Issues with health insurance coverage
Recently I have needed to go to the doctor’s and hospital a few times. On my insurance statement I keep getting “Charge exceeds Cayman Islands Legislated Standard Fee Schedule” and have to pay more money out as well as my co-pay. Why does the standard fee schedule not seem to be compatible with a lot of health care providers and when was the last time it was updated?
Just as a note I have also seen a doctor in the US whose charges were a lot higher and I was covered 100%. Why can’t the insurance companies be made to pay the full amount as they do in the US (this is all with a Cayman policy)?
Auntie’s answer: This was clearly a question for the experts so I contacted the Health Insurance Commission (HIC). I received answers for both of your questions.
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First, about your issue with the charges exceeding the fee schedule. A representative from the HIC pointed to Section 19 of the Health Insurance Law (2013 Revision) which provides for the fees that must be paid by the insurance company to the registered medical practitioner or healthcare facility for services to an insured person in the Cayman Islands.
The official explained that these fees are looked at regularly, with actuaries conducting the last review between June and September 2015. The government is “considering the recommendations provided by the actuaries on the matter” but, at this point, it is not clear when any decision will be made on those suggestions. The HIC representative said he understands that when that happens the “recommendations will be fully disclosed”.
For your second question, without all the details of your particular case – such as the schedule of benefits of your insurance provider and your contract – it would be difficult to provide a definitive answer.
Generally speaking, though, it was explained that health insurance companies may reimburse medical providers for services to their clients by utilising the Usual, Customary and Reasonable (UCR) fees for that particular area (zip code) of the US.
While the level of fees will vary, the HIC official said, “I would hazard a guess that the reader’s health insurance provider may also have an agreement with a ‘network’ of medical providers which could include that doctor (you saw in the US).” In the circumstance where there is a network arrangement, the doctor would be reimbursed at the level of fees specified in the agreement.
The health insurance company is usually able to obtain significant discounts on the UCR fees in the US when a patient uses the services of a medical provider in its network, and they can cover 100% of the fees.
For Cayman, the law establishes Standard Health Insurance Fees and the percentage of those fees that will be paid to the medical provider is based on the terms of the health insurance contract.
The law mentioned in this column can be found on the CNS Library.
Category: Ask Auntie
As long as healthcare and health insurrance is in private hands, you will pay the return on investment for their shareholders.
I have also experienced this same situation. However I do not blame my doctor for the difference in charges/payments because I see how little the insurance company pays. It sees as though I get two or three visits and one set of blood tests and after that my “benefit level exceeded” which means after that I pay 100% of my doctors fees. Not bad for over $4000.00 per year! With this type of set up I can understand why so many people simply can’t pay their hospital bills.
Remember, the official fee schedule also sets what the government pays insurance companies. It is not in government’s interest to raise those fees. So once again the government is for itself and the big influential insiders!
East End you are exactly right. Auntie why did you not ask the question – when was the fee schedule last adjusted?. The HIC is hoodwinking you – we hear of these regular reviews, but the fact is nothing is done and fees ar still limited to the schedule established I believe around 12 years ago. Virtually no fees or service charges have remained static for the last 12 years, just look at the increases in charges made by the Government hospital. The insurance companies use the “Legislated Fee Schedule”as an excuse to inflate thir profits, and hypocritically have increased their premiums many times over the last few years.
I have this issue a lot too. The Drs, specialists, hospitals, dentists etc – all charge more for their services than the approved “Cayman Islands Legislated Standard Fee Schedule”, but the insurance companies are only required to pay up to the standard fee when processing the claim. This constantly leaves the insured person further out of pocket, sometimes substantially, by having to pick up this excess charge personally.
I feel that medical practitioners should be made to declare and clearly disclose where they are charging more than the approved rate, so that patients are fully aware of the charges they will eventually be forced to pay – often unexpectedly.