Navigating health-care expenses costly [The Philadelphia Inquirer]

Oct. 21--When 87-year-old Lee Koff received a new defibrillator implant in January at Lourdes Medical Center in Camden, he paid estimated out-of-pocket costs of $125.

That was not much more than the $81 he paid in 2010 for his previous defibrillator, a device that regulates his heartbeat.

But about two months after the January procedure, Koff, who has Medicare Advantage health insurance from Horizon Blue Cross Blue Shield of New Jersey, received a statement saying he owed Lourdes $6,071.

Koff was dumbfounded. He and his daughter, Wendy Krevitz, said they had asked Lourdes office personnel if there were any other costs Koff would have to pay and were not told of any.

"If they had said the estimate was $6,100, I would have said, 'Whoa, I have to think about that,' " Koff said.

Koff, who recently moved from a Marlton retirement facility to live with another daughter in Huntingdon Valley, was determined not to pay a bill that, as far as he could tell, came out of nowhere.

But his telephone calls seeking relief from Lourdes and Horizon, his insurer, were in vain.

Then last week, Lourdes yielded after a query from an Inquirer reporter led to a review of Koff's case by executives.

"Lourdes Health System acknowledges there was an error in the estimate for Mr. Koff's out-of-pocket expenses for his procedure. After reviewing the history, we have determined that the best course is to resolve the issue by honoring the original estimate of $125," Lourdes said in a statement.

Koff was happy with the outcome, but he still wanted the story of his trip through the health-care/insurance maelstrom to be told to draw attention to the problem.

"I'm willing to lose my credit to help other seniors," Koff said before the Lourdes decision in his favor. "They're just paying these bills as they come in. It's a disgrace."

Koff's story is a reminder during the current Medicare Advantage open enrollment period -- which started Oct. 15 and runs through Dec. 7 -- that seniors need to examine insurance plans carefully to avoid devastating financial surprises.

It's not easy, though, as insurance becomes increasingly complex with sometimes widely disparate rules for various scenarios. At the same time, more financial responsibility is pushed onto patients, a trend that will continue under the Affordable Care Act.

"Almost nobody understands their health insurance," said Gene Bishop, a retired internist in Philadelphia.

"Because people on Medicare sometimes have cognitive issues, they are at greater risk," said Bishop, also a former physician adviser to the Pennsylvania Health Law Project, which aids low-income consumers, the elderly, and the disabled.

"[Koff's] absolutely right that people just pay these bills that they don't understand or they don't pay them and they find out that their credit is ruined," Bishop said.

Koff is mentally sharp, but he followed the tendency of consumers to focus on monthly premiums when he received a notice of a change in his insurance plan a year ago, rather than the overall cost.

The overall cost, which is virtually impossible to predict because no one knows what will happen to them, includes co-pays and coinsurance, an additional payment of as much as 20 percent of the claim.

"The thing I looked for when I got the notification is, how much more is the premium. It went from $146 a month to $175.80," Koff said.

Coinsurance is the piece that caused Koff's $6,100 bill, but that change escaped him. "I think I'm pretty alert, but I didn't read every word" of the plan description, he said.

Koff's situation was complicated by the fact that his procedure was scheduled in September 2012 for Jan. 3, after changes to his insurance took effect. It's possible Lourdes' computers were not completely up-to-date with Koff's information.

After moving to Pennsylvania and receiving notification from Horizon that his plan was being discontinued, Koff started looking for new insurance with the help of Krevitz.

He remains baffled.

"We spent four hours with one insurance agent and 51/2 hours with another insurance agent and we're still not sure which plan is best for me. It's ludicrous," Koff said. "It should be more straightforward."

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