When Jodi Lemacks was five months pregnant, she learned that the child growing in her womb would need a complex surgery as soon as he steps into the world since he has a major defect in the heart. They did not want to choose any pediatric surgeon locally since they lacked confidence in them.
One of the surgeons in the vicinity had just performed such a surgery on a new born child, but the child eventually passed away. This propelled Lemacks and Mark, her husband, to look for options in other states. They opted for a pediatric surgeon in Philadelphia who was the most experienced surgeon in the United States and adept in performing this surgery. As a part of this surgery, doctors had to pump out the blood from the body while the surgeon worked on the deformed aorta of the child which as thin as a string. Despite undergoing surgery in the hands of the best possible surgeon, there were only 5% chances of Joshua living to undergo the next surgery that would be performed six months down the line.
While the parents rejoiced at the success of the surgery in 2003, it lasted a short while until they incurred a bill of $70,000 which they had to pay since their health insurance provider backed out despite being informed earlier on. The provider, Anthem Blue Cross and Blue Shield of Virginia, who approved of their choice of surgeon, left the family in a financial lurch. The second surgery increased their dues by another $15,000. The family has been hounded by debt collectors ever since.
Mark Lemacks, whose company caters to office supplies, laments they will reel under this debt forever and that their credit rating has dipped so badly that they were denied the financing option when they went shopping for a mattress.
The Lamackses were annoyed because they were hit by “balance billing”. This occurs when medical facilities bill the difference between the amount paid by the insurers and the amount billed by the hospital. This is brought into foray when health providers outside the network of the insurance provider are not in agreement with the pre-decided rates for payment.
When people opt for hospitals and doctors outside the network, this cost is justified, though unwelcome. However, advocates for customers are looking for government protection being offered to patients who have no choice but to opt for doctors outside the network due to unforeseen emergencies, like during accidents or in cases where patients were treated by doctors outside the network while in the hospital in the network. The latter is what the Lemackses fall under.
To the dismay of the advocates, the Senate and the House support balance billing, which is the main reason for bankruptcies that are health related.
The aides of the Congress say that the practice is limitless and this legislation that is pending implies that the insurance company liaises with a lot more doctors and hospitals so the insured can avail options within the network.
However, in the case of Lemackses, it shows that despite the insurance provider having an extensive coverage, there are chances that patients may have to choose an option outside the prescribed network.