“No Surprise Charges” is one of the key Lessons Learned in Elisabeth Rosenthal’s fabulous new book AN AMERICAN SICKNESS (Penguin Press, 2017). “Hospitals in your network should also be required to guarantee that all doctors who treat you are in your insurance network.”
We have all harshly experienced or heard about under-the counter out-of-network hospital charges:
“A Kaiser Family Foundation survey finds that among insured, non-elderly adults struggling with medical bill problems, charges from out-of-network providers were a contributing factor about one-third of the time. Further, nearly 7 in 10 of individuals with unaffordable out-of-network medical bills did not know the health care provider was not in their plan’s network at the time they received care.”(A)
A study that looked at more than 2 million emergency department visits found that more than 1 in 5 patients who went to ERs within their health-insurance networks ended up being treated by an “out-of-network” doctor — and thus exposed to additional charges not covered by their insurance plan.” (B)
Here is a brief case study:
“When Janet Wolfe was admitted to the hospital near Macon, Georgia, a few years ago, her lungs were functioning at just one-fifth their normal capacity. The problem: graft-versus-host disease, a complication from a stem cell transplant she received to treat lymphoma. Over the course of three days she saw three different doctors. Unbeknownst to Janet and her husband, Andrew, however, none of them was in her health plan’s network of providers. That led the insurer to pay a smaller fraction of those doctors’ bills, leaving the couple with some hefty charges.” (C)
So what can you do to avoid out-of-network charges?
– Speak with a practice representative before being seen to understand the costs of seeing your doctor on an out-of-network or a cash basis. (DOCTOR note: maybe you need to leave and go to an in-network physician instead)
– If you need additional services, such as surgery, imaging or physical therapy, ask your doctor to refer you to an in-network facility to keep your costs down. (D)
A New York law is a great start toward transparency to reduce out-of-network surprises.
Under a recent New York law, Hold Harmless Protections for Insured Patients, “… patients are generally protected from owing more than their in-network copayment, coinsurance or deductible on bills they receive for out-of-network emergency services or on surprise bills.
A bill is considered a surprise if consumers receive services without their knowledge from an out-of-network doctor at an in-network hospital or ambulatory surgical center, among other things. In addition, if consumers are referred to out-of-network providers but don’t sign a written consent form saying they understand the services will be out of network and may result in higher out-of-pocket costs, it’s considered a surprise bill.” (E)
“Advocates for patients, senior citizens, labor unions, and businesses hailed Gov. Phil Murphy’s signing of a complex and controversial measure designed to curb the impact of costly “surprise” medical bills in New Jersey. Supporters said the law, nearly 10 years in the making, is the strongest of its kind nationwide…
The Democratic governor, who pledged his support for the bill in March, said the law closed a loophole to protect patients and make healthcare more affordable; sponsors called it the right thing to do to protect vulnerable residents. “We have put patients first. We have made clear that New Jersey stands for transparency when it comes to health care,” …
The reform is designed to protect patients, businesses, and others who pay for medical care from the high-cost bills associated with emergency or unintentional care from doctors or other providers who are not part of their insurance network. The law requires greater disclosure from both insurance companies and providers — so patients are clear on what their plan covers — ensures patients aren’t responsible for excess costs, and establishes an arbitration process to resolve payment disputes between providers and insurers, a mechanism intended to better control costs…
“It’s a solution that is fair to healthcare providers and consumers alike because it strikes a balance between providing reasonable compensation to facility-based providers, while protecting consumers from unexpected, nonnegotiable bills that drive health insurance premiums higher,” said NJBIA president and CEO Michele Siekerka. “This was an extremely difficult and complicated issue, and NJBIA commends the governor and the bill sponsors who worked hard to address the concerns of all stakeholders.”” (F)
A price transparency RFI released by the agency this week asks for input on how CMS might develop consumer-friendly policy. In a request for information announced Thursday, the Centers for Medicare & Medicaid Services asked whether providers and suppliers should be required to tell patients, in advance, how much a given healthcare service will cost out-of-pocket. If the agency were to move forward with a price transparency requirement on physician practices, it could prove controversial. Many doctors say they themselves lack the training they would need to have effective conversations about how much the healthcare services they provide will ultimately cost patients.
But CMS has repeatedly indicated that it aims to get more pricing information to consumers one way or another. “We are concerned that challenges continue to exist for patients due to insufficient price transparency,” the agency wrote in its RFI, which is included in proposed revisions to the Physician Fee Schedule, Quality Payment Program, and other policies for 2019…
In order to determine what additional actions may be appropriate to connect consumers with accessible price information, the CMS price transparency RFI includes a variety of questions, including the following:How should the phrase “standard charges” be defined in various provider and supplier settings?
Which information types would be most useful to beneficiaries, and how can providers and suppliers empower consumers to engage in price-conscious decision-making?
Should providers and suppliers have to tell patients how high their out-of-pocket costs are expected to be before providing a service?” (G)
“Patients are at a higher risk of receiving surprise medical bills on Affordable Care Act exchanges, according to a new report.
In 2018, more than 73% of plans available in the exchange marketplace offered restrictive networks, compared with 48% in 2014, according to the report (PDF) commissioned by Physicians for Fair Coverage. PFC is a nonprofit alliance of physician groups which advocates for ending surprise insurance gaps and improving patient protections…
“This research confirms what patients and physicians across the country have known for some time,” said PFC President and CEO Michele Kimball in a statement. “Insurers have been systematically narrowing their networks and increasing premiums, creating surprise insurance gaps that patients don’t realize exist until it’s too late. While insurers are making record profits, patients are paying more for less.”
The coalition, which includes tens of thousands of emergency physicians, anesthesiologists and radiologists from across the country, is pressing for more states to adopt legislation to solve the problem of surprise medical bills. The problem often occurs when a patient seeks care at an in-network hospital but is then surprised the doctor treating them is out of their insurance company’s network—a fact they usually find out when they get the doctor’s bill.
“When it comes to health care, nobody likes a surprise. This study confirms what we’ve been hearing from patients for years: there is no real way for patients to avoid a ‘surprise’ medical bill, even when they’re insured and try to stay in-network. We need a transparent healthcare system designed for patients, not profits,” Rebecca Kirch, executive vice president of healthcare quality and value at the National Patient Advocate Foundation, said in a statement…
The best estimates indicate that 1 out of 7 times someone goes to the emergency department, they are going to be stuck with a surprise bill.” (H)
A patient came to see me with lower abdominal pain. Was she interested in my medical opinion? Not really. She was told to see me by her gynecologist who had advised that the patient undergo a hysterectomy. Was this physician seeking my medical advice? Not really. Was this patient coming to see me as her day was boring and she needed an activity? Not really. After the visit with me, was the patient planning to return for further discussion of her medical status? Not really.
So, what was going on here. What had occurred that day was the result of an insurance company practice that I had thought had been properly interred years ago.
The woman had pelvic pain and consulted with her gynecologist. An ultrasound found a lesion within her uterus. A hysterectomy was advised. The insurance company directed that a second opinion be solicited. A second gynecologist concurred with the first specialist. The patient advised me that the insurance company wanted an opinion from a gastroenterologist that there was no gastrointestinal explanation for her pain. In other words, they did not want to pay for a hysterectomy that they deemed to be unnecessary.
How should we respond? (I)
“In the absence of laws barring balance bills and surprise bills, there are steps hospitals and health plans can take to protect consumers from medical debt. The Healthcare Financial Management Association urges hospitals to inform patients that they may be eligible for financial assistance provided directly by the hospital and make clear to patients what services are and are not included in their price estimates. Hospitals also need to communicate better with uninsured patients about medical costs and options for sharing costs..
Health plan best practices include helping members estimate expected out-of-pocket costs and sharing price information for providers in a given region.
Beyond that, hospitals need to double down to ensure they have contracts with as many in-network providers as possible. “It requires the physicians, hospitals, health plans all working together to make sure that everybody’s in-network or, if they’re not, the patient knows that clearly up front,” says Rick Gundling, HFMA’s senior vice president for healthcare financial practices. “It’s kind of a three-legged stool.”
Consumers also need to become savvier when it comes to costs of medical care. Most people do see providers in their network, says Gupta. However, “because of their high-deductible health plan, they often don’t recognize until they get hit with a bill that the same MRI might be $3,000 after the deductible at a local hospital that is convenient for them versus $1,000 a mile down the street at an imaging center,” he adds.” (J)
“Cooper works as a physician assistant and hears about medical billing problems all the time.
So when she initially found out she was pregnant, this health care provider did everything she could to make sure anyone associated with her pregnancy would be considered what’s referred to as “in-network.”
She contacted her insurance company, Aetna, and she also contacted Banner Gateway Hospital, the hospital where she planned to give birth. The hospital then sent her written confirmation that she had nothing to worry about.
“She said, ‘Send me a picture of your insurance card front and back and I’ll double check that you’re covered.’ And, she sent me back an hour later saying, ‘Yes, you are in network,'” Cooper said.
Cooper eventually delivered her little girl at Banner Gateway Hospital. But, not long after, Cooper started getting a number of large “out-of-network” medical bills.
“Aetna then sent me back something that said, ‘No you are out-of-network’ and that’s how everything started to trickle through,” she said.
“Out-of-network.” How could that happen? Remember, she got written confirmation from Banner Gateway Hospital indicating she was “in-network.”…
When she added them all up, her medical bills came to around $18,000, money she shouldn’t have been responsible for. Still, she says she wasn’t getting any resolution…
We asked them to review Cooper’s case and after they did, they acknowledged there was a mistake.
As a result, Aetna reprocessed all of Heather’s bills as “in-network.”..
That means Cooper will now only have to pay just $750 out of pocket, the cost of her deductible rather than $18,000. Cooper said she couldn’t be happier and says it all happened with the help of 3 On Your Side.” (K)
“On the first morning of Jang Yeo-im’s vacation to San Francisco in 2016, her eight-month-old son Park Jeong-whan fell off the bed in the family’s hotel room and hit his head.
There was no blood, but the baby was inconsolable. Jang and her husband worried he might have an injury they couldn’t see, so they called 911, and an ambulance took the family — tourists from South Korea — to Zuckerberg San Francisco General Hospital.
The doctors at the hospital quickly determined that baby Jeong-whan was fine — just a little bruising on his nose and forehead. He took a short nap in his mother’s arms, drank some infant formula, and was discharged a few hours later with a clean bill of health. The family continued their vacation, and the incident was quickly forgotten.
Two years later, the bill finally arrived at their home: They owed the hospital $18,836 for the 3 hour and 22 minute visit, the bulk of which was for a mysterious fee for $15,666 labeled “trauma activation,” which sometimes is known as “a trauma response fee.”
Update: After this story was published on June 28, Zuckerberg San Francisco General Hospital agreed to waive the $15,666 trauma response fee charged for Park Jeong-whan’s visit to the hospital. In a letter, the hospital’s patient experience manager said the hospital did a clinical review and offered “a sincere apology for any distress the family experienced over this bill.” Further, the hospital manager wrote that the case “offered us an opportunity to review our system and consider changes.” (L)
“The health insurer Anthem is coming under intense criticism for denying claims for emergency room visits it has deemed unwarranted…
The insurer initially rolled out the policy in three states, sending letters to its members warning them that, if their emergency room visits were for minor ailments, they might not be covered. Last year, Anthem denied more than 12,000 claims on the grounds that the visits were “avoidable,” according to data the insurer provided to Senator Claire McCaskill, a Democrat from Missouri, one of the affected states.
But when patients challenged their denials, Anthem reversed itself most of the time, according to data the company gave Ms. McCaskill. The report concludes that the high rate of reversals suggests that Anthem did not do a good initial job of identifying improper claims, meaning some patients who did not challenge their denials may have been stuck paying big bills they should not have been responsible for.” (M)
(A) Surprise Medical Bills by Karen Pollitz, kkf.org, http://kff.org/private-insurance/issue-brief/surprise-medical-bills/
(B) Many get hit with surprise ‘out-of-network’ bill after emergency rooms: Study” by Dan Mangan, CNBC, http://www.cnbc.com/2016/11/16/many-get-hit-with-surprise-out-of-network-bill-after-emergency-rooms-study.html
(C) When Out-Of-Network Charges Pop Up, Try An Appeal, by Michelle Andrews, NPR, http://www.npr.org/sections/health-shots/2011/06/21/137304710/when-out-of-network-charges-pop-up-try-an-appeal
(D) (D) What It Means If Your Doctor is Out of Network, by Sergio Viroslav, Angie’s list, https://www.angieslist.com/articles/what-it-means-if-your-doctor-out-network.htm
(E) (E) N.Y. Law Offers Model For Helping Consumers Avoid Surprise Out-Of-Network Charges by Michelle Andrews, KHN http://khn.org/news/n-y-law-offers-model-for-helping-consumers-avoid-surprise-out-of-network-charges/
(F) Governor Signs Nation’s Strongest Law on ‘Surprise’ Medical Bills, by Lilo H. Stainton, https://khn.org/news/n-y-law-offers-model-for-helping-consumers-avoid-surprise-out-of-network-charges/
(G) SURPRISE MEDICAL BILLS: SHOULD CMS MAKE DOCTORS GIVE PRICE INFO UP FRONT?, by STEVEN PORTER, https://khn.org/news/n-y-law-offers-model-for-helping-consumers-avoid-surprise-out-of-network-charges/
(H) Patients on ACA plans at higher risk for surprise bills, physician coalition says, by Joanne Finnegan, https://www.fiercehealthcare.com/practices/aca-exchanges-restrictive-networks-surprise-bills-physicians-for-fair-coverage
(I) Let’s tell the truth about what’s going on, by Michael Kirsch, https://www.medpagetoday.com/blogs/kevinmd/74070?xid=nl_mpt_hemoncvideo_2018-07-20&eun=g1223211d0r&pos=9&utm_source=Sailthru&utm_medium=email&utm_campaign=Daily%20Headlines%202018-07-20&utm_term=Daily%20Headlines%20-%20Active%20User%20-%20180%20days
(J) Some patients fight back against surprise medical bills, by Meg Bryant, https://www.healthcaredive.com/news/some-patients-fight-back-against-surprise-medical-bills/526576/
(K) Gilbert mom fighting medical bills she says she shouldn’t owe, by LiAna Enriquez, http://www.azfamily.com/story/38722098/gilbert-mom-fighting-medical-bills-she-says-she-shouldnt-owe
(L) A baby was treated with a nap and a bottle of formula. His parents received an $18,000 bill, by Jenny Gol and Sarah Kliff, https://www.vox.com/2018/6/28/17506232/emergency-room-bill-fees-health-insurance-baby
(M) A Health Insurer Tells Patients It Won’t Pay Their E.R. Bills, but Then Pays Them Anyway, https://www.nytimes.com/2018/07/19/upshot/anthem-emergency-room-bills.html?utm_source=STAT+Newsletters&utm_campaign=24e499fa7a-MR_COPY_09&utm_medium=email&utm_term=0_8cab1d7961-24e499fa7a-149527969