Syosset News

A 1. The Syosset School District Board of Education meeting is tonight at 8 p.m. at South Woods Middle School .

When Sharon Smith chose an out-of-network specialist to perform a complicated jaw surgery on her teenage son last May, she knew it would cost her more. But she was not expecting $15,000. Consumers have long complained about the cost of going outside their health plan's network, but Smith encountered a new twist: A growing number of insurers have changed the way they calculate reimbursements to shift more of the expense to patients. Now, instead of paying a percentage of the 'usual and customary' charges from physicians and other providers, insurers are basing reimbursements on a percentage of what Medicare pays, which can be much less. 'Every carrier is moving to this,' said Ken Sperling, global health care practice leader at the benefit consulting firm Aon Hewitt. Many employers welcome the change as a way to slow rising premiums, but some 'employees are going to get stuck shouldering a significant portion of the bill because they don't understand how it's done,' Sperling said. Consumers are responsible for the difference between what the out-of-network doctor charges and what their insurer pays. But few understand the basis on which plans reimburse, let alone the widely varying prices doctors and hospitals charge. As a result, they may be blindsided by big bills, said Lynn Quincy, senior health policy analyst at Consumers Union. Insurers that use the Medicare-based method -- including Oxford, a subsidiary of the nation's largest insurer UnitedHealthcare, Cigna and Empire Blue Cross Blue Shield -- say the new approach offers greater consistency and thwarts efforts to game the system. 'Usual and customary became abused by a minority of physicians,' said Mark Wagar, CEO of Empire in New York, which is switching most policies to the new method. 'It was not infrequent to see an emergency case where 98 percent of the physicians would charge $5,000, but some outlier would decide to charge $50,000,' which would drive up the average. There are no good estimates of how many consumers are affected by the switch, but tens of millions have the type of health plan that allows them to seek care outside the insurer's network. Some say they discover the change only after they rack up big bills. Smith, a certified public accountant in Syosset, N.Y., said she thought her Oxford plan would cover as much as 80 percent of the total and was shocked when it paid $2,500 toward the surgeon's $18,000 fee. That $2,500 is 150 percent of the Medicare rate. Smith owed the rest. Had the usual and customary standard been used, her policy would have paid at least $12,000, said Oxford spokesman Tyler Mason. 'If I had set out knowing all these costs ahead of me, I could have negotiated, or I could have said, 'Wow, I can't afford this,' ' said Smith, 53, who is not currently working because of a medical disability. To be sure, the information about how the insurer would calculate the payment was included on page 108 of a 126-page booklet outlining the Oxford plan offered by her husband's employer. The two-page explanation says the employer purchased a rider from Oxford that changed out-of-network payments from a percentage of usual and customary charges to Medicare rates plus 50 percent. 'It was so buried, I never saw it,' said Smith, adding that even if she had, there was no easy way to find out what Medicare pays for a procedure. Mason said Smith should have asked her surgeon how much he would charge, and then called the insurer to see how much it would pay toward that charge. He also noted Smith received a letter from Oxford a month before the surgery saying her costs would likely be higher if she went out of network. However, it did not spell out the Medicare-based method or her exact liability. Her cost would have been only about $500, on top of her deductible of about $2,000, if she had chosen from among several dozen in-network oral surgeons in nearby New York City, he said. Insurer networks are designed to slow rising health care costs, in part by getting doctors and hospitals who join to agree to negotiated rates, which are generally lower than their usual fees. Out-of-network hospitals and doctors can set their own fees and 'balance bill' patients for the portion insurers don't cover. Medicare strictly limits how much patients can be balance billed by doctors who don't participate in the program. 'One of the most expensive decisions that a customer could make is going out of network,' said Alan Muney, chief medical officer at Cigna. Smith said she went outside her network because she wanted a surgeon with experience in the type of complicated jaw surgery needed by then-18-year-old Thomas. 'This is my son's face,' she said. Benefit consultants, insurers, patient advocates and actuaries say the shift to Medicare rates began after a national database tracking usual and customary charges -- run by UnitedHealthcare subsidiary Ingenix -- was shuttered in 2009 following an investigation by the New York attorney general, who questioned whether the data were skewed in favor of insurers. While the closure was touted as a consumer win, 'Unfortunately, it's worse now,' said Jennifer Jaff, executive director of Advocacy for Patients with Chronic Illness, a group that helps file insurance appeals for consumers. 'Once New York said you can't use those [Ingenix figures] anymore, the insurers looked at it as an opportunity to pay even less.' After the closure, some insurers turned to basing payments on Medicare rates, said Rob Parke, an actuary at the consulting firm Milliman. While an office visit for a primary care doctor paid at 170 percent of Medicare might be similar to payments made under usual and customary calculations, Parke said, specialist visits and other types of care often don't come close. Stepping into the data gap left by Ingenix is a new nonprofit created by settlements paid by insurers involved with the investigation. Called Fair Health, the New York-based group began selling data a year ago that tracks doctors' usual and customary charges and includes a website calculator for consumers to figure their costs. It now contracts with medical and dental plans covering more than 170 million people, said Robin Gelburd, president of Fair Health. 'Employers can choose to use Medicare rates, that's totally fine,' but it needs to be put in context, Gelburd said. Cigna's Muney said the insurer has decided to use Fair Health's usual and customary calculations but will continue to offer the Medicare rate method as an option because it was well-received by employers. Like several insurers, Cigna also has an online calculator that shows policyholders how much they would pay for services in and out of their networks.

A Giants win! Giants win! Did you go to the parade to celebrate? Do you still want to party and pretend football season isn't over? Between Syosset's Cutest Couple , the best places for a romantic dinner in the neighborhood, and the perfect Valentine's playlist , we've got you covered for planning the perfect day! And there's still more to come! ... (more)

A Future Nobel Prize winners may very well be graduates from Syosset schools. Science Olympiads from Syosset High School , Thompson and South Woods Middle Schools presented their projects to parents, teachers and administrators.

Start your Friday with this daily guide, where you will find five pieces of information you should know today, like events happening in town or topics being covered on the site.

A In honor of Valentine's Day, Patch wants to know who the cutest couple in Syosset is.

The provider of after-hours pediatric urgent care expanded its Syosset site from 5,000 to 7,000 square feet, including additional treatment rooms, a larger reception area, new X-ray room and updated dA©cor. "The expansion of our Syosset practice is a reflection of both the company's continued growth since we first opened seven years ago as ... (more)

When Sharon Smith chose an out-of-network specialist to perform a complicated jaw surgery on her teenage son last May, she knew it would cost her more.

A Weather Reminder: The Syosset area is due for snow beginning in the early afternoon and going through midnight.

A Though TOBAY unemployment decreased in December 2011, the improvement was only slight .

The Civil War was not fought in New York, but the state, including Long Island, did contribute significantly to the war with men, supplies and related events.

A The bustling little Long Island town of Syosset has had many facelifts over the years.

Nassau County Legislator Judy Jacobs wants answers concerningA County Executive Ed Mangano 's new plan to consolidate county police precincts.

A Claiming it will save money and not diminish police protection,A Nassau County Executive Ed Mangano A announced Monday that the county's eight police precincts will merge into four.

A Although Borders is the most prominent empty business in Syosset, a scenic trip down Jericho Turnpike involves a lot of For Sale and Office Space signs.A Syosset Patch will be highlighting those empty buildings in the neighborhood, asking our readers what should replace it.

A A Syosset man is charged with criminal possession and sale of marijuana after attempting to sell it in front of his home, according to second squad detectives.

Fridays feel so good, don't they? We'll help you get into that weekend groove with our guide to this weekend's nightlife and a couple of games that are sure to be great matchups tonight! Here's what else you need to know: 1. Chaminade basketball is back on the court tonight in a matchup against reigning champion St.

"I want to implement improvements that will make Syosset an even better place to get an education than it already is.A In these difficult financial times, the school district, led by a proactive board, should behave much like a current Fortune 500 company.A Creating improved efficiencies, realizing greater yield for each dollar spent, and squeezing ... (more)

A 1. The prescription drug epidemic is the focus of tonight's wellness program, " The Rx Nightmare ." Guest speaker Steven Chassman will speak to parents and students at 7 p.m. in the Syosset High School auditorium.

A The Syosset Board of Education said they will be posting updated budget information on the new district website as soon as it becomes available.