JustCare

Tag: Out of network

  • Expect high out-of-pocket costs if you’re hospitalized, with insurance–and fight them

    Expect high out-of-pocket costs if you’re hospitalized, with insurance–and fight them

    Michael Levenson reports for the New York Times on a woman who had to go to court to avoid paying hundreds of thousands of out-of-pocket health care costs. The woman, Lisa Melody French, went to her local hospital for back surgery. The hospital told her to expect about $1,300 in out-of-pocket costs given her health insurance; but, because she received out-of-network care and the hospital “misread” her insurance, it charged her $229,000.

    If you’re hospitalized and have commercial health insurance, including Medicare Advantage, you could be faced with higher out-of-pocket costs than you expected. You have little control over the doctors who see you and are at high risk of out-of-network doctors providing your care. They generally can’t charge above Medicare’s rate, but that can still be a lot. That said, depending on your income, you could qualify for charity care if you are in a non-profit hospital.

    Ms. French challenged her hospital charges in Colorado state court. Fortunately, the Colorado Supreme Court ruled in her favor. She was liable for only $766.74. It took eight years for her to get that decision.

    How did Ms. French end up with more than $200,000 in out-of-pocket costs? Centura Health, which runs the hospital that provided the surgery, billed her because her providers were out of network and her insurer would not cover their charges. And, Ms. French signed two agreements to pay all hospital charges after the hospital told her that her estimated out-of-pocket costs would be $1,300.

    Out-of-network rates can be ridiculously inflated: The out-of-network charges were the hospital’s full rates–the amounts listed on its “chargemaster.” The court ruled in Ms. French’s favor because she did not know there was a chargemaster and had never agreed to pay its rates. The hospital did not tell her anything about the chargemaster nor would it disclose the chargemaster during the litigation, claiming that the chargemaster was proprietary, a trade secret.

    Hospitals should not be able to charge any rate they please for out-of-network care: Chargemasters “have no basis in reality,” according to Gerard Anderson, a Johns Hopkins professor. They are not tied to the actual cost of a given treatment or procedure. Likely for this reason, hospitals tend to keep them confidential. President Trump ordered that hospitals make this information public, but they have never done so in a way that anyone can understand.

    Patients have no way to comparison shop for hospital care: Since patients have no clue what procedures providers will undertake, no control over them and little information about their costs, patients have no way to comparison shop for their care.

    What if you’re in a Medicare Advantage plan? As with insurance for working people, with Medicare Advantage plans, corporate health plans that cover Medicare benefits, your costs can be insanely high, especially if you’re in an HMO; in an HMO, if you see out-of-network providers, there is no limit on your out-of-pocket costs.

    Here’s more from Just Care:

  • Will we see an end to surprise medical bills?

    Will we see an end to surprise medical bills?

    Doctors and other health care providers are billing unsuspecting patients ever increasing amounts for out-of-network care. A new report from the Health Care Cost Institute reveals which doctors and other health care providers are more likely to charge insured patients for out-of-network care, sending out “surprise medical bills.” Congress agrees surprise medical billing is a problem, but it can’t seem to agree on how to address it.

    In many cases, surprise medical bills are for thousands of dollars, and patients have no control over them. Too often, patients end up in medical debt. Fortunately, it is less of a problem for people with Medicare because providers are limited in what they can charge people with Medicare.

    Pathologists, specialists who study tissues and fluids to help diagnose medical conditions, are the health care providers who most frequently bill for out-of-network care. More than one in three pathologists billed hospitalized patients for out-of-network care more than 90 percent of the time. And about one in five pathologists billed patients for outpatient visits out-of-network more than 90 percent of the time.

    Much like pathologists, a large share of emergency care providers bill patients for out-of-network inpatient care. About 44 percent of providers in both specialties. Emergency care doctors do not send out surprise medical bills as frequently as pathologists. But, when they do bill for out-of-network care, the charges can be sky-high.

    Members of Congress on both sides of the aisle support legislation to address surprise medical bills. But, they have not been able to reach agreement on a solution. The simplest solution would be for the government to limit what health care providers can charge for their services out of network. But, hospitals and private-equity firms, which sometimes own pathology and emergency care medicine practices, are arguing for arbitration.

    Recent Congressional legislation appropriating stimulus money for hospitals in response to the coronavirus pandemic specifically forbids hospitals from sending surprise bills to patients receiving COVID-19 care. Still, stories abound of patients receiving surprise bills for COVID-19 care, including one person in Denver who received a bill for $140,000.

    HCCI researchers found that in addition to pathologists and emergency medicine providers, many other types of specialists bill patients for out-of-network care, though at different frequencies. The proportion of providers with at least one out-of-network claim for inpatient visits ran the gamut from 18% for cardiology to 44% for emergency medicine. For outpatient visits, the share of providers with at least one out-of-network claim ranged from 15% for behavioral health to 49% for emergency medicine.

    Here’s more from Just Care: