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GEHA’s Seven-Year “Glitch”

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 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 US 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 Government Employees Health Association (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 $50-100 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 EOB’s personally, a clear and definitive pattern of fraud emerges demonstrating GEHA makes every single patient responsible for $50-100 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 $50-100 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 – it 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?

 

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JulieRes Morgan M.D.Niran Al-AgbaBarry Carolpjnelson Recent comment authors
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Julie
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Julie

I also agree that this situation should be brought to your local congressmen’s attention. It seems that the insurance company is not interesting in fixing this issue. I share a similar experience where I went in for a preventive visit but ended up with a bill from the lab. This was quite shocking considering, basic blood work in included in an annual physical. It wasn’t a huge bill, but I technically it was suppose to be covered. I honestly think insurance companies nad labs try to play it off and pretend they didn’t know patient are being charged for things… Read more »

Res Morgan M.D.
Member
Res Morgan M.D.

We had a similar “glitch” where the local BC/BS, our largest payer, entered our contracted fees incorrectly into their computer system. Every single claim was paid wrong (i.e., under payed) for eighteen months. Absolutely no response to our problems, no help from the state insurance commissioner. Finally, my office manager and I scheduled a meeting at their headquarters with an “executive VP.” Arriving with 10 boxes of incorrect EOBs, we were informed that there was no office available in which to meet, and we would have to talk to said VP standing up in the lobby. When we started calling… Read more »

Barry Carol
Member
Barry Carol

If the glitch has persisted for as long as you say it has, why haven’t you and your patients contacted your congressman and senators to bring the matter to their attention and request that the matter be dealt with? I doubt that the potential savings amount to more than a relative pittance as a percentage of total claims paid by this insurer either locally or nationally. I also wonder what percentage of these patients are perfectly capable of paying for these services out of pocket and how many are not getting their children vaccinated because the insurer won’t pay. I’ll… Read more »

Niran Al-Agba
Member

Barry, at the one year point, we wrote to the Washington State Insurance Commissioner because that is who usually has jurisdiction. I actually heard back from them today that it is the U.S. Office of Personnel, so contacted them and have suggested patients struggling with this issue do the same. So as far as the savings goes, for some individuals it can be $50/per injection/toxoid and counseling on immunizations charges. In the first two years of life a child receives approximately 22 shots but many toxoids are included in that portion. After correcting one group of claims from a family… Read more »

Barry Carol
Member
Barry Carol

Niran, my brother-in-law worked for the VA his entire career. He tells me when the folks there got an inquiry from a congressman (usually a staff member representing the congressman), the sense of urgency to resolve the issue was much higher than it would otherwise be. I think you and your affected patients should contact your congressman and your two senators. The potential for getting the issue resolved that way is high and the cost in time is low. Even in this high tech email and smart phone era, I think an old fashioned letter might be more effective, in… Read more »

Niran Al-Agba
Member

Barry, this is great advice. I will send off the letters Monday. Thank you. I will keep you posted if I and when I hear back. As always, thank you for your thoughts.

pjnelson
Member
pjnelson

GEHA has been around a very long time. The National Post office uses them. They have always paid poorly. Somehow, it seems they have been able to shield their business model to withstand the changing times. The irony, of course, is that Congress and all of its employees have there own separate health insurance and retirement plan. That is, they don’t participate in Medicare and their health insurance is isolated from national healthcare reform. Another attribute of our healthcare industry that is self-serving.

pjnelson
Member
pjnelson

Nira,

Well-said!

Paul

P.S.: I’ve always thought that this happens repetitively for Primary Healthcare because there is an institutional, co-dependent relationship between the payers of Complex Healthcare and the providers of Complex Healthcare. It is sustained at the expense of the providers of Basic Healthcare (PCPs and mental health). Since 1960, our nation’s healthcare spending has increased 1.98% annually compounded, faster than our nation’s economic growth through 2016. In effect, there is an evolving shortage of Primary Physicians and a glut of Specialists. Parkinson’s Law reigns supreme!

Steve2
Member
Steve2

“The Affordable Care Act – the health insurance reform legislation passed by Congress and signed into law by President Obama in March 2010 – requires new health plans to cover preventive services and eliminates cost sharing (such as co-pays and deductibles for certain services). You may be eligible for preventive services including coverage for vaccines. Most insurance companies are now required to cover the cost of immunizations and preventive care, but a select number of older and more limited plans don’t yet apply to the new law.” It looks like older plans, not just the GEHA, were exempted. Not having… Read more »

Niran Al-Agba
Member

GEHA does have to pay for these services. So far, every family that has called to have it corrected immediately has a check issued to the provider. They know it is part of the mandate. They are dragging their feet. They are being allowed to do so at the expense of the patient and the physician. Period.