Costs Can Go Up Fast When E.R. Is in Network but the Doctors Are Not

[eridani]

http://www.nytimes.com/2014/09/29/us/costs-can-go-up-fast-when-er-is-in-network-but-the-doctors-are-not.html

Patients have no choice about which physician they see when they go to an emergency room, even if they have the presence of mind to visit a hospital that is in their insurance network. In the piles of forms that patients sign in those chaotic first moments is often an acknowledgment that they understand some providers may be out of network.

But even the most basic visits with emergency room physicians and other doctors called in to consult are increasingly leaving patients with hefty bills: More and more, doctors who work in emergency rooms are private contractors who are out of network or do not accept any insurance plans.

When legislators in Texas demanded some data from insurers last year, they learned that up to half of the hospitals that participated with UnitedHealthcare, Humana and Blue Cross-Blue Shield — Texas’s three biggest insurers — had no in-network emergency room doctors. Out-of-network payments to emergency room physicians accounted for 40 to 70 percent of the money spent on emergency care at in-network hospitals, researchers with the Center for Public Policy Priorities in Austin found.

“It’s very common and there’s little consumers can do to prevent it and protect themselves — it’s a roll of the dice,” said Stacey Pogue, a senior policy analyst with the nonpartisan center and an author of the study

.

Center for Public Policy Priorities study of out-of-network emergency room doctors:
http://forabettertexas.org/images/HC_2014_09_PP_BalanceBilling.pdf

KFF on state balance billing restrictions:
http://kff.org/private-insurance/state-indicator/state-restriction-against-providers-balance-billing-managed-care-enrollees/

Comment by Don McCanne of PNHP: A consequence of allowing health insurers to contract selectively with health care professionals (physicians) and institutions (hospitals) is that patients not only are financially penalized should they elect to obtain their care outside of the contracted networks, they may unavoidably face such penalties when they have sought care only within networks.

One of the more egregious examples is when they obtain emergency services at a contracted emergency room only to find out after the fact that the physicians staffing the emergency room are not in the network. The patient then is billed not only for deductibles and copayments applied to allowed charges, but also for the balance of the charges in excess of the allowed charges - a process known as balance billing.

“The Affordable Care Act provides some protections for enrollees in need of emergency services, but does not prohibit balance billing by out-of-network providers” (KFF). For further information on state restrictions on balance billing, use the KFF link above.

When something is not right, as it clearly isn’t here, it is important to define the problem before crafting a solution. State regulators and legislators are defining this as a problem of balance billing “abuse” and are looking at mechanisms to prohibit balance billing. But is that really the problem?

Insurers, with the complicity of state and federal legislators, have established limited networks of providers to leverage more favorable payment rates for health care services. But these rates neglect the health care delivery system outside of the networks. Now states are considering making out-of-network physicians comply with contracts to which they never agreed. That is as unreasonable as making insurers pay out-of-network fees in full simply because the insurers did not have a contract with the physicians. Do you have a contract or not? You can’t have it both ways.

The problem here needs to be redefined. Balance billing is not the primary defect. It is the nature of our complex, dysfunctional financing infrastructure that leads to a multitude of perverse consequences such as balance billing - an infrastructure that was perpetuated and expanded by the Affordable Care Act. We need to rebuild the infrastructure. We need a single payer national health program. Balance billing would not exist under such a system.

[eridani]

1. LTEs

To the Editor:
Re “Costs Can Go Up Fast When E.R. Is in Network but the Doctors Are Not” (“Paying Till It Hurts” series, Sept. 29):

The real culprits behind out-of-network charges are hiding in plain sight: health insurance companies. While emergency physicians are bound by ethics and law to treat anyone who comes for help, regardless of insurance status or ability to pay, insurance companies are free to set rates of reimbursement as they see fit.
Our goal is to deliver care to anyone who needs it, whenever they need it. And to be paid fairly for doing so. Emergency physicians would gladly join networks set up by insurance companies if they agreed to reimburse fairly. But most insurance companies vigorously resist any calls to pay “usual and customary” charges; instead, most unilaterally set rates that are unreasonably low. Their goal is to maximize profits, often at the expense of patients.

ALEX ROSENAU
President, American College of Emergency Physicians
Washington, Sept. 29, 2014


To the Editor:

Your “Paying Till It Hurts” series provides compelling stories of patients unexpectedly hit with high out-of-network bills. Our research suggests that there are more than a few isolated cases.

We conducted a nationally representative survey of privately insured adults and indeed found that involuntary use of out-of-network doctors was common: Of the 8 percent of patients who saw an out-of-network doctor in the past year, 40 percent — representing about 3 million people — did not intend to do so.Furthermore, half of patients who saw an out-of-network doctor were not aware of the costs at the time of service, and a quarter reported financial difficulty paying out-of network bills.

Our research confirms what your articles indicate anecdotally is true — that it is often not obvious if a doctor is out-of-network, especially for emergency and inpatient care, and even if you know the doctor is out-of-network, determining how much it might cost can be challenging.

KELLY A. KYANKO
SUSAN H. BUSCH
New York, Sept. 29, 2014
Dr. Kyanko, an internist, is an assistant professor at the New York University School of Medicine, and Dr. Busch is an associate professor at the Yale School of Public Health.


To the Editor:

The emergency room doctors and the hospitals whose patients they are being allowed to prey upon are violating the trust inherent in the relationship between patients and the medical profession and, perhaps irrevocably, altering how the profession is perceived — with potentially disastrous consequences for all parties.

Is that really the path they want to take?

JOE CORNELIUS
Boulder, Colo., Sept. 30, 2014

[TexasMommaWithAHat]

5. Yes, this is infuriating

I saw an out-of-network doctor a few months ago in the emergency room, and a was shocked to get the bill! arrrgggghhh

[dbackjon]

2. Great topic

I am fighting that very issue right now

[Brigid]

3. There is a solution.

But I don't think it will ever happen in this country.

[eridani]

4. But it can still happen in individual states n/t