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%.
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?”
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.)
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?