Moral Dilemma?

By on January 14, 2011 6:45:31 PM from JoeUser Forums JoeUser Forums

Tova7

Join Date 09/2005
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Warning:  This is a bit of a ramble…doing it very fast….but if you can make it through, would love your feedback!

I went to get my wig today.

It’s a nice wig, looks just like my old hair, except a little longer. Insurance covers 80% of a “cranial prosthesis,” but once in a lifetime.

I went to a Network provider (NP). A NP is someone who signs a contract with my insurance company agreeing to accept payment for whatever amount my insurance company deems worthy of the service. If there is any difference in what the NP charges and is allowed by the insurance company, the NP agrees to write it off, (ie eat it and not try to get the money from the client.) My insurance pays 80% of the amount they deem the service is worth/product, and my co-pay is 20%.

Good. Great.

My doctor gives me a prescription for a cranial prosthesis (wig) a few months ago. My insurance company sends me a letter of approval, and lists the NP in the area. I call the NP and make an appointment. A hair salon on one side, a wig shop on the other, and named after the owner who still cuts hair for a living.

When I arrive, I ask to make sure they take my insurance, they do. Said they received the approval from my insurance company via fax just before I walked in.

We spent over an hour trying to find the right wig, length and color for me. I picked one, they ordered it and told me they will file with my insurance company when it comes in and I accept it. (It was on backorder though so it took almost two months.)

Yesterday the NP (in this case the owner) calls and says my wig is FINALLY in..WOO HOO!! I show up and the owner is cutting someone’s hair, but the girl who does the wigs took me back to the wig chair. She opened the box, took it out, we messed with it, and then the owner comes over and asks if I would like her to trim it. (The flyer my insurance company gave me for the NP says a cut is included in the price of the wig.) I said yes, and went to sit in her chair. Ten minutes with a razor and she made a generic wig fit my face, and look a lot like my old hair.

I was very satisfied. And because I waited for 2 months and didn’t complain, she threw in some leave-in conditioner as well. WOOT!

Wearing my new wig, I went back into the wig section to bag up my things. I was just about to walk toward the front, having finished business, when the wig girl approached me. The following conversation ensued:

Girl: “B’s been having problems with some insurance companies not paying the full amount for our wigs. So the only way you can take the unit (wig) home today is if you pay full price right now.”

Me: “How much is the full price?”

Girl: “$600.”

Me: “Um, B is a network provider. By definition she’s agreed to accept what my insurance pays her minus my co-pay. Do you know what my co-pay is?”

Girl: “No, we don’t know until your insurance co. pays us because it’s different for every claim. But, if you don’t have the $600 on you, you can sign this form. It basically says you will pay the difference, what your insurance doesn’t pay, you will cover.”

Maybe I’m wrong, but this felt like SUCH a scam. Not once during this entire process was price mentioned. (It is never mentioned when I use other NPs either. They know beforehand what my insurance pays, and offer service/products accordingly…if they don’t like it they stop being a NP.) They let me wait two months, until the wig is on my head, cut to fit my face, and then tell me they want the money up front? (Direct violation of their contract with my insurance company.)

Me: “This isn’t right. I’ve never had this issue before with any other NP.  And my insurance company sends out literature all the time telling us to NEVER pay full price up front, though a co-pay is acceptable.”

Girl: “Let me get B.”

B comes over. “Here’s the deal. Lately, your insurance company has only been paying me about $175 for each unit. This one cost me $550 and that’s LAST year’s price, I’m giving you a deal since technically you ordered it last year. I can’t just eat the difference between $175 and $585 with tax and stay in business.”

Me: “I understand your frustration, that seems odd they are only paying $175 though.”

B: “Well it’s some bureaucrat deciding how much it’s worth, they don’t know. And if that’s all I’m getting, then you need to take off that unit and pick out a $175 wig.” (First time anyone said this to me or that’s exactly what I would have done initially.)

Me: “I am responsible for my co-pay, not paying full price up front.”

B: “I can’t eat that loss. You can’t leave the shop with the unit unless you pay for it up front, or sign this sheet saying you’ll pay the difference.” She hopes I understand and goes back to her side of shop.

Girl: “Do you want to sign this?”

No I didn’t. But I’ve waited two months for this stupid wig…so I read the sheet and all it says is I agree to pay what my insurance doesn’t cover. I figure it’s my bad and I’ll just have to suck up the difference. So I signed it. (But it felt kinda like a bait and switch scam…)

I came home and called my insurance company.

They said B was in violation of her contract just for asking me to pay up front, mostly because she hadn’t filed a claim yet. Depending on the code she used, my insurance may give her the full asking price, minus my co-pay, or they may give her $175.

My insurance lady also told me that even though I signed a paper agreeing to pay the difference, B has already signed a contract saying that she would NOT seek the difference from clients, and any promise I made to pay the difference can only apply to the co-pay. That is specifically signed out in her contract with the insurance company.

She also told me that no matter what B paid for the wig (even if it was $1000), she KNEW (because she is a NP and deals with my insurance company all the time) what my insurance pays for “cranial prosthesis” and therefore is responsible for the difference (if any).

Here is what I think happened.

I think B is a hair dresser, she doesn’t understand the intricacies of insurance, and has no support staff to help her.

B posted signs in her shop that state “If your insurance company only pays $175 for a wig, you are responsible for the difference.”

(I asked wig girl on the first day if my insurance company was one of those that only pay $175.  She assured me they were NOT, that they pretty much covered any “unit in the shop.”)

B thinks those little signs negate her contract with insurance providers. To save herself from eating the difference, she should tell people when they come in…”Your insurance company will only pay $175 for wigs. You may choose from these which are all $175 or below.”

Instead, they showed me high end wigs, assuring me my insurance was good about covering the costs (and I couldn’t get specific cost information from the insurance company because there are a bunch of different codes (which pay different maximums) the wig shop can use to determine payment). The Insurance Comp told me NPs are versed in these codes and should have told me right off how much my co-pay would be at the very first appointment. It (the code) was on the authorization the insurance company sent to the shop before I arrived.

So for instance if the code is for medical supplies and the max is $700, they tell me when I walk in the door, your max is $700 and your co-pay is 20%.  So if you choose a $500 wig, you will pay $100 before leaving with the unit.  (This is how every NP I’ve ever worked with does it.)

Whew.

So “legally” I am only responsible for 20% of what my insurance company says the unit is worth. The insurance company said if B has a problem with pricing she has a representative in the insurance company she needs to call to hash it all out. Technically she doesn’t have to be a NP, she volunteered for the gig and does brisk business as she is the ONLY NP for wigs in this area.

Morally however, I understand B’s position. While she didn’t deal with me directly, she may assume the wig girl discusses insurance claims with each client. She doesn’t. Also, she cuts hair for a living. I don’t think she understands all the ins and outs of insurance billing. (Like the coding…I think she’s probably coding all wigs the same and that’s why she’s getting $175…some are able to be coded as “medical supplies” which ups the maximum. The insurance lady told me today I was allowed $700 for medical supplies, but if B bills it as just a wig…$175.)

And finally, I feel bad for her. She provides this very necessary service to cancer patients and I know she feels taken advantage of. She knows so little about it, she told me to be sure to explain to the insurance co. that there is a difference between a cranial prosthesis and wig. I’m not the one who hashes that out….she is since she has agreed to be a NP. She is responsible for negotiating prices.  But she doesn’t know this.

My husband says none of that is our problem. He was livid wig girl told me my insurance covered any wig in the shop, showed me only high end units and encouraged me in what to choose (since I was basically wig retarded).

No mention of full price until I’m in it, cut, and walking out the door. (In this instance I don’t pay my co-pay until my insurance sends me an explanation of benefits, how much they deemed the unit is worth, and what my co-pay is because the wig shop has “no idea” for sure how much the insurance co will pay because its “different all the time”…).

I’m seriously thinking about paying the difference, but my husband vehemently disagrees. Even the insurance lady told me NOT to pay it, and she is sending some “educational” material to B to help her understand her contractual obligations better.

Even though it felt like such a scam…I dunno. She’s a small business owner, and I think there is some miscommunication between her and the insurance comps.

Of course I could take it back, but I know she can’t sell it for what she will lose between me and the insurance co if I don’t pay the difference…its cut to fit my face.

 

So what would you do?

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January 14, 2011 6:57:25 PM from JoeUser Forums JoeUser Forums

 

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January 14, 2011 7:11:44 PM from Stardock Forums Stardock Forums

I don't know how much is her misunderstanding and how much is her intentionally scamming people because of her problems with misunderstanding.

 

It's not your responsibility to pay the difference, though.  Imagine if she is doing this to lots of other women who don't know they don't have to pay that and who don't really have the money to spare.  

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January 14, 2011 7:29:48 PM from Stardock Forums Stardock Forums

read this whole thing to my husband and he said "make them ( honor their contract." 

She has to do what she agreed to do. 

Obviously if this isn't working for her she'd get out of the NP business. 

I agree with your husband. 

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January 14, 2011 7:38:32 PM from Stardock Forums Stardock Forums

If your having some kind of crisis of conscience then I would say pay it, if you feel she was out of line then don't. Bottom-line, whatever makes you feel comfortable then that's what you should do. "cranial prosthesis' wow that's strange terminology for a wig ; -)

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January 14, 2011 7:52:17 PM from JoeUser Forums JoeUser Forums

She has to do what she agreed to do.

That's what the insurance co said too.  It just seems to me that she doesn't know her wig girl is basically selling her high end wigs for $175.  That's probably why she put up signs ...

This is hard because all wigs are not created equal and it sounds like between her insurance coding ignorance, the wig girl's incompetence, and the insurance company, she is getting the same price for ALL of them.  (And probably can't figure out why clients are ordering $600 wigs!!  She doesn't realize she has to tell us how much the insurance co pays (ie how she will code it) and what our co-pay is.)

 

It's not your responsibility to pay the difference, though. Imagine if she is doing this to lots of other women who don't know they don't have to pay that and who don't really have the money to spare.

I'm going to the local office Monday or Tuesday Tex to make sure they know a NP is doing this.  I don't want to get her in trouble, but it is exactly for the reason you stated. 

I wonder how many women have paid up front, or left in tears because they didn't know what to do.  I'm bald and I think she assumes that = desperate.

I'm not desperate because I have other alternatives (like hat hair, ha) I bought cheap on the net...but some women are desperate because this insurance covered wig is the only one they get.

 

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January 14, 2011 7:53:56 PM from JoeUser Forums JoeUser Forums

If your having some kind of crisis of conscience

It's not a crisis necessarily, I just want to do the right thing.  My husband and I usually agree on what that is, but not this time....

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January 14, 2011 9:33:09 PM from JoeUser Forums JoeUser Forums

Seems like everyone has the right take on this...as far as I am concerned.  All the other players in this scenario are trying to make their problem your problem.   

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January 14, 2011 10:38:49 PM from JoeUser Forums JoeUser Forums

There is no moral or ethical issue here for you to struggle with, Tova.  B is immoral, unethical and the one whose conscience should be bothering her.  B's 'position' is none of your doing.  It's not surprising, knowing what little I know of you from these blogs, that you are sympathetic - that's just how you roll and I admire your compassion.  But...

Here's the 'right thing':

B is legally obligated to honor the terms of the contract she signed with your insurance company.  You are under no moral, ethical or legal obligation to solve problems she signed up for.  She can't obligate you to bail her out.

You have the wig.  Let B file the insurance claim (as a contracted provider, they are obligated to do so) and do not pay her a penny more than the amount your insurance company says you owe (you have a contract with them, too).   The piece of paper B had you sign when you picked up the wig is fraudulent, completely worthless, obligates you to nothing and would be laughed out of court if B tried to go after you.

If you were covered by Medicare, this would be 'Medicare Fraud' and subject to criminal penalties.

May you sleep soundly with a clear conscience.  It really steams me that there are people who would stoop this low and take advantage of cancer victims at a time when most are very vulnerable (not that you are, mind you).  B is a vulture and this story made my skin crawl.

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January 15, 2011 11:11:55 AM from JoeUser Forums JoeUser Forums

You have the wig. Let B file the insurance claim (as a contracted provider, they are obligated to do so) and do not pay her a penny more than the amount your insurance company says you owe (you have a contract with them, too). The piece of paper B had you sign when you picked up the wig is fraudulent, completely worthless, obligates you to nothing and would be laughed out of court if B tried to go after you.

Thanks D.  I like the way you laid it all out.  I read it to my husband and he said, "That's exactly what I've been telling you!!"  heh.

I slept on it and was able to winnow down my personal issues, why it bugs me: 

1.  I feel partly responsible.  I didn't push to know how much the wig cost in the beginning.  I trusted them to show me the appropriate units based on my insurance coverage and take care of it like any other NP.  My bad.

2.  Wig girl screwed up.  She didn't do her job (ie show me only $175 or below units).  So do I just say, "sorry for ya!"  It's kind of like the "finders keepers" mentality.  And in my mind, taking advantage of someone else's mistake, when they let you know it will harm them, is kinda like stealing.

Having said all that however, I thought about my other NPs and applied the same logic.  They give me the same services as everyone else and write off any differences, and yet I don't feel like that is stealing.

So why the difference?

Because the owner handled me personally once the unit arrived...she was the one who cut it...then was in my face with this, telling me she couldn't afford to eat the difference.

It was more personal.  She was willing to sell me a $175 wig to accommodate my insurance yesterday (after ordering this one, waiting two months, cutting it to fit my face, then telling me how much it cost). 

It must be chemo, I'm not usually this wishy washy...lol.  I am going to my insurance's local office next week after my chemo treatment and let them know what's going on.

Right now my husband says we are only paying our co-pay, and since I am conflicted I will bow to his judgment.  (Though the wig is tainted to me now...lol) 

He plans on going in personally to the wig shop and paying it.  THAT will be interesting.

Seems like everyone has the right take on this...as far as I am concerned. All the other players in this scenario are trying to make their problem your problem.

Ha.  That's what my husband says!  lol

I think I may be too close to this whole situation to be logical....(it's HAIR after all, and she tugged on my heart strings, and she was SO NICE (at first)). 

 

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January 15, 2011 12:09:39 PM from JoeUser Forums JoeUser Forums

1.  I feel partly responsible.  I didn't push to know how much the wig cost in the beginning.  I trusted them to show me the appropriate units based on my insurance coverage and take care of it like any other NP.  My bad.

No siree, Bob.

B needs to take responsibility for her mistake (if it was one - I'm frankly not so sure) and for those of her employees.  If they showed you the wrong wig, knowing you were a contracted insurance patient, ordered the wrong wig, knowing you were a contracted insurance patient, waited 2 months for it to come in, knowing you were a contracted insurance patient, and cut the wig to your liking, knowing you were a contracted insurance patient, they knew you were a contracted insurance patient.  There are only two explanations for what happened: 1) it was an honest mistake, for which you are not in any way responsible, or 2) they scammed you hoping to get around the insurance restrictions & score more money.  Either way, B's 'position' is reprehensible.

Remember, the reason you went to her shop in the first place was because she's a contracted provider.  You shouldn't feel conflicted at all.  If B pushes it, you should report her ass to the insurance company and the BBB (not that either ever does much, mind you, but if the insurance company cancels her provider contract, which they should if 2) above is the case, at least she won't be able to lure any more women in under false pretenses).

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January 15, 2011 1:03:06 PM from JoeUser Forums JoeUser Forums

I'm with Daiwa.  It's nice that you care about how it will affect her but it's really not your fault and not your problem.  And like Daiwa I'm not convinced it's such an honest mistake on her part.  

 

I'm glad your husband is going to go in and deal with the co-pay.  You don't need a guilt trip.

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January 15, 2011 2:15:18 PM from JoeUser Forums JoeUser Forums

You don't need a guilt trip.

Amen.

An honest and ethical businesswoman would never mention the mistake, but if she did let it slip, would follow it with: "Our mistake.  Enjoy your wig and we hope you don't need it too long.  We're counting on you being cured, girl."

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January 15, 2011 6:16:00 PM from JoeUser Forums JoeUser Forums

I'm glad your husband is going to go in and deal with the co-pay. You don't need a guilt trip.

Yeah no kidding....he can't wait to go...he's really mad.  I want to talk to the insurance office first...and report it.

B needs to take responsibility for her mistake (if it was one - I'm frankly not so sure) and for those of her employees. If they showed you the wrong wig, knowing you were a contracted insurance patient, ordered the wrong wig, knowing you were a contracted insurance patient, waited 2 months for it to come in, knowing you were a contracted insurance patient, and cut the wig to your liking, knowing you were a contracted insurance patient, they knew you were a contracted insurance patient.

Omgoodness...never thought of it like that...but you're right...there is no way they could just keep overlooking my insurance like that....and to not mention price or co-pay AT ALL until I was walking out the door?  My gut said it was dishonest, so much so I almost just pulled it off and told them to keep it...but I checked that reaction, nipped it in the bud, and started thinking maybe it was my fault somehow....

 

Here is the tainted wig....no lauging..keep in mind I am learning as I go and haven't mastered styling it yet...just putting it on!!

And the back...

 

 

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January 15, 2011 7:33:55 PM from JoeUser Forums JoeUser Forums

Looks great, Tova.  It's a keeper.

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January 15, 2011 8:41:47 PM from JoeUser Forums JoeUser Forums

Looks great, Tova. It's a keeper

Well it makes me feel a little more human, a little less like a freak.  Of course when the eyebrows go...lol, the freak show begins!

It's real human hair, which is why it was so expensive.  (Or in my mind $600 is expensive, some of my black girlfriends who are really into wigs told me that it's a good deal.)

Thanks D, I appreciate your feedback so much!

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January 15, 2011 8:56:29 PM from JoeUser Forums JoeUser Forums

Tonya, even sick you puts other women to shame.  The wig looks great and you look so lovely.  

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January 15, 2011 11:58:38 PM from JoeUser Forums JoeUser Forums

Tonya, even sick you puts other women to shame. The wig looks great and you look so lovely.

Ah thanks Tex...fake hair and make-up go a looooong way while on chemo

The chemo is eating my muscle up though....I'm not half as strong as I was before...but I'll work on that when its done...

Tuesday I take #3 (of 6) big gun chemo (the one that makes me bald and gives me black veins!)  So half way...but I will be on a single chemo for an entire year...but after the big guns...should not be so bad....

See what I mean about cutting it to my face?  No one really wears bangs anymore...but I do... I don't think most wig wearing women (who would pay $600 for a wig) would get one with bangs...lol, but I guess they are starting to make a come back....

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January 17, 2011 10:17:29 AM from JoeUser Forums JoeUser Forums

Late to the comments, but I agree with Daiwa.  I hope that B learns how to deal with Insurance companies - or gets out of the business.  While we can be responsible for simple mistakes (getting too much change back), we cannot be responsible for bad business decisions and that is what this sounds like.  T here is a reason that people are hired to do insurance paperwork - so mistakes are not made.

And the wig looks great!  If you had not told us, I doubt anyone would know.

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January 17, 2011 10:36:54 AM from JoeUser Forums JoeUser Forums

If you had not told us, I doubt anyone would know.

lol, I pretty much tell anyone who compliments my hair....the women say, "Oh, you have such beautiful hair!"  But the whole time they're eyeing it like....how the heck does she grow that stuff so thick and perfect?

I say, "Thank you.  It's not mine." 

Usually they smile with relief because OBVIOUSLY it couldn't be real, NO ONE has hair like that...so I'm just "one of those women," you know the "fake" kind, so no matter how their hair looks, it is instantly better in their minds because it's "real."

Actually I prefer the sniff and turn which usually accompanies them labeling me a faker, than the false sympathy if for some reason they find out I have breast cancer.  (Occasionally someone will see my port and ask about it...)  The false sympathy is the ONLY reason I don't wear a scarf...it SCREAMS cancer patient...and I'd just rather not be a poster child for it.  Derision is much easier to stomach.

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January 17, 2011 12:15:48 PM from JoeUser Forums JoeUser Forums

You are looking great, kiddo.  Very natural looking wig...you deserve it, quitcherbellyachin.

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January 17, 2011 2:28:44 PM from JoeUser Forums JoeUser Forums

quitcherbellyachin

I'm not belly achin!  I like it. 

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January 17, 2011 4:12:36 PM from JoeUser Forums JoeUser Forums

lol, I pretty much tell anyone who compliments my hair....the women say, "Oh, you have such beautiful hair!" But the whole time they're eyeing it like....how the heck does she grow that stuff so thick and perfect?

I'm just the same way T.  Quite often I'll get complimented on something I wear and then I'll tell them "well I got the pants for 50 cents and the top for $1.25 at Bealls so the whole outfit is less than two bucks!  I probably shouldn't but I do. 

I have no trouble growing thick..it's the perfect part I have trouble with. 

 

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January 17, 2011 7:59:47 PM from JoeUser Forums JoeUser Forums

I probably shouldn't but I do.

I think it's a personality thing. 

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January 18, 2011 1:27:44 PM from JoeUser Forums JoeUser Forums

I wanted to give an update since so many took the time to share their thoughts on this topic.

After chemo today I strolled up to the Insurance office (same building).  I spoke with a representative and he said exactly what everyone here is saying.  My insurance was for any wig in the store.  (I could have gotten the most expensive one there!)  It is spelled out in their contract with the wig shop.  Asking me to pay walk-in-off-the-street-price when she negotiated a pre-determined price with the Insurance company is immoral and frankly bad business.  But she's been getting away with it.

The Insurance Co. is calling B today because she is in direct violation of her contract.  They want to know how many other women they insure have fallen for this and paid in full.  Though B will not tell them, they will likely call recent claims made by her shop.  The insurance comp said they'd hate to lose her because she is the only 'reputable" wig shop in the area.  However, they did tell me I am not at fault in any way and to not pay a single penny more than my deductible.  They also told me the agreed negotiated price for that unit is $262.  That's all they're giving her.  And if she calls me about the rest I am to contact them right away.

So, it seems in this instance I let my emotions get in the way of common sense.  It is difficult when someone looks you in the eye and says they can't afford you...basically you and your insurance company are ripping them off, and they're just a helpless small business owner.

Thank goodness for my husband, you all, and sound advice.  It gave me food for thought and showed me emotion and money do not mix well in my life. 

Always good to learn new things about yourself...even when they ain't purty.

Thanks Again!

 

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January 18, 2011 1:35:09 PM from JoeUser Forums JoeUser Forums

It is difficult when someone looks you in the eye and says they can't afford you

But they do have a choice.  They could have chosen not to join the program.

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