PART 2. May 20, 2019. OUT-OF-NETWORK BILLS. Private Equity is a Driving Force Behind Devious Surprise Billings

ASSIGNMENT: Draft the principles for federal “surprise bill” legislation

I thought I was a good OUT-OF-NETWORK detective and could avoid SURPRISE MEDICAL BILLS. Not so! Recently I switched physicians within a sub-specialty practice group. The first MD took my Medicare “GAP” insurance but the second did not. This lesson already cost me $1,000 versus an in network cost of probably $200. One can never be too vigilant!

New PART 2 after PART 1.

PART 1. July 29, 2018. SURPRISE MEDICAL BILLS.  Write in AS LONG AS THE PROVIDERS ARE IN MY NETWORK…before you sign any hospital admission documents accepting financial responsibility for your care.

“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)

PART 2. Private Equity is a Driving Force Behind Devious Surprise Billings,

 “The expectant mother was in labor at South Shore Hospital when she requested a common pain medicine, which was administered by an anesthesiologist. Home with a newborn days later, she was surprised when a bill arrived from the doctor’s group for $2,143.44.

Another patient who went to Emerson Hospital’s emergency department for what turned out to be a broken rib also received a surprise bill: $300.91, for the services of the doctor who read the X-ray…

Patients should not have to “contact their health plan and complain,’’ said David Seltz, executive director of the Massachusetts Health Policy Commission, which monitors health care spending in the state. “Through no fault of their own they are being put in this situation.’’

An analysis by the policy commission found that 10,000 Massachusetts patients in just one year may have received surprise bills for so-called out-of-network care, and policy experts believe that figure underestimates the extent of the problem…

More than 35 percent of complaints filed with Healey were over out-of-network charges, which can be up to 200 percent higher than what insurers pay in-network doctors. Among the physicians that were outside the patients’ insurance networks were anesthesiologists assisting in colonoscopies and emergency medicine doctors repairing broken bones and treating heart attacks, something that frustrated patients told Healey’s office they had no way of knowing in advance. Radiologists and pathologists also directly billed patients out-of-network charges.

It’s not unusual for a hospital to have practitioners working in their facilities who are not covered by all their agreements with insurers, a technicality that is often not apparent to patients.” (A)

“ (Trump)” In my State of the Union address, I asked Congress to pass legislation to protect American patients.  For too long, surprise billings — which has been a tremendous problem in this country — has left some patients with thousands of dollars of unexpected and unjustified charges for services they did not know anything about and, sometimes, services they did not have any information on.  They weren’t told by the doctor.  They weren’t told by the hospitals in the areas they were going to.  And they get, what we call, a “surprise bill.”  Not a pleasant surprise; a very unpleasant surprise.

So this must end.  We’re going to hold insurance companies and hospitals totally accountable.” (B)

“But physician advocacy groups, including the American Medical Association (AMA) while applauding the effort to eliminate surprise bills, expressed some concern that a simplified approach to a complex problem could have unintended consequences for healthcare delivery…

“We agree with the president that patients should not be responsible for coverage gaps and for any costs beyond their in-network cost sharing when they do not have an opportunity to choose an in-network physician,” said Barbara L. McAneny, MD, AMA’s president in a statement. “We also agree that physicians and hospitals should be transparent about their costs, and payers should offer transparency about their networks, scope of coverage, and out-of-pocket costs. In addition, insurers should be held accountable for their contributions to the problem and ensure network adequacy, adherence to the prudent layperson standard for emergency care in current law, and reasonable cost-sharing requirements.”” (C)

“Reps. Frank Pallone (D-NJ) and Greg Walden (R-OR), the top Democrat and Republican on the House Energy and Commerce Committee, have jointly released a draft bill that would prevent patients from facing unexpected charges after they go to the emergency room or receive other non-emergency medical care…

The Pallone and Walden bill takes a multi-pronged approach to ending surprise medical bills:

Health insurers would be required to treat out-of-network emergency care as in network for their enrollee’s cost-sharing and out-of-pocket obligations. So patients wouldn’t have to pay any more for receiving emergency treatment at an out-of-network hospital than they would at an in-network one.

Balance billing — when a health care provider sends a patient a bill charging them whatever the difference is between the price set for a service by the provider and the price the health insurer is willing to pay — would be prohibited.

Insurers would have to make a minimum payment to out-of-network providers for their enrollee’s care, based on the price the insurer pays to nearby in-network providers… (D)

“These protections would apply to all out-of-network emergency services and to all out-of-network nonemergency services received at an in-network facility from “facility-based providers,” which the bill defines to include anesthesiologists, radiologists, pathologists, neonatologists, assistant surgeons, hospitalists, intensivists, and any additional provider types specified by the Secretary of Health and Human Services (HHS). Other provider types would still be allowed to treat patients on an out-of-network basis in nonemergency situations if they met the strong notice and consent requirements detailed in the discussion draft. Limiting notice and consent exceptions to physician specialties that patients typically actively choose strikes a sensible balance. It preserves patients’ ability to seek out-of-network care in circumstances where it is appropriate, while mitigating the risk that the flood of paperwork involved in seeking medical care will result in some patients consenting to out-of-network billing without understanding what they are consenting to or whether they have a reasonable alternative.” (E)

“A new draft bill released this morning sets up a so-called “baseball-style” arbitration process for providers and plans as an option to settle payment disputes, POLITICO’s Rachel Roubein writes. Today’s draft comes after Sens. Bill Cassidy (R-La.), Michael Bennet (D-Colo.) and four others spent eight months refining legislation first introduced in September. More for Pros.

— Today’s legislation prohibits balance billing in three instances, Rachel writes. (1) For emergency care, (2) during elective care at an in-network facility but when a service is performed by an out-of-network provider and (3) when a patient needs additional medical care after an emergency at an out-of-network facility but can’t travel elsewhere.

— The most contentious part of addressing surprise medical bills: the payment. Under the new bill, providers would automatically be paid the median in-network rate. But they can dispute that, initiating a so-called “baseball-style” arbitration process, where mediators will base decisions on “commercially reasonable rates” (the in-network rates for that area and not actual charges).” (F)

“The House of Representatives and the Senate have unveiled dueling legislation aimed at surprise billing, and the two are split on one key element: arbitration.

The House bill (PDF), which was introduced earlier this week by Reps. Frank Pallone, D-New Jersey and Greg Walden, R-Oregon, would require insurers to cover out-of-network emergency care at in-network rates and would ban balance billing.

Balance billing most often occurs in emergency departments or during elective surgery, when a patient goes to an in-network facility but is treated by an out-of-network clinician, typically an anesthesiologist or radiologist.

The Senate’s bill, however—which is backed by Sens. Bill Cassidy, R-Louisiana, and Maggie Hassan, D-New Hampshire—would include a “baseball-style” arbitration program to mitigate disputes, alongside similar elements to the House iteration.” (G)

“The administration said its top priority is to make sure patients no longer receive separate bills from out-of-network doctors, an approach known as a “bundled payment.”..

Vidor Friedman, president of the American College of Emergency Physicians, said a bundled payment puts too much pressure on hospitals to contract with physicians, essentially making hospitals take on the role of insurer.

“It would create another layer between the patient and providers of care,” Friedman said, noting that doctors would need to negotiate directly with hospitals for payment, rather than with insurance companies…

Instead, doctors and hospitals want an independent arbitrator to examine the amount the doctor is charging and what the insurer is agreeing to pay — and then determine which one is fairer…

But insurers are opposed to arbitration, and they’re pushing for Congress to set reimbursement rates.

In a letter to House and Senate leaders in March, America’s Health Insurance Plans urged lawmakers to “avoid the use of complex, costly and opaque arbitration processes that can keep consumers in the middle and lead to higher premiums.”

The White House also threw cold water on arbitration. During a briefing with reporters on Thursday, administration officials called arbitration an “unnecessary distraction.”..

 “Providers point fingers at payers, payers point fingers at providers, and the American people are left really getting the shaft,” a senior administration official said.

The White House and lawmakers have been warning all the players to solve the problem on their own. But now with pressure from the White House, Congress is likely to act.

“There will come a point in time when they want to move a solution forward,” AHA’s Smith said. “It’s unlikely you’ll come to a solution where every one of the stakeholders is happy.”” (H)

“One of the major drivers of surprise bills is the deliberate decision by health insurance plans to narrow the networks of providers available to their insureds—core network adequacy requirements should be an essential component of any solution,” AMA Executive Vice President and CEO James L. Madara, MD, wrote in the letters to committee leaders. “Shrinking networks increase the likelihood that patients may receive care from an out-of-network provider, particularly in emergency situations.”

..Patients are shouldering more of the costs through larger deductibles and higher copays. The median out-of-network deductible for individual marketplace is $12,000 and almost a third of individual market plans have deductibles of more than $20,000 according to research by the Robert Wood Johnson Foundation cited in the letter.

“Limited networks of providers and unaffordable deductibles for care outside those networks can expose patients to high out-of-pocket costs,” Dr. Madara wrote.

..Often insurance companies will use tactics such as prior authorization or “fail-first” step therapy protocols to make patients pay out of pocket for medically necessary treatment they refuse to cover.

.. Despite federal mental health-parity requirements, patients can feel squeezed by their health plans when it comes to mental health and substance-use disorder treatments—and that leads to a greater reliance on out-of-network care…

..Some insurance companies have enacted policies of not paying for emergency care after it was determined that patients did not require it—even though the severity of their symptoms at the time made it prudent to go to the nearest emergency department.

..Insurance companies often change their drug formularies after patients are locked into their plan. This can lead to restricting access to treatment that has proven to work for them and has stabilized their condition. Patients may seek to pay out of pocket to continue their treatment rather than jump through their insurance company’s prior-authorization hoops.” (I)

“Surprise medical bills exist for a number of reasons, each of which are specifically rooted in problems inherent to a privatized, profit-driven health-care system. For one thing, there wouldn’t be out-of-network bills without networks themselves—a health insurance innovation put forward in the 1980s. Unlike more regulated health-care systems in peer nations, the American health-care system lacks a robust mechanism to control prices. This leaves each insurance plan to negotiate with providers on its own, and gives the latter more power to set prices.

Once health-care prices began to skyrocket in the 1970s, insurance companies began to try several cost-cutting measures that are now all too familiar to modern policyholders…The theory behind networks was simple enough: By contracting only with certain providers, insurers could deliver a higher volume of patients to each one and thereby gain more leverage over pricing negotiations. They could then translate the savings into lower premiums, attract more customers, and increase market share…

..and it’s the same problem underlying the proliferation of varied “insurance products” that cater to different types of patients. The degree of “choice” a given person has is overwhelmingly determined by their income and health status, which is a shamefully unjust way to allocate the costs of running a health-care system. The healthiest people are able to take their chances on a narrow network, while those with greater health-care needs are financially penalized for needing a wider breadth of providers. Meanwhile, the less money someone has available, the more they’re coerced into “choosing” a plan based on price rather than benefits…

Discussing and tackling the inequities—and potential for financial ruin—in our health-care financing system demands an acknowledgment that the sheer diversity of insurance plans in this country, each with their own pricing and benefit structures, is an inherently bad thing. When it comes to insurance policies, a multitude of consumer choices translates into genuine differences in the ability to access care. “Surprise out-of-network bills” are one highly visible example of how that hurts people. Others are never hard to find.” (J)

“While President Donald Trump prods Congress to limit surprise billing, at least three states are debating legislation to ban the practice…

Current state laws vary in scale and effectiveness. Federal legislation would be more effective, as it would protect the millions who receive self-funded coverage through their employer. But the political climate in Washington, where even historically bipartisan efforts move slowly at best, has left states to step in and do what they can…

The Colorado General Assembly passed a bill earlier this month that prohibits surprise billing and sets a reimbursement rate based on either commercial claims data or the insurers’ median in-network rate for the service. Gov. Jared Polis, a Democratic, is expected to sign the bill Tuesday, a spokesman told Healthcare Dive.

A surprise billing law is also on the governor’s desk In Washington. It calls for a “commercial reasonable amount” to be paid to out-of-network providers and establishes arbitration if the parties cannot agree on a rate through negotiation.

In Texas, a bill has passed the Senate and is currently making its way through the House. It requires an arbitration process for payments that do not include patient involvement. Previous legislation in the state required people receiving surprise bills to request remediation…

The Employee Retirement Income Security Act of 1974 limits the effectiveness of state surprise billing legislation because state laws can’t apply to employer self-funded plans, which cover the majority of Americans. Still, the laws can serve a few key purposes.

Several of the bills proposed in Congress defer to state laws on issues like rate setting or arbitration. So even if Washington passes a ban on surprise billing, states that want to set their own plans can count on using their own laws going forward…

“States have a lot of authority over providers … just making sure the providers have posted information and are being as informative as possible when consumers are coming into their facilities,” she said.” (K)

Arizona’s new law on surprise medical bills went into effect January 1. It sets up a procedure where patients can request dispute resolution through the state’s Department of Insurance. Unresolved disputes will enter arbitration. If an enrollee participates in an informal settlement teleconference (IST) beforehand, the law spells out what an enrollee’s liability: “By virtue of having participated in the IST, the enrollee can only be held responsible for paying the amount of the enrollee’s cost-sharing requirements (copay, coinsurance and deductible) plus any amount the health insurer paid the enrollee for the services provided by the out-of-network health care provider.” (L)

“Consumer complaints about surprise medical bills have fallen substantially in New York in the wake of a 2014 law that established a “baseball-style” arbitration protocol to address these situations, according to a new report.

Researchers at the Georgetown University Center on Health Insurance Reforms (CHIR) conducted a case study (PDF) on the state’s Emergency Services and Balance Billing Law and found that state officials report a “dramatic” decline in consumer reports about balance bills since the law took effect in 2015.

Based on an analysis of calls to the Consumer Service Society’s helpline for surprise billing, 57% of complaints were handled using the systems established under the law.

 “It’s downgraded the issue from one of the biggest [consumer complaints our call center receives] to barely an issue,” a state regulator told the CHIR researchers.

In addition to surveying state officials, the Georgetown researchers also interviewed physicians, insurers and patients, and they found that overall the participants view the arbitration process as fair. However, providers were more enthusiastic than insurers, according to the study.

As of October, the number of resolutions in favor of insurers and in favor of physicians is about even, according to the study—618 were decided in favor of payers and 561 in favor of providers. 

Insurers were more likely to win disputes over out-of-network emergency care billing, while providers were more likely to win in situations where a patient is treated by an out-of-network physician without his or her knowledge during an elective procedure.” (M)

“The American Hospital Association was among six national hospital groups that sent a letter to Congress on Wednesday to suggest parameters and ideas that legislators should keep in mind as they pursue a solution to surprise medical bills…

The letter to Congress, a copy of which was obtained by ROI-NJ, asks federal representatives to consider:

Defining what is considered a surprise bill;

Ensuring patients are protected and not balance billed;

Ensuring patients are not denied emergency coverage if a visit is considered non-emergent in retrospect;

Avoiding setting a fixed payment rate;

Ensuring patients are educated about their rights and coverage;

Supporting state laws (like those in New Jersey) that are protecting consumers.”  (N)

“Assemblyman Nick Chiaravalloti is planning to introduce legislation in May that would plug a loophole in the (New Jersey) out-of-network law that has been affecting patients transferred out of state…

Health care professionals would be required to document in the patient records and notify patients of

The patient’s right to receive care at a facility of choice;

Clinical rationale for the out-of-state transfer;

Location of the out-of-state facility;

Availability of clinically appropriate services at nearby New Jersey facilities;

The nature of the relationship if the patient is being transferred or referred to an affiliated facility; and

In instances of trauma, stroke or cardiovascular diagnoses, an explanation as to why the patient is not being transferred to a facility in New Jersey.

The bill also requires patients be provided information from their insurance providers as to their potential out-of-pocket costs for an out-of-state facility, and requires health facilities to disclose to patients their relationships with out-of-state providers the patients are being referred to.

This is particularly important with the recent merger activity in South Jersey with some hospitals tied to health systems in Pennsylvania…

 “To ensure that health care consumers are able to make well-informed health care decisions, patients should be informed of their right to select the facility in which they receive their care before being transferred to another state,” he said. “Patients should have all the information about why they are being transferred, and their financial responsibilities associated with the transfer — only then can a patient make an informed choice.” (O)

“One of the many wonderful advantages we have as residents of New Jersey is access to high quality, advanced health care. In fact, more than half of New Jersey’s 67 acute-care hospitals received an “A” rating in the Leapfrog Hospital Safety Report, the highest percentage of “A” ratings in any state across the nation. New Jersey is also home to tremendously skilled physicians and nurses, as well as 13 academic health systems training the next generation of health care professionals and researchers. Clearly, New Jersey residents have access to some of the nation’s greatest health care resources.

Despite these facts, a significant number of patients are referred or transferred to health care providers and hospitals located out of state. Some estimates indicate that New Jersey residents spend more than $2 billion annually on health care services out of state. Often these patients are paying considerably more for their out-of-state health care and receiving care that is equal to or less effective than they could have received at hospitals in New Jersey. With health care consumers paying a larger percentage of their health care costs through higher deductibles, copayments, and coinsurance, paying more for the same quality of care further from home makes little sense.

New Jersey residents should have the right to obtain health care wherever they believe it is best, but often patients do not have critical information necessary to make an informed decision. Moreover, many New Jersey residents do not understand the strong consumer protections they are forfeiting by seeking care outside of the state.” (P)

“Bob Ensor didn’t see the boom swinging violently toward him as he cleaned a sailboat in dry dock on a spring day two years ago. But he heard the crack as it hit him in the face.

He was transported by ambulance to an in-network hospital near his home in Middletown, N.J., where initial X-rays showed his nose was broken as were several bones of his left eye socket. The emergency physician summoned the on-call plastic surgeon, who admitted him to the hospital and scheduled him for surgery the next day.

Shortly before surgery, the doctor introduced Ensor to a second plastic surgeon who would assist in the 90-minute procedure. Entering through Ensor’s nose, the physicians realigned his facial bones, temporarily sewing Ensor’s left eye shut so that the lids would stay in place as the bones knitted back together.

Six weeks later, as Ensor, then 65, continued to make an uneventful recovery, a collection agency called to inquire how he and his wife planned to pay the $71,729 bill for the assistant surgeon. Ensor’s company health plan had denied payment because the surgeon wasn’t part of its contracted physician network.

There was more bad news. Ensor received notice that the health plan wouldn’t cover the $95,885 charged by the first plastic surgeon either because he also was out-of-network.

“The hospital knew these doctors were out-of-network and didn’t bother to tell us,” said his wife, Linda Ensor, noting they faced more than $167,000 in charges. “We were panicked.”

Riverview Medical Center in Red Bank, N.J., where Ensor was treated, said that it “empathizes with patients who are trying to navigate the complexity of the health care billing system” and that transparency in billing has not always been optimal for emergency department patients…

Many plastic surgeons don’t participate in health plans because they have flexibility other physicians may not have — their practices often focus on elective cosmetic procedures like nose reshaping and breast augmentation that patients pay for on their own…

Luckily for the Ensors, the sailing club stepped in to take up his case with the out-of-network plastic surgeons. Since sailing club members were required to volunteer on work projects to keep membership costs in check, the club’s insurer agreed to cover the accident as a workers’ compensation case. It paid 100% of the outstanding bill.” (Q)

“In an email to a complaining patient, the CEO of Spectrum Health acknowledged there needs to be more transparency regarding how patients are billed for doctor visits.

“We agree with you that a more transparent process is necessary,” Spectrum Health CEO Tina Freese Decker wrote (PDF) in response to a complaint. “I have shared your suggestion (for additional transparency) with our Spectrum Health Medical Group leadership so that we can apply this suggestion into our workflow.”..

The patient who sent the email to the CEO — and shared the response with Target 8 — had been charged $142 for a second appointment because she briefly discussed two minor issues with her doctor during her annual exam…

A month later, the patient received her bill. The annual wellness visit was covered by insurance, but there was a second charge for the same day that was not covered…

Additionally, a single mother from a small town in Kent County, who Target 8 is identifying only as Lindsey, previously reached out to Target 8 regarding a bill she got after a wellness visit with a physician at Spectrum medical building in Grand Rapids. While she waited for the appointment, Lindsey filled out the standard questionnaire, checking a box to indicate she had periodic leg cramps.

“(The doctor) looked at the form and she said, ‘Oh, I see you checked yes to leg cramps. Tell me more about it,’” Lindsey recalled.

Lindsey said the doctor showed her some stretches, told her to drink more water and checked her magnesium and iron levels in addition to the routine blood tests that were already scheduled for her annual physical.

“I get the bill… and I was charged for two office visits,” Lindsey said in an interview with Target 8 Thursday. “I called the doctor’s office right away and I said, ‘This can’t be right. Is this a mistake?’”

But it wasn’t a mistake…

If you’re going in for preventive services, know that there is a scope of services that’s considered preventive with zero cost, but if you go in and have a complaint or a scenario diagnosed, then it changes… to another category of care,” ”.. (R)

“Yale researchers Zack Cooper and Fiona Scott Morton looked at emergency department visits that occurred at hospitals that were in insurers’ networks, in a paper for the New England Journal of Medicine. “On average,” they found, “in-network emergency-physician claims were paid at 297% of Medicare rates,” while “out-of-network emergency physicians [within in-network hospitals] charged an average of 798% of Medicare rates.”

A study from UnitedHealthGroup, looking at its own claims nationwide, recently estimated that out-of-network emergency physicians increased health care charges by $6 billion per year.” (S)

What’s behind this explosion of outrageous charges and surprise medical bills? Physicians’ groups, it turns out, can opt out of a contract with insurers even if the hospital has such a contract. The doctors are then free to charge patients, who desperately need care, however much they want.

This has made physicians’ practices in specialties such as emergency care, neonatal intensive care and anesthesiology attractive takeover targets for private equity firms…

A 2018 study by Yale health economists looked at what happened when the two largest emergency room outsourcing companies — EmCare and TeamHealth — took over hospital ERs. They found:

“…that after EmCare took over the management of emergency services at hospitals with previously low out-of-network rates, they raised out-of-network rates by over 81 percentage points. In addition, the firm raised its charges by 96 percent relative to the charges billed by the physician groups they succeeded.”

TeamHealth used the threat of sending high out-of-network bills to the insurance company’s covered patients to gain high fees as in-network doctors. The researchers found:

“…in most instances, several months after going out-of-network, TeamHealth physicians rejoined the network and received in-network payment rates that were 68 percent higher than previous in-network rates.”

What the Yale study failed to note, however, is that EmCare has been in and out of PE hands since 2005 and is currently owned by KKR. Blackstone is the once and current owner of TeamHealth, having held it from 2005 to 2009 before buying it again in 2016.

Private equity has shaped how these companies do business. In the health-care settings where they operate, market forces do not constrain the raw pursuit of profit. People desperate for care are in no position to reject over-priced medical services or shop for in-network doctors.

Private equity firms are attracted by this opportunity to reap above-market returns for themselves and their investors.

Patients hate surprise medical bills, but they are very profitable for the private equity owners of companies like EmCare (now called Envision) and TeamHealth. Fixing this problem may be more difficult than the White House imagines. (T)

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