In the ongoing debate about out-of-network balance billing, or so-called “surprise billing,” a recent national study found that the average anesthesiologist, radiologist, emergency physician, pathologist, and neurosurgeon charge at least four times what Medicare reimburses for the same services. Which means uninsured or out-of-network patients are on the hook for much higher balances than what the federal government pays. In-network patients with high deductibles would at least benefit from contractual adjustments.
The Johns Hopkins University study of more than 400,000 U.S. doctors across 54 specialties was published in January in the Journal of the American Medical Association (JAMA).
According to a Consumer Reports article about the study, four states have passed laws against the practice of balance billing since 2015, including California, Connecticut, Florida, and New York. In Indiana, House Bill 1273 has been introduced by author Rep. James Baird and co-authors, Rep. Robert Heaton, Rep. Earl Harris, and Rep. Donna Schaibley, which would require noncontracted providers who render health care services in a contracted facility to inform insured patients in writing before rendering any services that the provider is noncontracted and that the patients can be billed for any services not paid by the insurance company.
Proposed legislation also is pending in Georgia, Washington, Utah, and other states. As well, on the federal level, Consumer Reports journalist Donna Rosato said the Federal Trade Commission is looking into the issue, at the request of Sen. Bill Nelson, D-Fla., and proposed House legislation—the End Surprise Billing Act—was reintroduced on February 2, 2017, by Rep. Lloyd Doggett, D-Texas.
According to the American Society of Anesthesiologists (ASA), however, the study focuses on the wrong issues. “‘Surprise medical bills’ are caused by ‘surprise insurance gaps,’ or gaps in insurance coverage that occur when the insurance plan offers a low premium but limits the number of physicians available to patients in the plan’s network,” the ASA said in a statement published on their website in January 2017.
To that end, the ASA claims that insurance plans “with narrow networks remove or reduce patient choice by providing coverage with a limited number of physicians, high deductibles, co-pays and coinsurance. These inadequate networks limit insurance companies’ costs and shift them to patients and other stakeholders.”
In addition to their role in the operating room, ASA President Jeffrey S. Plagenhoef, M.D., says anesthesiologists also are committed to finding a more transparent payment process so patients know what to expect.
“Physician anesthesiologists are committed to safe, high-quality care for all our patients,” Dr. Plagenhoef said. “This means not only overseeing your care in the hospital or the office, but advocating for you with legislators, hospital administrators, insurance companies – everyone who plays a role in making sure patients get the care they deserve, which is the best care possible.”
The ASA encourages patients to call their insurance company before procedures when possible to understand which providers are in-network, as well as recognize that “low premiums don’t necessarily mean affordable care.”
Consumer Reports’ Rosato also counsels patients to appeal to all parties involved to ease the burden of surprise billing, including educating themselves more thoroughly on the provisions of their insurance plan. Rosato’s four-step plan to avoid surprise bills includes:
- Talk to your doctor for in-network referrals and out-of-network negotiations.
- Call your health insurer before you go out of network to see what services are actually covered and to ask for an exception when needed.
- Understand what is covered in an emergency … before an emergency actually happens.
- Fight the bill with both the insurer and the provider, even filing appeals with the state insurance commission if necessary.
For physicians and their staff, knowing patients are being counseled to fight out-of-network bills means being prepared with policies and procedures for handling complaints, helping patients with insurance appeals, and offering payment plans and financial hardship policies for patients who just can’t pay their balances or at least not all at once.
For more tips about effectively managing out-of-network patients, review the following CIPROMS article: “When Patients Are Out of Network.”
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