By Julie Appleby, Kaiser Health News
After Pam Durocher was diagnosed with breast cancer, she searched her insurer’s website for a participating surgeon to do the reconstructive surgery.
Having done her homework, she was stunned to get a $10,000 bill from the surgeon.
“I panicked when I got that bill,” said the 60-year-old retired civil servant who lives near Roseville, Calif.
Like Durocher, many consumers who take pains to research which doctors and hospitals participate in their plans can still end up with huge bills. Sometimes, that’s because they got incorrect or incomplete information from their insurer or health-care provider. Sometimes, it’s because a physician has multiple offices, and not all are in network, as in Durocher’s case. Sometimes, it’s because a participating hospital relies on out-of-network doctors, including emergency room physicians, anesthesiologists and radiologists.
Consumer advocates say the sheer scope of such problems undermine promises made by proponents of the Affordable Care Act that the law would protect against medical bankruptcy.
“It’s not fair and probably not legal that consumers be left holding the bag when an out-of-network doctor treats them,” said Timothy Jost, a law professor at Washington and Lee University. Jost said it’s a different matter if a consumer knowingly chooses an out-of-network doctor.
Durocher learned only after getting her surgeon’s bill that just one of his two offices participated in her plan and she had chosen the wrong one. She said the doctor’s staff later insisted that they had raised the issue during her initial consultation, but she doesn’t recall that, possibly because she was distracted by her cancer diagnosis.
Adding insult to injury, insurers are not required to count out-of-network charges toward the federal health law’s annual limit on how much of their medical costs patients can be asked to pay out of their own pockets.
Efforts by doctors, hospitals and other health providers to charge patients for bills not covered by their insurers are called “balance billing.” The problem predates the federal health law and has long been among the top complaints filed with state insurance regulators.
Because the issue is complex and pits powerful rivals against one another—among them, hospitals, doctors and insurers—relatively few states have addressed it. What laws do exist are generally limited to specific situations, such as emergency room care, or certain types of insurance plans, such as HMOs.
The federal health law largely sidesteps the issue as well. It says insurers must include coverage for emergency care and not charge policyholders higher copayments for ER services at non-network hospitals, because patients can’t always choose where they go. While the insurer will pay a portion of the bill, in such cases, doctors or hospitals may still bill patients for the difference between that payment and their own charges.
That means that in spite of having insurance, a consumer involved in a car wreck and taken to a non-network hospital might receive additional bills, not just from the hospital, but from the radiologist who read his X-rays, the surgeon who repaired his broken leg and the laboratory that processed his blood tests.
Networks Get Narrower
Advocates believe a growing number of consumers are vulnerable to balance billing as insurance networks grow smaller in the bid to hold down costs.
For example, there were no in-network emergency room physicians or anesthesiologists in some of the hospitals participating in plans offered by three large insurers in Texas in 2013 and 2014, according to a survey of state data by the Center for Public Policy Priorities, a Texas advocacy group.
Smaller networks are also becoming more common in employer-based insurance: About 23 percent of job-based plans had so-called “narrow networks” in 2012, up from 15 percent in 2007, according to a May report from the Urban Institute and Georgetown University Center on Health Insurance Reforms.
To protect consumers, advocacy groups, including Consumers Union and the American Cancer Society Cancer Action Network, want regulators to strictly limit balance billing when an insured person gets care in a medical facility that is part of an insurer’s network.
“Without protection from balance billing, the cost of out-of-network care can be overwhelming,” wrote Consumers Union in a recent letter to the National Association of Insurance Commissioners (NAIC), which is updating a model law that states could adopt to regulate insurance networks.
NAIC’S current draft does not directly address the issue of balance billing and consumer efforts have drawn sharp opposition from insurers, hospitals and doctors.
Some states have taken other steps to protect consumers:
· Earlier this month, California set out new rules, requiring some insurers to provide accurate lists of medical providers in their networks.
· New Jersey specifies that insurers guarantee that certain providers be available “within 20 miles or 30 minutes average driving time.”
· Colorado insurers must pay non-network medical providers their full charges, not discounted network rates, for care at in-network hospitals.
· In Maryland, insurers must pay for “covered services,” which includes emergency care, but the state sets standardized payment rates.
· Starting in April, New Yorkers won’t face extra bills for out-of-network emergency care, when an in-network provider is unavailable or when they aren’t told ahead of time that they may be treated by a non-participating provider. Instead, the bills must be settled in arbitration between the providers and the insurance companies.
Insurers defend the move to smaller networks of doctors and hospitals as a way to provide the low-cost plans that consumers say they want. Since insurers can no longer reject enrollees with health problems or charge them more, the plans are using the tools left to them to reduce costs.
If regulators required them to fully cover charges by out-of-network doctors, that could reduce “incentives for providers to participate in networks” and make it harder to have adequate networks, America’s Health Insurance Plans, the insurers’ trade group, and the Blue Cross Blue Shield Association wrote in a joint letter to the NAIC.
It would also raise premiums.
Instead, AHIP says, states could require out-of-network doctors to accept a benchmark payment from insurers, perhaps what Medicare pays, rather than balance billing patients.
Physicians, meanwhile, blame insurers for inadequate networks.
“There’s no ‘free’ anywhere,” said Lee Spangler, vice president of medical economics with the Texas Medical Association. “You either pay for the coverage through premiums, or you pay for service when you receive it.”
Doctors choose whether to balance bill, he added—and some don’t.
But he noted that patients “have received professional services in the expectation that they will get alleviation of what ailed them, and the physicians provided it in the expectation they would be paid. There’s no in between,” Spangler said.
For patients like Durocher, who got billed even after doing everything she was told, the only recourse is to negotiate with the physician or hospital to ask them to lower or drop the charges.
“Fortunately for me,” Durocher said, “this doctor was very nice and wrote off almost $7,000 of the bill.”