Having good insurance doesn’t always mean that you won’t be caught with a huge surprise medical bill you didn’t expect and won’t know where to turn. But politics and self-interest on the part of insurers and health care providers have gotten in the way of a workable solution.
Such bills result when someone goes to the emergency room and the physicians treating them – primarily ER doctors, anesthesiologists and radiologists – don’t belong to a patient’s insurer’s network of providers. In other words, those providers are out-of-network and can bill what they please. And they do.
What happens is that the patient’s insurer pays the in-network negotiated rate, and soon afterwards the patient receives a surprise bill from an out-of-network doctor for the balance of his or her fee. Sometimes these are large like the $109,000 bill a 44-year-old Texas schoolteacher received for care after a heart attack. His insurance carrier paid nearly $56,000, and the out-of network hospital offered to accept a $782 payment after the teacher’s story appeared as part of a Bill of the Month feature on the Kaiser Health News website. After national publicity, the hospital offered to slash the bill even more – to $332, which the teacher paid.
But most cases don’t receive such publicity, and consumers are at the mercy of inadequate state protections against such practices. In nearly all states, it’s patient beware!
Recently David Bordewyk, executive director of the South Dakota Newspaper Association, called me to complain about a CBS This Morning segment, which gave advice for dealing with surprise bills. Bordewyk thought the advice fell way short.
The program’s advice suggested patients negotiate with their hospital before writing a check, a tactic that has worked for some people. But as the first line strategy for solving this problem, Bordewyk believed it was not workable. “That advice seemed useless to me and insufficient,” he said. “It seemed so lacking; it was frustrating.”
CBS reported that 21 states have surprise billing laws, which don’t work very well. Still it advised viewers to check the laws in their state, check with their health plan, and always fight back.
Most people who followed that advice would be hard-pressed to find some useful protections against surprise bills. Checking your state’s laws is not much of a solution.
Last year The Commonwealth Fund, a philanthropic organization in New York City, studied surprise bills and found that many states “typically rely on market forces to minimize surprise bills.” The hope is that if a few doctors are not engaging in the practice, then maybe market competition would prevent others from using it.
Among the 21 states with some kind of regulation, only six – New York, California, Connecticut, Illinois, Maryland, and Florida – have comprehensive statutes, according to the Fund.
In those states, protections apply to consumers who belong to HMOs (health maintenance organizations) and PPOs (preferred provider organizations) and extend protection to emergency room patients as well as those who are hospital inpatients. They also free the patients caught in the middle from paying the extra provider charges and may have a process for resolving disputes.
But in other states with some regulations, protections may be limited. For example, they may apply only if their cases involve emergency room treatment but not hospital inpatient care.
Furthermore, surprise billing protections apply only to consumers who are in what are called “fully-insured” health plans that are subject to state regulation. Those in self-insured plans, generally through large employers, have no protections.
The answer to this inadequate patchwork of state laws is federal legislation. But according to Chuck Bell, program director for Consumers Union, it’s tough to craft a bill acceptable both to insurers who still want to drive hard bargains with doctors and to physicians who want to make as much money as they can.
Insurers are getting pickier in setting up their networks. That means there may be fewer doctors who will accept the fees an insurer is willing to pay and, potentially, more surprise billing.
Michele Kimball, president and CEO of Physicians for Fair Coverage, a group of doctors who are lobbying for state legislation, calls insurer practices “strong arming” physicians. She says the doctors are “willing to accept a ban on balance billing. They just want to be fairly and adequately reimbursed.”
A bipartisan group of six senators has just released a discussion draft with proposals to fix the problem. Whether anything comes of it next year is anyone’s guess. Says Bell, “Congress has to find a solution that will be accepted by both providers and insurance companies at the national level where their lobbying power is the strongest. That’s tricky from a political point of view.”
What has been your experience with surprise bills? Write to Trudy at trudy. firstname.lastname@example.org.