Do all Cigna plans make you have diagnostic tests in non-hospital associated facilities to avoid deductibles?

Question

My HMO plan allows me to have routine tests such as mammograms, MRI's, Xrays, bone density screens, etc in a hospital or hospital facility without paying the hospital deductible ($200 for my plan). BUT, if, I need a follow-up test (further mammogram pictures, etc) OR, if I have any diagnostic exams/tests at the same hospital-associated facility, I must pay the $200. And no co-pay if I go to a facility NOT associated with a hospital. This is not written in any of my plan documents. It cost me $200 to find out this hidden "fine print", and my primary doctor's staff still refers me and my children to the hospital for all tests. I find an optional facility by myself, then call the doc to have a new referral made. Cigna said that my doc probably gets a kickback from the hospital . Anyway, after my $200 lesson, I SAVED $1000 copays for my family this year. Is this feature common with all of the Cigna plans? Is it common with all HMO's? Does everyone know this already?

No, my deductible is not $200. My copay IF I go to a hospital facility is $200 each time until I meet the deductible. I am asking if this is common in HMO's, or if people don't realize that this expense is avoidable. My mammo was free, as long as it was routine, at any in-network facility, but when they called me back for additional views, because they found something in the original mammo, it was additional $200 at a hospital facility, but covered at an independent facility. Same for the additional breast ultrasound, and the aspiration, which, according to the insurance policy, had to be done on a another appointment. (everything was negative). Anyway, it was a maze for me, and knowing the steps, saved me a lot of money. Please check your policies to make sure you know your options.

Oh, Cigna did tell me that diagnostic tests had to be coded as an office visit and not an out-patient or in-patient in order to avoid the copays. Hospital-associated facilities usually bill as out-patient.

Answer 1

Doctors usually refer to whatever hospital they have privledges at, simply because it's a known facility. Don't you recommend places you know? "Kickbacks" don't usually come into play. It is not their responsibilty to know where your insurance's "preferred provider" is - it's YOURS. (It's impossible for a doctor or his staff to know the difference between the thousands of insurance plans they deal with - you only have one or two plans to deal with.) If you know of another location for certain things - it's your responsibilty to speak up and let the office know, as you found out the hard way.

All insurance plans try to save whatever money they can - why should they pay for something when you can? That's why the $200 copay for outpatient visits. Many people use hospitals for primary care instead of a regular doctor and therefore it costs insurance companies more money when people do this, and money doesn't grow on trees for anyone. (I know someone who went to the local ER - which is minimum $1000 a visit billed to the insurance - because her child was diagnosed with a heart murmur and she wanted to know more about it. This person could not understand why her insurance refused to pay for this visit. Ummm. Because that's why they have doctors in their network!!)

As you found out the hard way, which is sucky, it's the patient's responsibility to know their own insurance. Every single plan is different - there's no "common for all HMOs" - it's all based on individual employers and what they're willing to allow.

Answer 2

CIGNA, as most insurance companies, have many networks and you cannot generalize. I would say it could be something to do with how your hospital bills. My mamography is done at the out patient clinic which is part of my hospital. But you have to be careful how the bill is coded. I'd say you are lucky if your deductible is only $200. Once you meet that you're covered for the year and any additional costs will be coverd.

Answer 3

Cigna is one of the worst carriers I have delt with. Check you plan book. Ask your benefit rep. Do your homework. The more you know, the less hassle you will get. An educated consumer scares insurance companies.