PART 3. SURPRISE MEDICAL BILLS. “I was never in a position to preselect who (would) perform my heart transplant,” (and if the physicians and surgeons were in network)….because I did not know when a new heart would become available.

THIS CASE HAS BEEN ABRIDGED TO FACILITATE DISCUSSION. Parts 1-4 have been condensed 40%.

Going forward all new cases will be shorter and for ongoing cases new and previous posts will be thoughtfully edited.

On continuing cases do you prefer that new posts be shown first or last?

Reminder. You can edit these cases for classroom use with attribution to Doctor, Did You Wash Your Hands? ®      http://doctordidyouwashyourhands.com/

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Please post your comments, feedback and suggestions and/ or email me at jonathanmetsch@gmail.com

thanx! for your interest

Jon

Jonathan Metsch, Dr.P.H.

https://www.mountsinai.org/profiles/jonathan-m-metsch

PART 1: January 31, 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 “

PART 2: February 20, 2019. A new bill would outlaw the big, surprise bills that Zuckerberg San Francisco General Hospital has sent to hundreds of patients.

PART 3: April 18, 2019. “Zuckerberg San Francisco General Hospital announced Tuesday it has overhauled its billing policies…

PART 4: August 20, 2019. Hospitals kept ER fees secret

ASSIGNMENT: How do other states address financial sustainability for their “safety-net” hospitals?

PART 1: January 31, 2019. “If you’re shot, stabbed, hit by a car, fall off …

“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)

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.” (E)

“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.”  (F))

“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.” (G)

“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…”  (H)

“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.. (I)

“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.” (J)

“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.”  (K)

“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…

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.” (L)

 “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.” (M)

 “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…

Immediate Changes.

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 (N)

(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)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/

(F)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

(G)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/

(H) 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/

(I)Taking Surprise Medical Bills To Court, by Julie Appleby, https://khn.org/news/taking-surprise-medical-bills-to-court/

(J)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

(K)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

(L)Trump boosts fight against surprise medical bills, by PETER SULLIVAN, https://thehill.com/policy/healthcare/427066-trump-boosts-fight-against-surprise-medical-bills

(M)Emergency rooms are monopolies. Patients pay the price, by Sarah Kliff, https://www.vox.com/health-care/2017/12/4/16679686/emergency-room-facility-fee-monopolies

(N)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

PART 2:  February 20, 2019. 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…

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.”  (A)

“Publicity over “balance billing,” a practice that at Zuckerberg San Francisco General Hospital has left some patients with insurance on the hook for thousands of dollars in bills, has prompted San Francisco lawmakers to call for a ban.

SF General made headlines recently for being out of network with all private insurance companies and charging its insured patients high bills — in one case $20,000 for a broken arm — without informing them first of the practice.

Assembly Bill 1161, introduced by Assemblymember David Chiu and state Sen. Scott Wiener, would mandate that insured patients across the state owe the same copayment or deductible they would normally pay for their in-network emergency care.

The ban would apply regardless of whether or not the emergency room is in-network or out-of-network with a patient’s insurer.

Patients receiving non-emergency care already benefit from protections of a similar state law. However, the law does not apply to Preferred Provider Organization (PPO) patients.

Some 6 million people across the state have federally regulated self-insured plans, and some 1 million have plans regulated by the California Department of Insurance who don’t benefit from this protection, per the bill…

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.” (B)

Dear Congressional and Committee Leadership: (C)

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…

Ensure patient access to emergency care…

Preserve the role of private negotiation…

Remove the patient from health plan/provider negotiations…

Educate patients about their health care coverage…

Ensure patients have access to comprehensive provider networks and accurate network information…

Support state laws that work…

Sincerely,

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 18, 2019. “Zuckerberg San Francisco General Hospital announced Tuesday it has overhauled its billing policies…

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)

A.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

B.Publicity spurs billing revamp at Zuckerberg hospital, by Kelly Gooch, https://www.beckershospitalreview.com/finance/publicity-spurs-billing-revamp-at-zuckerberg-hospital.html

PART 4: August 18, 20129. Hospitals kept ER fees secret.

Zuckerberg San Francisco General and the University of California San Francisco are two of the city’s busiest hospitals, about 4 miles apart. But if you have private insurance and visit Zuckerberg General, you could end up paying a lot more for the same treatment.

For an especially serious visit, Zuckerberg General charges a facility fee of $11,176, 46 percent more than UCSF, which charges an average of $7,635.

The hospital is also out-of-network with all private insurance, leaving patients responsible for the fee and the cost of treatment. UC San Francisco, meanwhile, accepts insurance from most big providers. Insurers generally negotiate lower prices for patients, and many plans cover ER visits in part or in full…

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…

 “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.” (A)

“Frustrated by waiting for federal lawmakers to act, states have been trying to solve this issue. As of December 2018, 25 states offered some protection against surprise billing, and the protections in nine of those states were considered “comprehensive,” according to the Commonwealth Fund. California, New York, Florida, Illinois and Connecticut are among the nine.

New state laws also have been adopted since, including in Nevada, which will limit how much out-of-network providers, including hospitals, can charge patients for emergency care, starting next year.

In California, a 2009 state Supreme Court ruling protects some patients against surprise billing for emergency care, and a state law that took effect in 2017 protects some who receive non-emergency care.

But millions remain vulnerable, largely because California’s protections don’t cover all insurance plans. The California Supreme Court ruling applies to people with plans regulated by the state Department of Managed Health Care. That leaves out the roughly 1 million Californians with plans regulated by the state Department of Insurance and the nearly 6 million people with federally regulated plans, most of whom have employer-sponsored insurance.

The state law governing non-emergency care also doesn’t apply to the millions of residents with health plans regulated by the federal government…

The California Hospital Association opposes the measure, which would limit the amount hospitals could charge insurance plans to a certain rate for each service, varying by region…

 “We fully support the provision of the bill that protects patients. It is the rate-setting piece that is our concern,” she said.”  (B)

“Legislation to prohibit California hospitals from sticking patients with huge emergency room bills that their insurers won’t cover has cleared a crucial hurdle in the state Capitol.

Lawmakers in the Assembly voted 48-9 on Thursday to approve AB1611, which would prohibit hospitals from “balance billing” patients if their insurance won’t cover the full cost for care.

Assemblyman David Chiu and state Sen. Scott Wiener, both Democrats from San Francisco, co-wrote the legislation. The bill now moves to the Senate…

AB1611 would prohibit hospitals from billing patients for any cost beyond their insurance deductible and co-payment. It also spells out rules for how hospitals and insurers resolve cost disputes.” (C)

 “Hospitals focused their opposition on a provision of the bill that would have limited charges for out-of-network emergency services.

The proposal would have required hospitals to work directly with health plans on billing, leaving the patients responsible only for their in-network copayments, coinsurance and deductibles.

Citing fierce pushback from hospitals, California lawmakers sidelined a bill Wednesday that would have protected some patients from surprise medical bills by limiting how much hospitals could charge them for emergency care.” (D)

The legislation, which contributed to the intense national conversation about surprise medical billing, was scheduled to be debated Wednesday in the state Senate Health Committee.

Instead, the bill’s author pulled it from consideration, vowing to bring it back next year.

“We are going after a practice that has generated billions of dollars for hospitals, so this is high-level,” said Assemblyman David Chiu (D-San Francisco). “This certainly does not mean we’re done.” (E)

 “California hospitals want you to know that they’re fully on board with the idea that emergency room patients shouldn’t be hit with thousands of dollars in surprise billings because the ER isn’t in their insurance plan’s network.

You should also know, however, that the hospitals just killed a measure in Sacramento that would have accomplished that goal, and that the reason they did so was to protect their own revenues….

The state’s hospitals went to the mattresses over the payment provision, cursing it as “government rate setting” that they would never accept.

Hospital executives inundated legislators with warnings that rate-setting would force their institutions to shut down.

We have 450 hospitals in California,” says Anthony Wright, executive director of Health Access, “and every hospital CEO has the cellphone number of his state senator and assemblyman. A hospital saying it would close would give pause to any lawmaker.”

The proponents were aware that they were poking a stick into a tiger’s cage. “We’re going after a practice that has generated billions of dollars in profits for hospitals, Chiu told me, “and hospital CEOs around the state waged very aggressive lobbying to protect those profits.”” (F)

“San Francisco’s health network has finalized its first contract with a private health insurer, Canopy Health Canopy — meaning Zuckerberg San Francisco General Hospital, long perceived as the hospital of last resort, is now in the business of wooing expectant mothers to choose to deliver at its Family Birth Center…

Department of Public Health staff said the signing of this contract was not a reaction to billing controversies at ZSFGH that erupted earlier this year, when it was revealed that even insured patients were being hit with crippling debts through the practice of “balance billing.” Because the hospital was out-of-network for private insurance companies, there was often a great divergence between what ZSFGH billed the insurance and what the insurance company would deign to pay — leaving individuals responsible for the “balance.”

This situation, however, did highlight the hospital’s unhealthy and precarious “payer mix.” With few privately insured patients, ZSFGH ministers mostly to Medi-Cal recipients or the marginally insured. Deals like the one initiated July 15 with Canopy would begin to change that mix, however.”  (G)

A.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

B.Lawmakers Push To Stop Surprise ER Billing, by Ana B. Ibarra, Lawmakers Push To Stop Surprise ER Billing, by Ana B. Ibarra, https://www.google.com/search?q=lawmakers+push+to+stop+surprise+er+billingby+ana+b.+ibarra&ie=&oe=

C.Legislation prompted by huge SF General bills passes California Assembly, by Dustin Gardiner, https://www.sfchronicle.com/politics/article/Legislation-prompted-by-huge-SF-General-bills-13908291.php

D.Hospitals block California’s balance-billing legislation, By Ana B. Ibarra, https://www.benefitspro.com/2019/07/11/hospitals-block-californias-balance-billing-legislation/

E.Lawmakers Push To Stop Surprise ER Billing, by Ana B. Ibarra, https://californiahealthline.org/news/lawmakers-push-to-stop-surprise-er-billing/

F.Column: How the hospital lobby derailed legislation to protect you from surprise hospital bills, by MICHAEL HILTZIK, https://www.latimes.com/business/story/2019-08-01/hospital-lobby-surprise-billing-legislation

G.San Francisco inks first contract with private health insurer, by Joe Eskenazi, https://missionlocal.org/2019/07/san-francisco-inks-first-contract-with-private-health-insurer/

Prequel ((still unabridged))

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