deductibles, co-pays, co-insurance, in-network vs out-of-network, and out of pocket maxes can make a big difference in anticipated costs.

  • If you're looking to change health insurance but want to keep your current providers, the healthcare exchange gives you the opportunity to sort through plans that are in-network with your providers. Extra hint: before switching, call your provider to ensure that they are currently accepting the insurance plan.

  • Before choosing your healthcare plan, establish what type of care you want, what you are willing to pay for it, and the risk vs. reward of various plans. In hindsight, if accidents could be predicted, I would have chosen a different plan for us.

Stay tuned for part 2 - Surgery results, recovery, and final costs

Dr Jessica Klain PT, DPT, COMT, CSCS, OCS, CNPT

Board Certified Orthopedic Clinical Specialist (OCS)

Certified Strength and Conditioning Specialist (CSCS)

Certified Orthopedic Manual Therapist (COMT)

Certified Nutritional Physical Therapist (CNPT)

Certified Vestibular Specialist

Certified Concussion Specialist

Trigger Point Dry Needling Certified, Level 1&2

Certified Yoga Teacher

University of Florida, Doctorate in Physical Therapy (2009)

The Ohio State University, Bachelor of Science in Biology (2006)

Call/text: 720-295-0060


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