ASSIGNMENT: What is the California state legislature doing to address the Out-of-Network challenge?
PART 1. March 21, 2019
“If you’re shot, stabbed, hit by a car, fall off a roof or suffer any other major injury in San Francisco, you’ll be whisked to San Francisco General Hospital, the only trauma center in the city. …But you may leave with a very unpleasant side-effect: a shockingly high bill. …That’s because S.F. General — whose patients are overwhelmingly poor and are on Medicare or Medi-Cal, or have no insurance at all — lacks a good way to deal with patients who are actually insured.” (A)
“Under a new state law, if you visit an in-network facility – such as a hospital, lab or imaging center – you will only be responsible for your in-network share of the cost, even if you’re seen by an out-of-network provider…
The new law covers Californians with private health insurance plans that are regulated by the state Department of Managed Health Care, or DMHC, and the state Department of Insurance, which includes roughly 70 percent of the state’s private insurance market, according to the California Health Care Foundation.
It does not cover some 5.7 million people whose employer-sponsored insurance plans are regulated by the U.S. Department of Labor…
The key point to remember is that you shouldn’t pay more than your in-network copayment, coinsurance or deductible, as long as you visited an in-network facility for non-emergency services.” (B)
“The trauma center has no contracts with private insurance companies. If it did, there would be agreements with those insurers on how much a particular drug or a particular procedure costs.
Instead, the hospital charges the highest rates approved by the Board of Supervisors and the mayor, receives whatever amount the patient’s insurance company decides to pay, and bills the patient for the rest.” (C)
On April 3, Nina Dang, 24, found herself in a position like so many San Francisco bike riders — on the pavement with a broken arm.
A bystander saw her fall and called an ambulance. She was semi-lucid for that ride, awake but unable to answer basic questions about where she lived. Paramedics took her to the emergency room at Zuckerberg San Francisco General Hospital, where doctors X-rayed her arm and took a CT scan of her brain and spine. She left with her arm in a splint, on pain medication, and with a recommendation to follow up with an orthopedist.
A few months later, Dang got a bill for $24,074.50. Premera Blue Cross, her health insurer, would only cover $3,830.79 of that — an amount that it thought was fair for the services provided. That left Dang with $20,243.71 to pay, which the hospital threatened to send to collections in mid-December…
Most big hospital ERs negotiate prices for care with major health insurance providers and are considered “in-network.” Zuckerberg San Francisco General has not done that bargaining with private plans, making them “out-of-network.” That leaves many insured patients footing big bills.
The problem is especially acute for patients like Dang: those who are brought to the hospital by ambulance, still recovering from a trauma and with little ability to research or choose an in-network facility.
A spokesperson for the hospital confirmed that ZSFG does not accept any private health insurance, describing this as a normal billing practice. He said the hospital’s focus is on serving those with public health coverage — even if that means offsetting those costs with high bills for the privately insured.
“It’s a pretty common thing,” said Brent Andrew, the hospital spokesperson. “We’re the trauma center for the whole city. Our mission is to serve people who are underserved because of their financial needs. We have to be attuned to that population.”
But most medical billing experts say it is rare for major emergency rooms to be out-of-network with all private health plans. (D)
“The largest public hospital in the city, Zuckerberg San Francisco General cares for 20 percent of all San Franciscans, according to the hospital’s website..
But contrary to the hospital’s position, only 1 percent of ambulance rides nationwide drop patients at out-of-network emergency rooms, according to a study by economist Christopher Garmon at the University of Missouri Kansas City. The study also found that approximately 20 percent of emergency department admissions nationwide resulted in a surprise medical bill. Because of its size and top-tier emergency room, Zuckerberg San Francisco General takes in one-third of ambulances in the city, meaning many of its patients, some unconscious on arrival, are unaware of the hospital’s unusual lack of support for their insurance…
“As a Level 1 trauma center, we must meet certain requirements, 24/7/365, as delineated in the California Code of Regulations (CCR) and by state and national credentialing agencies. The requirements are substantial and, because they require such commitment of resources, costly,” a statement from ZSFG released to Newsweek reads. “We realize there are challenges, difficulties and inefficiencies in our national system of healthcare insurance. We realize burdens are often placed on individuals who are least able to afford them. And we are not in the position of defending the inequities of this system, only working within our prevailing system to the best of our abilities.” (E)
On its web site, ZSFG declares that “everyone is welcome here” regardless of their financial situation or immigration status:
Everyone is welcome here, no matter your ability to pay, lack of insurance, or immigration status. We’re much more than a medical facility; we’re a health care community promoting good health for all San Franciscans.
We’re part of a large group of neighborhood clinics and healthcare providers, the San Francisco Health Network. In partnership, we provide primary care for all ages, specialty care, dentistry, emergency and trauma care, and acute care for the people of San Francisco…
“Our mission is to serve people who are underserved because of their financial needs,” the spokesperson also stated. “We have to be attuned to that population.” (F)
“More than half of U.S. adults “have been surprised by a medical bill that they thought would have been covered by insurance,” according to a new survey from research group NORC at the University of Chicago…
The big picture: Drug prices have been in the crosshairs of lawmakers, and health insurers have always been a punching bag. But hospitals and doctors aren’t attracting any large-scale movement to rein in pricing and billing tactics.
“There’s a huge amount of trust in the providers people choose to go to,” said Caroline Pearson, senior fellow at NORC. “I think we’ve got a long way to go until we have backlash against those providers. But as insurance gets more complicated and out-of-pocket costs rise, we’re going to see more and more surprise bills.”
The other side: Ashley Thompson, SVP of policy at the American Hospital Association, said in a statement that “patients and their families should be protected from…unexpected medical bills,” but “insurers have the primary responsibility for making sure their networks include adequate providers.”” (G)
“U.S. Sen. Bill Cassidy, R-La., said federal lawmakers on both sides of the aisle are moving closer to an agreement on legislation to prevent surprise medical bills, according to a Bloomberg Government report…
Republicans and Democrats have been working to address the issue, and bipartisan legislation is predicted for early 2019, Mr. Cassidy told Bloomberg Government…
There have been legislative efforts related to surprise medical bills. In September, a bipartisan group of senators unveiled the Protecting Patients from Surprise Medical Bills Act. Then on Oct. 11, Democrat Sen. Maggie Hassan of New Hampshire introduced the No More Surprise Medical Bills Act of 2018. The first draft bill focuses on preventing out-of-network providers from charging patients more for emergency care than what they would pay using insurance. The second bars healthcare providers from out-of-network billing for emergency services, according to the report.
Meanwhile, Bloomberg Government notes, insurers and hospitals are pointing the finger at each other over who is at fault for the problem.
Mr. Cassidy told the publication there are “bad apples with both groups” and anticipates both sides “are going to have to give a little bit” when it comes to changes.” (H)
“Congress is considering bipartisan legislation to limit balance billing. But some legal scholars say that patients should already be protected against some of the highest, surprise charges under long-standing conventions of contract law.
That’s because contract law rests on the centuries-old concept of “mutual assent,” in which both sides agree to a price before services are rendered, said Barak Richman, a law professor at Duke University.
Thus, many states require, and consumers expect, written estimates for a range of services before the work is done — whether by mechanics and plumbers or lawyers and financial planners.
But patients rarely know upfront how much their medical care will cost, and hospitals generally provide little or no information.
While consumers are obligated to pay something, the question is how much? Hospitals generally bill out-of-network care at list prices, their highest charges.
Without an explicit price upfront, contract law would require medical providers to charge only “average or market prices,” Richman said.
In several recent cases, for example in New York and Colorado, courts have stepped in to mediate cases where a patient received a big balance bill from an out-of-network provider. They ordered hospitals to accept amounts far closer to what they agree to from in-network private insurers or Medicare.
“This is the amount they are legally entitled to collect,” said Richman…
That complexity — and the cost of hiring an attorney — have made legal challenges to medical bills on the basis of contract law relatively scarce.
Also, “it’s not a well-settled area of the law,” said Hall. “(I)
“Payer groups, including America’s Health Insurance Plans, are joining forces with employers, consumers and other stakeholders in support of a plan they say will tackle surprise billing.
The groups signed on to a set of guiding principles aimed at protecting consumers from the practice. The guidelines are: inform patients when care is out of network, support federal policy that protects consumers while restraining costs and ensuring quality networks and pay out-of-network doctors based on a federal standard.
Meanwhile, the American Hospital Association and the Federation of American Hospitals released a joint statement saying hospitals and health systems also support patient protections from surprise billing but place blame on insurers, not providers…
AHIP said surprise billing happens because providers aren’t participating in certain networks. “When doctors, hospitals or care specialists choose not to participate in networks — or if they do not meet the standards for inclusion in a network — they charge whatever rates they like,” the group wrote.
In their statement, the hospital groups also backed consumer protections, but pointed the finger at payers for the issue. “Inadequate health plan provider networks that limit patient access to emergency care is one of the root causes of surprise bills. Patients should be confident that they can seek immediate lifesaving care at any hospital. The hospital community wants to ensure that patients are protected from surprise gaps in coverage that result in surprise bills, and we look forward to working with policymakers to achieve this goal,” they wrote…
National leaders have been working on the issue too, but so far a bipartisan effort has only resulted in drafted legislation. The bill would require payers to reimburse out-of-network providers at 125% of the average in-network rate while limiting patient liability to in-network costs.” (J)
“For the past 15 months, I’ve asked Vox readers to submit emergency room bills to our database. I’ve read lots of those medical bills — 1,182 of them, to be exact.
My initial goal was to get a sense of how unpredictable and costly ER billing is across the country. There are millions of emergency room visits every year, making it one of the more frequent ways we interact with our health care system — and a good window into the health costs squeezing consumers today…
I’ve read emergency room bills from all 50 states and the District of Columbia. I’ve looked at bills from big cities and from rural areas, from patients who are babies and patients who are elderly. I’ve even submitted one of my own emergency room bills for an unexpected visit this past summer.
Some of the patients I read about come in for the reasons you’d expect: a car accident, pains that could indicate appendicitis or a heart attack, or because the ER was the only place open that night or weekend….
I’ll stop collecting emergency room bills on December 31. But before I do that, I wanted to share the five key things I’ve learned in my year-long stint as a medical bills collector.
1) The prices are high — even for things you can buy in a drugstore
2) Going to an in-network hospital doesn’t mean you’ll be seen by in-network doctors
3) You can be charged just for sitting in a waiting room
4) It is really hard for patients to advocate for themselves in an emergency room setting
5) Congress wants to do something about the issue.. (K)
“Zuckerberg General’s emergency room fees are also higher, on average, than ERs nationally, in the state of California, and in the city of San Francisco. In the city, they’ve charged up to five times as much. The fees are set by the San Francisco Board of Supervisors, which has voted for steady increases, doubling the charge since 2010.
When asked about the fees, board members admitted that they hadn’t kept a close eye on the prices and said they plan to hold hearings on the issue.
“It turns out we should have been monitoring this much more closely,” says Aaron Peskin, a supervisor who has previously voted in favor of the hospital prices and who is now calling for the hearings…
The city of San Francisco manages Zuckerberg General and sets the prices the hospital charges.
The task falls to the San Francisco Board of Supervisors, an 11-member board that oversees city policies and budgets. Every year or two, they approve a lengthy document that lists hospital prices for everything from an emergency room fee to a day in the obstetrics unit to a primary care exam. The document describes the fees as “proper reasonable amounts.”
The current prices were approved at a board a meeting in July 2017. A video recording of that meeting shows there was no debate or discussion of the prices. Instead, the board of supervisors unanimously approved the ZSFG charges in a voice vote that latest less than a minute…
But there is little record of public discussion or debate over that increase. Meeting records for each vote on the hospital prices since 2010 show that the fees have always been approved unanimously.
“I cannot recall there ever being any discussion of them,” says Peskin, a board member who has served on and off since 2001. “I don’t think there has ever been a split vote, and that’s been true as long as I’ve been on the board of supervisors. But that will probably change now.”..
The San Francisco Board of Supervisors now plans to bring greater scrutiny to the hospital’s billing practices in light of Vox’s reporting.” (L)
“Zuckerberg San Francisco General Hospital is reducing a bike crash patient’s $20,243 bill down to $200 — only after the case drew national attention to the hospital’s surprising policy of being out-of-network with all private health insurance…
The San Francisco Board of Supervisors, which oversees the hospital, now plans to hold hearings on Zuckerberg General’s billing practices as well.
“While we as a city should absolutely seek reimbursement from private insurers, we should not be placing the burden of exorbitant bills on patients — who deserve the highest quality care, not the highest possible costs,” said Gordon Mar, the supervisor who chairs the board’s government audit and oversight committee…
Zuckerberg San Francisco General Hospital has not commented on whether it plans to change its policies, and go in-network with private health insurance, although a spokesperson told Vox they are looking into how to make sure other patients don’t end in a situation like Dang’s.
“We are focused on reducing the number of people who could be in this predicament, through a variety of methods, including our own practices, insurance payments, and policy solutions,” spokesperson Rachael Kagan told Vox in an email.” (M)
“Momentum is building for action to prevent patients from receiving massive unexpected medical bills, aided by President Trump, who is vowing to take on the issue.
Calls for action against so-called surprise medical bills have been growing, spurred by viral stories like one involving a teacher in Texas last year who received a $108,951 bill from the hospital after his heart attack. Even though the teacher had insurance, the hospital was not in his insurance network.
Lawmakers in both parties say they want to take action to protect people from those situations, marking a health care area outside of the partisan standoff over ObamaCare, where Congress could advance bipartisan legislation to help patients.
Trump gave a boost to efforts on Wednesday.
“[People] go in, they have a procedure and then all of a sudden they can’t afford it, they had no idea it was so bad,” Trump said at a roundtable with patients about the issue.
“We’re going to stop all of it, and it’s very important to me,” he added.
But the effort still faces obstacles from powerful health care industry groups — including hospitals, insurers and doctors. Those groups are jockeying to ensure that they avoid a financial hit from whatever solution lawmakers and the White House back.” (N)
“And the Republican chairman of the Senate health committee told reporters recently he expects pushback from the industry — but warned industry to act before Congress does. “The first place to deal with it is for the hospitals and doctors and insurance companies to get together and end the practice,” Sen. Lamar Alexander, R-Tenn., said. “And if they don’t, Congress will do it for them.” The senator hasn’t, however, put forward any specific legislation or scheduled hearings on the topic yet.” (O)
“There are 141 million visits to the emergency room each year, and nearly all of them.. have a charge for something called a facility fee. This is the price of walking through the door and seeking service. It does not include any care provided.
Emergency rooms argue that these fees are necessary to keep their doors open, so they can be ready 24/7 to treat anything from a sore back to a gunshot wound. But there is also wide variation in how much hospitals charge for these fees, raising questions about how they are set and how closely they are tethered to overhead costs.
Most hospitals do not make these fees public. Patients typically learn what their emergency room facility fee is when they receive a bill weeks later. The fees can be hundreds or thousands of dollars. That’s why Vox has launched a year-long investigation into emergency room facility fees, to better understand how much they cost and how they affect patients…
We found that the price of these fees rose 89 percent between 2009 and 2015 — rising twice as fast as the price of outpatient health care, and four times as fast as overall health care spending.” (P)
“Matt Gleason had skipped getting a flu shot for more than a decade.
But after suffering a nasty bout of the virus last winter, he decided to get vaccinated at his Charlotte, N.C., workplace in October. “It was super easy and free,” said Gleason, 39, a sales operations analyst.
That is, until Gleason fainted five minutes after getting the shot. Though he came to quickly and had a history of fainting, his colleague called 911. And when the paramedics sat him up, he began vomiting. That symptom worried him enough to agree to go to the hospital in an ambulance.
He spent the next eight hours at a nearby hospital — mostly in the emergency room waiting area. He had one consult with a doctor via teleconference as he was getting an electrocardiogram. He was feeling much better by the time he saw an in-person doctor, who ordered blood and urine tests and a chest-X-ray.
All the tests to rule out a heart attack or other serious condition were negative, and he was sent home at 10:30 p.m.
And then the bill came.
Total Bill: $4,692 for all the hospital care, including $2,961 for the ER admission fee, $400 for an EKG, $348 for a chest X-ray, $83 for a urinalysis and nearly $1,000 for various blood tests. Gleason’s insurer, Blue Cross and Blue Shield of North Carolina, negotiated discounts for the in-network hospital and reduced those costs to $3,711. Gleason is responsible for that entire amount because he had a $4,000 annual deductible. (The ambulance company and the ER doctor billed Gleason separately for their services, each about $1,300, but his out-of-pocket charge for each was $250 under his insurance.)..
The biggest part of Gleason’s bill — $2,961 — was the general ER fee. Atrium coded Gleason’s ER visit as a Level 5 — the second-highest and second-most expensive — on a 6-point scale. It is one step below the code for someone who has a gunshot wound or major injuries from a car accident. Gleason was told by the hospital that his admission was a Level 5 because he received at least three medical tests.
Gleason argued he should have paid a lower-level ER fee, considering his relatively mild symptoms and how he spent most of the eight hours in the ER waiting area.
The American Hospital Association, the American College of Emergency Physicians and other health groups devised criteria in 2000 to bring some uniformity to emergency room billing. The different levels reflect the varying amount of resources (equipment and supplies) the hospital uses for the particular ER level. Level 1 represents the lowest level of ER facility fees, while ER Level 6, or critical care, is the highest. Many hospitals have adopted the voluntary guidelines…
Blue Cross and Blue Shield of North Carolina said in a statement that the hospital “appears to have billed Gleason appropriately.” It noted the hospital reduced its costs by about $980 because of the insurer’s negotiated rates. But the insurer said it has no way to reduce the general ER admission fee…
Gleason, in fighting his bill, actually got the hospital to send him its entire “chargemaster” price list for every code – a 250-page, double-sided document on paper. He was charged several hundred dollars more than the listed price for his Level 5 ER visit…
Resolution: After Gleason appealed, Atrium Health reviewed the bill but didn’t make any changes. “I understand you may be frustrated with the cost of your visit; however, based on these findings, we are not able to make any adjustments to your account,” Josh Crawford, nurse manager for the hospital’s emergency department, wrote to Gleason on Nov. 15.” (Q)
PART 2. April 7, 2019
Zuckerberg hospital puts balance billing on hold
Mayor London Breed and Supervisor Aaron Peskin Announce Halt to Balance Billing at Zuckerberg San Francisco General Hospital Until Plan to Improve Long-Term Billing Practices is Implemented
Friday, February 01, 2019
“Department of Public Health and ZSFG will develop a comprehensive plan for improvements within 90 days to address the issue of patients being billed the balance of their bills when their private insurers refuse to cover their bills
San Francisco, CA —Today Mayor London N. Breed, Supervisor Aaron Peskin, the Department of Public Health and Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG) announced immediate steps to improve billing practices at ZSFG for patients who have gotten stuck in the middle of disputes between the hospital and their insurance provider, including a temporary halt to the practice of balance billing.
The San Francisco Department of Public Health (DPH) operates ZSFG as part of the San Francisco Health Network, the City’s public health care system. As San Francisco’s public hospital, the vast majority of ZSFG patients have Medi-Cal, Medicare or are uninsured. About 6 percent of patients have commercial insurance (including HMO or PPO plans) and come to ZSFG through trauma and emergency services. For those patients, their insurance is billed for services, and the insurance company decides what to pay. When an insurance company does not pay in full, PPO patients can be billed for the balance, a practice known as “balance billing.”
“Although ‘balance billing’ affects a very small number of ZSFG patients, the stress and hardship they experience when it happens is very real,” said Mayor Breed. “We need to look hard at our current billing practices, and until we come up with a plan that works for patients, we will not continue the practice of balance billing. In an emergency, people’s focus should be on getting help quickly, not on what hospital they should go to. Private insurance companies also need to be held accountable to actually pay for the healthcare for anyone they cover.”
“The City is taking the right step by stopping the practice of balance billing at SF General, because there’s nothing ‘balanced’ about it,” said Supervisor Peskin. “It’s extra billing for services that patients don’t have a choice about receiving, further delaying their ability to move on and heal. This immediate halt also covers the previous patients who’ve been stuck with crippling bills, including those being sent to collections. Healing delayed is healing denied, so I’m looking forward to working with the Department of Public Health on a new path forward.”
Greg Wagner, Acting Director of Health, and Dr. Susan Ehrlich, CEO of ZSFG, outlined a set of immediate actions and elements of a comprehensive plan for improvement that will be developed within 90 days. This includes making changes to billing practices, financial assistance and patient communications. In addition, DPH and ZSFG are exploring policy solutions in coordination with local and state elected officials.
“The billing practices at Zuckerberg San Francisco General Hospital and Trauma Center for privately insured patients who receive trauma and emergency services are not working for some of our patients,” Wagner said. “Keeping the patients’ experience as the focal point, we will explore ways to protect patients from financial hardship, increase participation in financial assistance programs and where possible, recover costs for services from insurers to avoid lost revenues to the City.”
“While hospital billing in the United States is very complicated, patients should not be caught in the middle of disputes between hospitals and insurance companies,” Ehrlich said. “At ZSFG, our mission is to provide high quality health care and trauma services with compassion and respect to everyone in San Francisco. We are working to ensure that our billing practices better align with that mission. We are sensitive to people’s circumstances and our patients come from all over the economic spectrum. We cannot solve the problems of the entire health care system, but we can do better to serve San Franciscans, who consistently have supported ZSFG and the rest of the City’s excellent public health programs and services.”
DPH and ZSFG have continued to address the problem of insurance payment shortfalls. DPH sued insurers for underpayment and reached settlements, reducing the number of privately insured patients who might be affected by a dispute. DPH’s patient financial services department works with individuals year-round to help them with billing issues, including financial assistance and appeals to insurance plans.
Temporarily halt all balance billing of patients
Effective immediately until a better plan is determined
Make financial assistance easier to get
Proactively begin the process of assessing a patient’s eligibility for assistance, rather than waiting for them to apply
Improve patient communications
Proactively reach out to patients who are receiving large bills to explain the situation, remove the element of surprise, and offer to help
Create a Frequently Asked Questions document to clear up many of the routine questions about billing and financial assistance
Publicize the patient financial services hotline, (415) 206-8448, so that people know where to go for help
Increase communication with patients and provide information about financial assistance opportunities
Additional elements of a comprehensive plan to be developed within 90 days
Make financial assistance easier to get
Adjust charity care and sliding scale policies to expand the number of people who are eligible
Revise ZSFG catastrophic high medical expense program to support more patients who are faced with high, unexpected bills for catastrophic events
Streamline the process of applying for assistance
Protect patients’ financial health
Establish an out-of-pocket maximum for patient payments to ZSFG
Pursue agreements with private insurance companies
Work with state partners to explore additional efforts to improve insurance payments
Ensure ZSFG prices and practices are fair
Undertake a study of hospital charges regionally, comparing trauma centers, academic medical centers, San Francisco and Bay Area hospitals
Research billing and financial assistance practices of California public hospitals to identify opportunities for improvement
Conduct financial analysis of impact on the City of proposed changes (R)
(A)San Francisco General Hospital Lacks A Good Way To Deal With Patients Who Are Actually Insured, https://californiahealthline.org/morning-breakout/san-francisco-general-hospital-lacks-a-good-way-to-deal-with-patients-who-are-actually-insured/
(B)Nasty surprise bills prohibited by new California law when people visit facilities in their insurance network , by Emily Bazar, https://www.sacbee.com/news/local/health-and-medicine/article157970259.html
(C)SF General’s insured patients suffer further trauma when bill arrives, by Heather Knight, https://www.sfchronicle.com/bayarea/heatherknight/article/SF-General-s-insured-patients-suffer-further-13543542.php
(D)A $20,243 bike crash: Zuckerberg hospital’s aggressive tactics leave patients with big bills, by Sarah Kliffsarah, https://www.vox.com/policy-and-politics/2019/1/7/18137967/er-bills-zuckerberg-san-francisco-general-hospital
(E)Zuckerberg Hospital ER Doesn’t Take Private Insurance, Sticking San Francisco Patients With Huge Bills, by Andrew Whalen, https://www.newsweek.com/zuckerberg-hospital-er-private-insurance-medicare-medicaid-mark-facebook-san-1282274
(F)Report: Zuckerberg Hospital Gouges Paying Patients to Pay For Illegals, by Kit Daniels, https://www.infowars.com/zuckerberg-hospital-offsets-healthcare-costs-of-illegals-by-gouging-privately-insured/
(G)A Fainting Spell After A Flu Shot Leads To $4,692 ER Visit, http://health.wusf.usf.edu/post/fainting-spell-after-flu-shot-leads-4692-er-visit#stream/0
(H)Report: Zuckerberg Hospital Gouges Paying Patients to Pay For Illegals, by Kit Daniels, https://www.infowars.com/zuckerberg-hospital-offsets-healthcare-costs-of-illegals-by-gouging-privately-insured/
(I)Why there’s no surprise hospital bill backlash — yet, https://www.axios.com/hospital-medical-bill-backlash-21127cf3-cffc-4751-9ae5-cadda7b5d3c4.html
(J) Payer, hospital groups trade blame on surprise billing, by Les Masterson, https://www.healthcaredive.com/news/payer-hospital-groups-trade-blame-on-surprise-billing/544064/
(K)Taking Surprise Medical Bills To Court, by Julie Appleby, https://khn.org/news/taking-surprise-medical-bills-to-court/
(L))Prices at Zuckerberg hospital’s emergency room are higher than anywhere else in San Francisco, by Sarah Kliff, https://www.vox.com/2019/1/22/18183534/zuckerberg-san-francisco-general-hospital-er-prices
(M) After Vox story, Zuckerberg hospital rolls back $20,243 emergency room bill, by Sarah Kiff, https://www.vox.com/health-care/2019/1/24/18195686/vox-zuckerberg-hospital-emergency-room-bill
(N)Trump boosts fight against surprise medical bills, by PETER SULLIVAN, https://thehill.com/policy/healthcare/427066-trump-boosts-fight-against-surprise-medical-bills
(O)Industry braces as more lawmakers seek to ban surprise billing, by Shannon Mushmore, https://www.healthcaredive.com/news/industry-braces-as-more-lawmakers-seek-to-ban-surprise-billing/547015/
(P) Sarah Kliff has spent the past year reporting on high ER fees. Ask her anything, by Lauren Katz, https://www.vox.com/health-care/2019/1/22/18188777/emergency-room-fees-health-care-costs
(Q)After Vox story, Zuckerberg hospital rolls back $20,243 emergency room bill, by Sarah Kliff, http://health.wusf.usf.edu/post/fainting-spell-after-flu-shot-leads-4692-er-visit#stream/0
(R)Zuckerberg hospital puts balance billing on hold, General Hospital Until Plan to Improve Long-Term Billing Practices is Implemented, https://sfmayor.org/article/mayor-london-breed-and-supervisor-aaron-peskin-announce-halt-balance-billing-zuckerberg-san
A new bill would outlaw the big, surprise bills that Zuckerberg San Francisco General Hospital has sent to hundreds of patients.
California lawmakers will introduce legislation Monday to end surprise emergency room bills like those that left one patient with a $20,000 treatment bill after a minor bike crash — a move they say was inspired by Vox’s reporting on the issue.
The new bill, introduced by Assemblyman David Chiu and Sen. Scott Wiener, would bar California hospitals from pursuing charges beyond a patient’s regular co-payment or deductible. The ban would apply even if a hospital was out-of-network with a patient’s health insurance.
“These practices are outrageous,” says Chiu, who represents part of San Francisco in the state assembly. “No one who is going through the trauma of emergency room care should be subsequently victimized by outrageous hospital bills.”..
California actually has some of the country’s strongest protections against surprise medical bills — but the state’s laws never anticipated a hospital with billing practices like Zuckerberg San Francisco General.
In 2016, California passed a law that protected patients from surprise bills from out-of-network doctors they didn’t choose.
This might happen if, for example, a patient went to an in-network hospital and then received a bill from an out-of-network anesthesiologist or radiologist they never even met.
That law covered patients receiving scheduled care like surgery or delivering a baby. Separately, a decade-old California Supreme Court ruling provided similar protections for emergency room patients.
Neither the court ruling nor the 2016 law anticipated a situation like Zuckerberg San Francisco General, where the entire hospital is “out of network” with all private health insurance.”..
“This new legislation would tackle that rarer situation where a hospital is not in network, and then sends the patient a bill for whatever balance their insurer won’t pay.
There are two key parts to the proposal. First, the bill would prohibit hospitals from pursuing any balance that the patient owed beyond their regular co-payment or contributions to the health plan’s deductible.
Second, the bill would regulate the prices that the hospital could charge for its care, limiting the fees to 150 percent of the Medicare price or the average contracted rate in the area, whichever is greater.
“Patients would no longer receive exorbitant, surprise bills,” says Chiu. “The discussion between insurers and hospitals would become far more predictable.” “ (A)
““At the heart of what we are trying to do is to ensure that if you or are a loved one are in the ER, the only thing you should be thinking about is how to get better and not about the bill for that care,” said Chiu.
He said that the bill is a response “in regard to what we learned is happening at [ZSFGH] — but also across California — this is the situation of patients who get a surprise bill after visiting an emergency room.”..
Rachael Kagan, a spokesperson for the San Francisco Public Health Department, which manages the hospital, said in a statement on Friday that the department can’t comment on the proposed legislation but that “we absolutely agree that there is a role for policy changes to improve patients’ experience with billing,” including “local state and federal efforts.”
She added that the hospital and department are working in the meantime on making improvements. One proposal so far suggests capping out-of-pocket payments made by insured patients receiving emergency services, as was previously reported by the San Francisco Examiner.” (B)
Joint Surprise Billing Letter to Congress and Committee Leadership (C)
Dear Congressional and Committee Leadership:
On behalf of our member hospitals, health systems and other health care organizations, we are fully committed to protecting patients from “surprise bills” that result from unexpected gaps in coverage or medical emergencies. We appreciate your leadership on this issue and look forward to continuing to work with you on a federal legislative solution.
Surprise bills can cause patients stress and financial burden at a time of particular vulnerability: when they are in need of medical care. Patients are at risk of incurring such bills during emergencies, as well as when they schedule care at an in-network facility without knowing the network status of all of the providers who may be involved in their care. We must work together to protect patients from surprise bills.
As you debate a legislative solution, we believe it is critical to:
Define “surprise bills.” Surprise bills may occur when a patient receives care from an out-of-network provider or when their health plan fails to pay for covered services. The three most typical scenarios are when: (1) a patient accesses emergency services outside of their insurance network, including from providers while they are away from home; (2) a patient receives care from an out-of-network physician providing services in an in-network hospital; or (3) a health plan denies coverage for emergency services saying they were unnecessary.
Protect the patient financially. Patients should have certainty regarding their cost-sharing obligations, which should be based on an in-network amount. Providers should not balance bill, meaning they should not send a patient a bill beyond their cost-sharing obligations.
Ensure patient access to emergency care. Patients should be assured of access to and coverage of emergency care. This requires that health plans adhere to the “prudent layperson standard” and not deny payment for emergency care that, in retrospect, the health plan determined was not an emergency.
Preserve the role of private negotiation. Health plans and providers should retain the ability to negotiate appropriate payment rates. The government should not establish a fixed payment amount or reimbursement methodology for out-of-network services, which could create unintended consequences for patients by disrupting incentives for health plans to create comprehensive networks.
Remove the patient from health plan/provider negotiations. Patients should not be placed in the middle of negotiations between insurers and providers. Health plans must work directly with providers on reimbursement, and the patient should not be responsible for transmitting any payment between the plan and the provider.
Educate patients about their health care coverage. We urge you to include an educational component to help patients understand the scope of their health care coverage and how to access their benefits. All stakeholders – health plans, employers, providers and others – should undertake efforts to improve patients’ health care literacy and support them in navigating the health care system and their coverage.
Ensure patients have access to comprehensive provider networks and accurate network information. Patients should have access to a comprehensive network of providers, including in-network physicians and specialists at in-network facilities. Health plans should provide easily-understandable information about their provider network, including accurate listings for hospital-based physicians, so that patients can make informed health care decisions. Federal and state regulators should ensure both the adequacy of health plan provider networks and the accuracy of provider directories.
Support state laws that work. Any public policy should take into account the interaction between federal and state laws. Many states have undertaken efforts to protect patients from surprise billing. Any federal solution should provide a default to state laws that meet the federal minimum for consumer protections.
We look forward to opportunities to discuss these solutions and work together to achieve them.
American Hospital Association
America’s Essential Hospitals
Association of American Medical Colleges
Catholic Health Association of the United States
Children’s Hospital Association
Federation of American Hospitals
(A) After Vox story, California lawmakers introduce plan to end surprise ER bills, by Sarah Kliff, https://www.vox.com/2019/2/24/18236482/zuckerberg-hospital-surprise-bills-california
(B) Controversial ZSFGH billing practice that left privately-insured owing thousands could be banned, by Laura Waxmann, http://www.sfexaminer.com/controversial-zsfgh-billing-practice-left-privately-insured-owing-thousands-banned/
(C) Joint Surprise Billing Letter to Congress and Committee Leadership, https://www.aha.org/letter/2019-02-20-joint-surprise-billing-letter-congress-and-committee-leadership
PART 3. April 23, 2019
“Zuckerberg San Francisco General Hospital announced Tuesday it has overhauled its billing policies, a move that comes three months after a Vox story drew national attention to the hospital’s abnormal and aggressive billing tactics.
The hospital has for years made the rare decision to be out of network with all private health insurance plans. This created an acute problem for patients like like Nina Dang, 24, who made an unexpected trip to the hospital’s emergency room, the largest in San Francisco. An ambulance took Dang to the trauma center after a bike accident last April. She is insured by a Blue Cross plan, but she didn’t know that the ER does not accept insurance. She received a bill for $20,243.
After the Vox story ran, the hospital reduced Dang’s bill to $200, the copay listed on her insurance card.
Now, Zuckerberg San Francisco General Hospital (ZSFG) is essentially making the same change for all future patients: Its new billing policies will no longer charge those with private coverage “any more than they would have paid out of pocket for the same care at in-network facilities, based on their insurance coverage.”
This will put an end to the hospital’s use of a controversial practice call “balance billing,” when a hospital sends a patient a bill for the balance that an insurer won’t pay.
ZSFG will also create a new out-of-pocket maximum on what patients could end up owing for their treatment. The maximum is tethered to a patient’s income and ranges from zero dollars for the lowest earners to a $4,800 maximum for those with the highest incomes (1,000 percent of the poverty line, or $251,400 for a family of four).” (A)
“The changes are aimed at shielding patients from large bills by removing them from payment disputes between the hospital and the insurance company, said Rachael Kagan, director of communications with the department.
“We don’t have a large number of privately insured patients at Zuckerberg San Francisco General Hospital, but some of those who have been in that situation in the past have had a terrible experience and we want to rectify that,” said Ms. Kagan.
“We don’t want that to happen in the future. We know that it’s very stressful to get a large bill and we consider our responsibility to the patients to care for them in all ways. They will have gotten excellent medical care from us, and we want to protect their financial well-being also,” she added.
The hospital estimated that up to 1,700 of its 104,000 patients a year may have received a balance bill…
Zuckerberg hospital will also set a maximum out-of-pocket cost for patients at all income levels, with any insurance status, and this maximum will be income-based. No one will be charged more than 5 percent of their income…
Additionally, the hospital will make its patient financial assistance programs easier to qualify for so more people will get financial assistance. This involves increasing the threshold to qualify for the hospital’s charity care program. The threshold to qualify will increase from 350 percent of the federal poverty level to 500 percent of the federal poverty level.
The hospital is also adjusting the “sliding scale” financial assistance program for San Francisco residents. Previously, Zuckerberg hospital assessed eligibility for the program based on income and assets but will now only take income into account…
Overall, she said she’s pleased the hospital is taking these steps to better align its billing with its values and mission.” (B)
“We may get called the “enemy of the people,” but the press can make a real difference in forcing the powers that be into changing some of their most horrific and unfair practices. Consider Zuckerberg San Francisco General Hospital, which has been hounded by pesky reporters covering their “aggressive billing tactics” with privately insured patients.
In the wake a January Vox report showing a fully insured woman was charged $20,000 for a broken arm and a San Francisco Chronicle exposé detailing a $92,000 appendectomy, the city’s only trauma center (named for a billionaire worth $70 billion, give or take) has announced a significant change to its billing policy. The Chronicle reports that Zuckerberg General is reversing the policy, and establishing “out-of-pocket” maximum that should not exceed $4,800 for patients with copays. Vox got a copy of the announcement which claims the practice was “was halted on February 1, 2019 and will not resume.”
The practice is called “balance billing,” an Orwellian term that indicates some sort of fairness and balance in a system that bills fully insured patients tens of thousands of dollars for routine injury treatments. Zuckerberg General, which primarily serves Medicare, Medi-Cal, and uninsured patients, had employed an unusual system where fully insured patients’ insurance companies could just choose how much they wanted to cover or not cover, effectively ignoring whatever copay amount they had communicated to the patient.” (C)
“A doctor assured DeAnn Allen the trace of blood in her urine after a car crash was just a little bruising, but she wouldn’t have guessed it by the size of her bill.
That urine test and visit with the doctor cost Allen, who was visiting Las Vegas, more than $1,800.
“If you care about your care, and have a choice, we urge you to go somewhere else!” Allen wrote in a review on Facebook for Elite Medical Center, Las Vegas’ newest emergency hospital situated just west of the Strip.
Just like any full-service emergency room, Elite Medical Center treats a range of urgent medical problems, from headaches to heart attacks. But unlike the other ERs in Southern Nevada, you’ll generally pay more for your care.
That’s because the facility doesn’t contract with any insurer. So if you break a bone or your child has an earache and you go there, you’ll be paying for out-of-network care.
Elite is licensed as a hospital by the state, but experts say it is operating similarly to freestanding emergency rooms that have become common recently in other states. It is the only unaccredited hospital in Clark County that provides emergency care but doesn’t contract with insurers…
There’s no license for a freestanding ER in Nevada, though hospitals are allowed to open satellite emergency rooms that provide care at other locations.
Elite Medical Center pursued a different path by getting the state to license it as a hospital. That means the facility has the capacity to keep patients for 48 hours.
State law doesn’t mandate these facilities be accredited by the federal Centers for Medicare or Medicaid Services or accept any insurance, private or public.” (D)
- After Vox stories, Zuckerberg Hospital is overhauling its aggressive billing tactics, by Sarah Kliff, https://www.vox.com/2019/4/16/18410905/zuckerberg-san-francisco-hospital-bills
- Publicity spurs billing revamp at Zuckerberg hospital, by Kelly Gooch, https://www.beckershospitalreview.com/finance/publicity-spurs-billing-revamp-at-zuckerberg-hospital.html
- Zuckerberg Hospital Revises Insane Billing Practices After Media Exposés, by JOE KUKURA, https://sfist.com/2019/04/17/zuckerberg-hospital-revises-insane-billing-practices-after-media-exposes/
- Emergency room off Las Vegas Strip makes waves with new business model, by Milbank News Writer, https://milbankmonitor.com/emergency-room-off-las-vegas-strip-makes-waves-with-new-business-model/14/04/2019/