In a little piece of legislation known as the Affordable Care Act, preventive services are mandated to be covered with no out-of-pocket expense to consumers. According to the Healthcare.gov website, approved insurance plans must cover a “list of preventive services for children without charging a copayment or coinsurance.”
Number 18 on that preventive care list is childhood immunizations for children from birth to age 18, acknowledging regional variation in the standard recommendation schedule. After all, vaccinations are the cornerstone public health achievement of the last century and have saved countless pediatric lives.
Alas, all fairy tales must come to an end. For government employees choosing Government Employees Health Association (GEHA) insurance coverage, that type of prevention comes at a definitive out-of-pocket cost. According to Wikipedia, GEHA is a self-insured, not-for-profit association providing health and dental plans to federal employees and retirees and their families through the Federal Employees Health Benefits Program (FEHBP) and the Federal Employees Dental and Vision Insurance Program (FEDVIP). According to the U.S. Census Bureau 2014 statistics, Washington State has approximately 341,000 state and local government employees. My hometown has three very large installations, the Puget Sound Naval Shipyard, Naval Undersea Warfare Center Keyport, and the Bangor Naval Submarine Base employing a large number of full-time employees and contractors. Many of these individuals have health insurance coverage provided by the GEHA insurance plan.
Surely, the benevolent executives at GEHA are familiar with the Affordable Care Act and its preventive provision mandate. They must also realize immunizations for children under 18 years of age qualify under the umbrella of preventive care. So what seems to be the problem?
For the past fifteen months, every single explanation of benefit (EOB) paperwork mailed to physicians who are practicing in the Pacific Northwest, and patients who are employed by the government shows $50 to 100 of “out of pocket” cost per visit for immunizations and their administration being kicked to patients. Isn’t it terrible the government can no longer afford comprehensive health insurance coverage in compliance with the ACA for the hardworking men and women they employ?
Can you imagine what will happen to these families when GEHA continues to operate unchecked and refuses to bear the costs of cholesterol testing, diabetes screening, or annual mammograms? Washington State already has a mumps outbreak which is massively out of control. Forcing employees of the federal government to fork over for each and every vaccination for their child is certainly not going to help improve health outcomes.
After reviewing more than 100 EOBs personally, a clear and definitive pattern of fraud emerges demonstrating GEHA makes every single patient responsible for $50 to 100 in out-of-pocket costs for immunizations. Language in our GEHA contract clearly states we must follow their specifications according to each EOB we receive. Being the diligent small pediatric office we are, a bill for the amount is sent off to the patient each and every time.
At first, families would call to inquire why they were “responsible” for “out-of-pocket” preventive care costs. My answer was simple. “It violates the central statute of the ACA, but no one can stop the government from ignoring the law of the land.” Underneath it all, the GEHA fraud is likely just another one of those oversights “allowed” to continue while the federal government looks the other way.
One meticulous parent called GEHA to figure out what the problem was. GEHA was “shocked” about this small, insignificant computer “glitch” and the customer service representative assured her the mistake would be corrected. (That was 15 months ago with still no correction in sight.) The mother forced GEHA to send us a corrected EOB reimbursing us properly for preventive services provided in accordance with ACA guidelines and removing the balance from the patient responsibility category.
Over the last 15 months, despite many employees complaining to their respective HR departments, patients complaining to the GEHA customer service line, and my office complaining to provider relations about the difficulty getting paid correctly for preventive visits the first time, all of our efforts have been in vain. The mysterious “glitch” simply cannot and will not be fixed. (My guess is it may be the same incompetent information technology team who were involved in the healthcare.gov site debacle working on this befuddling “glitch.”)
It got me to wondering about the number of offices who miss the fact GEHA is shorting them by $50 to 100 per patient well child check-up? And then I realized the indirect benefits of the GEHA “glitch” to the insurance company. GEHA must be saving an awful lot of money this way. This indomitable “glitch” might even be occurring nationwide, in which case, it is saving millions upon millions of cold hard cash.
Slowly the realization dawned on me that the chance GEHA will fix their innovative money-saving “glitch” is about the same chance a man with a wooden leg has of escaping a forest fire. I can tell you exactly who the one-legged man in the forest fire is: the primary care physician. Why does the insurer always get to strike the match, start the forest fire, and watch us burn? When will GEHA be forced to comply with the provisions mandated in the Affordable Care Act and who pray tell is going to enforce the law of the land?
Niran S. Al-Agba is a pediatrician who blogs at MommyDoc. This article originally appeared in the Health Care Blog.
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