JustCare

Tag: Out-of-network care

  • Out-of-network care: Don’t trust your insurer to pay the bills

    Out-of-network care: Don’t trust your insurer to pay the bills

    MultiPlan, a data analytics firm, works with UnitedHealthcare and many big insurers to calculate the amount insurers should pay for out-of-network care. As Chris Hamby reports for the New York Times, MultiPlan and the insurers make more money for themselves, the less they pay for employees’ care. So, many working people can’t trust their insurer to pay for their out-of-network care.

    Are MultiPlan and the insurers simply “containing” costs for employers or profiting wildly at the expense of working people? Profiting wildly. The less they pay for workers’ out-of-network care, the more revenue they generate for themselves. In 2023, MultiPlan advised insurers not to pay $23 billion in health care bills they claim were provider overcharges.

    How insurers benefit from out-of-network coverage, an example: The oncologist charges $100,000 for out-of-network care. MultiPlan says the appropriate charge is $5,000. The insurer pays $5,000. The employer saves. And, MultiPlan and the insurer receive a fee from the employer that is a high percentage of the “savings.”

    What’s most insane about this whole scheme is that in many cases the fees that MultiPlan and the insurer collect are way more than the physician or hospital receives as payment for services from the insurer! UnitedHealthcare charges employers around 30 to 35 percent of the difference between what the provider bills and what the insurer pays. MultiPlan receives an additional fee. The cancer patient could be stuck with a $95,000 bill. The less the employer pays, the more MultiPlan and the insurer earn in fees.

    How does MultiPlan calculate the insurers’ payment? Somehow, MultiPlan claims that the amount it determines to be the fair out-of-network rate is  “defensible, repeatable and completely transparent” and independent of insurance company influence.” Orwellian, to say the least.

    Don’t assume that your employer’s insurer doesn’t rely on MultiPlan. MultiPlan calculates out-of-network payments for more than 60 million people enrolled in 100,000 different health plans.

    What must workers pay for their out-of-network care? They could be stuck paying whatever the difference is between what the insurer pays and the physician bills. They are also likely to forgo needed care down the road for fear of incurring more bills.

    Who’s watching the store for workers? Honestly, no one. Regulators do not get involved with employer health plans, for the most part.

    Fool me twice? 15 years ago, the New York Attorney General intervened to stop a similar UnitedHealthcare scheme: “A payment system riddled with conflicts of interest had been shortchanging patients, and at its core was a data company called Ingenix, a subsidiary of UnitedHealth.” They lower their payments to providers inappropriately. requiring patients to pay more. UnitedHealth paid $350 million and new regulations were put in place to prevent this from happening again.

    Here’s more from Just Care:

  • Coronavirus: Medicare coverage

    Coronavirus: Medicare coverage

    The Centers for Medicare and Medicare Services and Congress have expanded Medicare coverage to help the 60 million older adults and people with disabilities who might need testing and treatment for the novel coronavirus and other health care services. People over 65 and people with disabilities are at particular risk if they get the virus.

    There is no vaccine or cure for COVID-19, the respiratory disease caused by the new coronavirus. People with fever, cough and other serious symptoms should quarantine themselves and, if they are having difficulty breathing, should get tested. If necessary, they should also have their symptoms treated.

    What is covered: Medicare Part B covers the full cost of testing, whether you are in traditional Medicare or a Medicare Advantage plan. For Medicare to pay, your doctor must order the testing. You pay no deductibles or coinsurance.

    Congress just passed a new law fully covering testing-related services, whether you are enrolled in traditional Medicare or a Medicare Advantage plan. And, Medicare Advantage plans cannot require prior authorization or other utilization management tools in order for people to receive these services. These services include the doctor visit, in person or electronically, and emergency department services. These are services that lead to the ordering or administering of the test.

    All Medicare inpatient and outpatient services continue to be covered. You are covered for all medically necessary services, including hospitalization, therapy, skilled nursing and home health care. Please click on the links to understand the scope of coverage. For skilled nursing facility care, Medicare has waived the three-day prior hospitalization requirement.

    Federal legislation also now allows Part B coverage for telehealth services for people in traditional Medicare during this emergency. Coverage is available no matter what health care services you need, related or unrelated to the coronavirus, including an office visit, mental health care and preventive care.

    The federal government has required Medicare Advantage plans to cover people’s out-of-network care from Medicare-participating facilities at the same cost as at in-network families. If you are enrolled in a Medicare Advantage plan, simply see any doctor or use any hospital that takes Medicare. About 95 percent of doctors and hospitals do. You do not need a referral.

    If there is a coronavirus vaccine, Medicare will cover it. It might be covered under Part B or Part D. And, there may be a deductible or copays.

    As for drugs, the federal government has not mandated that the Part D prescription drug insurers allow people to secure more drugs than usually permitted during this time of emergency. The Centers for Medicare and Medicaid Services simply states that it expects them to. Call your Part D insurer to find out whether you can get an extended supply of your drugs.

    What will you pay: If you are enrolled in a Medicare Advantage plan and you follow plan rules, you will be responsible for the deductible and copays up to the plan maximum, which can be no higher than $6,700 a year.

    If you are enrolled in traditional Medicare and do not have supplemental coverage to fill gaps–Medigap, retiree coverage or Medicaid–for inpatient hospital care, you will be responsible for the Medicare Part A deductible of $1,408 for each benefit period in 2020. After 60 days, you also must make a daily $352 copayment through day 90.  If you are quarantined in the hospital, you have no further financial responsibilities.

    If you were admitted to a skilled nursing facility, your copayments would be $176 a day for days 21-100.

    There is no limit on out-of-pocket costs if you are in traditional Medicare and do not have supplemental coverage. And, Medicare Advantage HMO plans can charge deductibles and copays up to $6,700 for in-network approved services. If you are enrolled in a PPO, the cap on out-of-network care is $10,000.

    Here’s more from Just Care:

  • Surprise! Congress supports legislation to protect Americans from unexpected medical bills

    Surprise! Congress supports legislation to protect Americans from unexpected medical bills

    The Hill reports that Democrats and Republican members of Congress are coming together over legislation that would protect some people from unexpected medical bills. Too often, Americans are going to the emergency room and finding themselves with thousands of dollars of medical bills they thought their insurance would cover. The proposed legislation would be beneficial, but only address the tip of the commercial health insurance iceberg.

    Here’s the heart of the problem:

    1. Congress does not regulate health care prices.
    2. Congress allows commercial insurers to restrict their coverage to a limited group of medical and hospital providers.
    3. And, Congress does nothing to protect, or require insurers to protect, people with insurance who are seen unknowingly or in emergency situations by providers who are not in their insurers’ networks.

    Medicare for all, improved and expanded Medicare, would address all these problems at once. Medicare for all does not mean Medicare for some.

    In our current commercial health insurance system, insured individuals can and do get billed tens of thousands of dollars if they end up receiving out-of-network care even in emergency situations. One insured teacher in Texas received a bill for $108,951 after a heart attack. And, the problem goes beyond emergency situations to situations in which individuals receive in-network hospital care but receive out-of-network doctor care, which is outside their control.

    It is not at all clear how often people enrolled in Medicare Advantage plans are faced with surprise medical bills. If you are enrolled in a Medicare Advantage plan, you should be protected against balance billing by out-of-network providers.

    For people not enrolled in Medicare, in the US House, Congressmen Frank Pallone(D-NJ) and Greg Walden (R-OR) propose turning responsibility for handling unexpected medical bills to providers and insurers, taking patients out of the middle in emergency situations. This would be a big step forward for patients. But, insurers and providers may try to derail the bill if insurers feel they would be expected to pay more than they think appropriate or providers feel they would be expected to accept lower rates than they think appropriate.

    In the Senate, Senators Bill Cassidy (R-La.), Maggie Hassan (D-NH) and Michael Bennet (D-CO) are working on legislation as well. A Senate bill was in play last October. With Congress, even small important bi-partisan fixes can take way too long.

    Here’s more from Just Care:

  • Bi-partisan bill in Congress would prevent surprise medical bills

    Bi-partisan bill in Congress would prevent surprise medical bills

    Millions of insured Americans go to the hospital, thinking that their bills will be covered only to be surprised by unexpected medical bills. Too often, they end up in medical bankruptcy. Out-of-network doctors and other health care providers may charge people tens of thousands of dollars. Finally, there’s a bipartisan bill in Congress that would prevent surprise medical bills.

    Senator Cassidy (R-LA), Michael Bennet (D-CO), Chuck Grassley (R-IA), Tom Carper (D-DE), Todd Young (R-IN), and Claire McCaskill (D-MO) have introduced S._____  The bill would forbid out-of-network care providers from billing patients for their services over which the patients have no control. These bills usually are a result of patients needing emergency hospital care and having no ability to ensure  the hospital they are taken to or the providers who treat them are in-network.

    The bill would protect patients from having to pay out of pocket for out-of-network care any more than they would pay for in-network care. Their health insurance would pay any additional charges up to a designated limit.  This bill would make a major difference for thousands of patients. Kaiser Health News has reported that people have received surprise bills for a $17,850 urine test and for $109,000 after a heart attack.

    The Senate bill would also protect emergency room patients in an out-of-network hospital once they are stabilized. At that point, the hospital would have to notify them in writing that they will be billed for its out-of-network services. The patients could sign a waiver agreeing to pay privately for that care. Or, they would have the right to move to an in-network hospital.

    More than half of all workers with health insurance through their employers (61 percent) are in self-funded plans. The employers pay claims directly rather than through insurance. And, out-of-network hospitals and doctors today can charge these plans what they will. This bill would no longer allow this type of balance billing.

    For now, here’s how to protect yourself from surprise medical bills.

    Here’s more from Just Care:

  • Could government price caps on out-of-network care lead to lower health care costs?

    Could government price caps on out-of-network care lead to lower health care costs?

    A new working paper from the Congressional Budget Office (CBO) shows that a government price ceiling on out-of-network care allows Medicare Advantage plans (commercial health plans that offer Medicare benefits) to contain in-network provider rates and keep premiums down. Would government price caps on out-of-network care for commercial health plans that provide coverage to working people lead to lower health care costs for in-network care as well?

    In brief, the CBO finds that Medicare Advantage plans pay providers close to the same amount as traditional Medicare, for which the government negotiates provider rates. Medicare Advantage plans are able to secure favorable doctor rates principally because doctors know that the traditional Medicare rate is the most Medicare Advantage plans are responsible for paying them for out-of-network services under the law. Moreover, doctors know that the traditional Medicare rate is the best rate they can get for treating people with Medicare not enrolled in a Medicare Advantage plan.

    In stark contrast, commercial health plans offering coverage to working people, pay on average as much as two times traditional Medicare rates for the same services. Doctors in many communities appear to have a lot of negotiating leverage with commercial health insurers. As a result, unlike traditional Medicare and Medicare Advantage plans, commercial health plans covering working people pay very different doctor rates both within geographic areas and among geographic areas.

    It is due time that Congress stepped in to rein in provider rates for everyone. As it is, one in four working people with health insurance skip care because of its cost, And, taxpayers are supporting these excessive provider rates. Taxpayer dollars subsidize the cost of commercial insurance both for people with workplace coverage and for people in the state health insurance exchanges. People with workplace coverage get preferential tax treatment for that coverage. And, many people in the state health insurance exchanges get taxpayer subsidies for their premiums and cost-sharing.

    With Medicare for all, as Bernie Sanders and 15 other Senators have proposed, Congress could ensure fair provider rates and lower premiums for everyone. Simply placing a cap on the amount commercial insurers pay for out-of-network care, as some have proposed, would not likely give commercial insurers the needed leverage to bring down provider rates. Providers would likely still have the leverage to raise their rates further for in-network care to compensate for the loss in revenue from out-of-network services. Similarly, extending Medicare to people without workplace coverage and allowing commercial insurance to continue for people with workplace coverage likely would not give the commercial insurers the needed leverage to rein in provider rates. Only about 10 percent of services are out-of-network.

    Providers have extra leverage over commercial insurers in the non-Medicare market because commercial insurers can pass on costs to businesses buying the health care coverage. It is hard to see providers conceding voluntarily to lower rates for people who have always paid more for their care than people with Medicare. We need Congress to extend Medicare to everyone in order for everyone to benefit from Medicare’s rates.

    If you agree that it’s time for Congress to allow Medicare drug price negotiation, please sign this petition.

    Here’s more from Just Care:

  • What to do if your in-network doctor goes out of network?

    What to do if your in-network doctor goes out of network?

    It used to be that our health care system valued continuity of care. Insurers covered care from virtually any doctor or hospital, and we could stick with our doctors over our lifetimes. And, that’s still the case with traditional Medicare. But, if you’re in a Medicare Advantage plan or virtually any other health plan, you are at risk of losing that continuity of care if your doctor pulls out of the network or you’re forced to switch plans. What can you do if your in-network doctor goes out of network mid-treatment?

    When you’re mid-treatment, it can be critical to stick with the doctors who have been treating you. They know your condition through and through. They know which treatments work and which don’t. And, you and they have developed a bond, a trust, that can be as valuable as the medical treatments you’re receiving. But, the cost of out-of-network care from the doctors you know and trust, can be astronomical. So here’s what to do:

    • If you are enrolled in a Medicare Advantage plan, call your State Health Insurance Assistance Program for help. You can find the number online at www.eldercare.gov or by calling 1-800-677-1116. You may be able to get your health plan to continue to cover your care from the doctors who have been treating you. Also, the Centers for Medicare and Medicaid Services (CMS) may grant members of a Medicare Advantage plan the right to switch plans as a result of a “significant” change in a health plan’s provider network.  CMS does not define “significant.” But, according to Kaiser Health News, it has been granting this right to some health plan members who have seen changes in their provider networks.
    • If you are not yet enrolled in Medicare, contact your state department of health or department of insurance to find out your rights. Some employers and some state laws allow–or are considering allowing–people with chronic, acute or terminal conditions to stick with their doctors for as long as a year (and longer for terminally ill patients), even if their doctors are no longer in their networks. Their new health plans must cover care from their providers so long as those providers are willing to accept the health plans’ payment rates.

    Here’s more from Just Care:

  • How to protect yourself against unexpected medical bills

    How to protect yourself against unexpected medical bills

    If you’ve been to the hospital at any time in the last several years–be it for a scheduled procedure or an emergency room visit–it’s more than likely that you’ve been hit with bills that you never expected. Inevitably, if you’re enrolled in an HMO or PPO, the doctors treating you at an in-network hospital are not all in your health plan’s network, and your health plan will not cover that care. Here’s how to protect yourself against unexpected medical bills.

    If you have traditional Medicare, you can avoid unexpected medical bills in hospital.  Traditional Medicare covers all your hospital care. Health insurance through an employer or the Affordable Care Act or a Medicare Advantage plan almost always restricts your coverage to in-network doctors and hospitals.  But, they do not guarantee that only in-network doctors will treat you.

    Neither federal nor state law requires all doctors at an in-network hospital to be part of your health plan’s network. And, worse still, these out-of-network doctors can charge you tens of thousands of dollars for the care they provide, unless you live in a state with strong consumer protections.

    While 21 states offer some consumer protections, a new report for the Commonwealth Fund finds that only six states do a good job of protecting patients who end up in the hospital, either for a scheduled procedure or in an emergency–California, Connecticut, Florida, Illinois, Maryland and New York. These states with the best consumer protections either forbid out-of-network doctors from billing additional charges to patients or require insurers to protect patients from the excess charges and resolve the excess charges directly with the out-of-network doctors.  Note: People enrolled in self-insured employer plans (ERISA) are exempt from state regulations and not protected under state law.

    New York State’s Department of Financial Services reports that unexpected medical bills for out-of-network care are the biggest health-insurance related complaint the Department receives.  Too often, services from pathologists, anesthesiologists and radiologists are out of network, and patients are wholly responsible for the cost. Consumers Union offers a case study in this report.

    In New York, out-of-network doctors must give notice to patients that they are providing services. Patients can then insist on receiving services from in-network doctors. Without this notice, patients are only responsible for the in-network cost, and insurers are responsible for settling disputes directly with doctors.

    No matter where you live, you should let the hospital know that you want to receive services only from doctors in your health plan’s network. And, before surgery, repeat that request to help ensure that the anesthesiologist, pathologist and radiologist are all in your plan’s network.

    Commonwealth Fund
    Commonwealth Fund

    Here’s more from Just Care:

  • Beware of high doctor charges

    Beware of high doctor charges

    Gerard Anderson, Johns Hopkins Bloomberg School of Health, and Ge Bai, Johns Hopkins Carey Business School, conducted a national study to determine the extent to which doctors charge patients in excess of Medicare’s approved rates. They found a very wide charge variation among doctors, with doctors charging on average two and a half times the rate they accept from Medicare. If you have commercial insurance–including a private Medicare Advantage plan–and get out-of-network care, beware of high doctor charges.

    Specialties in which patients have little or no choice of physician had some of the highest excess charges. Anderson and Bai found that the median charge to uninsured and out-of-network patients for anesthesiologists was 5.8 times Medicare’s approved charge. Emergency doctors, radiologists and pathologists on average charged four or more times Medicare’s approved rates to these patients.

    These findings underscore the plight of some patients in the health care marketplace, particularly the uninsured and people hospitalized, receiving out-of-network care unexpectedly. Many of these people lack choice of physicians or lack knowledge that their physician is out of network. And, they generally have no recourse. Just like drug companies with patented drugs, physicians treating the uninsured and out-of-network patients can charge whatever they please.

    To be clear, because the physician marketplace, for the most part, is not competitive, physicians generally command rates well in excess of Medicare’s rates from insurers. Insurers are largely unable to drive down provider charges to Medicare levels, which drives up premiums and deductibles for the insured patients. To rein in health care spending, we need to address this issue as well.

    Medicare Advantage plans come closest to negotiating rates akin to Medicare’s because of the competitive pressure the traditional Medicare program exerts on the market.

    Without a national database reflecting the amount physicians actually charge patients and how much patients pay, it’s impossible to know exactly what patients receiving out-of-network care and uninsured patients are paying for their care. But, the bigger issue is that even if we knew, it would not keep doctors from charging high rates whenever they can. The simplest way to drive these rates down is to expand Medicare, making it available to everyone without employer coverage and creating some competitive pressure in the marketplace.

    Here’s more from Just Care:

  • Beware of out-of-network ER bills

    Beware of out-of-network ER bills

    A new study by Zack Cooper and Fiona Scott Morton in the New England Journal of Medicine reveals that more than one in five emergency room visits involve out-of-network care. While most people choose emergency rooms at their in-network hospital, hospitals can and do often contract with emergency room (ER) doctors who are not in the hospitals’ insurance network.

    The problem of patients being forced to use out-of-network ER doctors is more serious in some parts of the country than in others. In McAllen, Texas, nearly nine of ten emergency department (ED) visits at in-network hospitals involved out-of-network ER doctors. In St. Petersburg, Florida, more than six in ten ED visits involved out-of-network doctors. But, in Boulder, Colorado and South Bend, Indiana, virtually everyone who visited an in-network hospital for emergency services received treatment by an in-network ER doctor.

    The cost to the 22 percent of patients who received bills from out-of-network doctors when they sought ER care was substantial. As it is, emergency room charges for in-network care are on average almost three times Medicare’s standard rate. But, out-of-network costs average eight times Medicare’s rate for services.

    If the patients’ insurers paid the in-network cost and left it to the patient to pay the difference, on average, patients would be expected to pay $622.55 for their ER care. That said, the costs can be far higher. The researchers found that out-of-pocket costs for one patient they studied was $19.603.30.

    What can patients do? Whatever your out-of-pocket costs, you should appeal to your health plans to pay them. If you followed the health plans’ rules and sought in-network emergency care, the health plan should pick up the additional costs. After all, you had no control over the doctors who treated you.

    The federal government has yet to address this enormous problem facing people seeking emergency department care in their health plan’s in-network hospital. Some states have passed laws holding the patient harmless for the additional costs imposed by out-of-network doctors and requiring the health plans to pay the difference. Of course, that rewards out-of-network doctors who charge exorbitant rates and ultimately drives up premiums for people in the health plans.

    New York requires insurers and out-of-network doctors to go through a mediation process to arrive at a fair rate.

    The best solution would be for Medicare rates or Medicare plus-a-small-percentage rates to apply to all providers, regardless of the health plan. It would help bring down costs for out-of-network care as well as in-network care. Health plans are hard-pressed to rein in costs. And, patients are not able to shop around for nonelective services, such as emergency care.

    Expanding Medicare to everyone in the U.S. is the easiest way to ensure fair provider rates, while giving people the choice of a plan that gives them access to their doctors and hospitals and the continuity of care they value.

    Here are more posts from Just Care:

  • Three reasons why you can’t choose a health plan that’s “right for you”

    Three reasons why you can’t choose a health plan that’s “right for you”

    If you’re struggling to choose a health plan that’s “right for you,” you’re in good company. It’s not possible. There’s generally no way to know whether your health plan will permit you to get care from the doctors you know and trust at a price you can afford, and that’s the chief reason you need health insurance. Here are three big problems you face and two recommendations for choosing a health plan:

    1. You can’t intelligently pick a private health plan based on its network of doctors and hospitals since you don’t know what your future needs will be. The odds may be against your having a stroke or heart disease or being hit by a truck, but it could happen. And, the network doctors you want to use may have left the network by that time or may not be taking new patients. Or, you might need to live with a family member away from home while you receive costly care. In all of these instances, you might need to see doctors or use a hospital not in your health plan’s network. And, your costs could be tremendous. (Keep in mind as well that you can’t trust a health plan’s provider directory.)

    2. You can’t easily compare costs among health plans because you don’t know what services you will need and what the health plan will charge you for them. If you choose a health plan based simply on premiums and deductibles and your current health care needs, you could get stuck with huge out-of-pocket costs–in-network copays and coinsurance–if you end up needing costly care. And, since you usually don’t know what the insurer will charge you in copays and coinsurance before you sign up, you can’t even calculate your out-of-pocket costs for different conditions.

    3. If you’re in a commercial health plan and need costly services, you may not be able to afford them. Health plans are not required to ensure that you can afford the care you need. They can set high deductibles before they begin covering your care, along with high copays for care you need. They also do not have to ensure doctors who treat you in a network hospital are also in your network. So, it’s not unusual for out-of-network emergency room doctors, anesthesiologists, radiologists and pathologists to treat you in a network hospital and for you to get stuck with unaffordable bills.

    What can you do?
    If you are eligible for Medicare and can afford the upfront costs, consider enrolling in traditional Medicare with supplemental coverage. You may pay more for it up front. But, if you end up needing costly care, it will likely save you money. And, it offers the greatest opportunity for coverage from the doctors and hospitals you want to use. Here are four things to think about when choosing between traditional Medicare and a Medicare Advantage plan. Health plan networks limit access to care.

    If you only have the choice of a private health care plan, try to pick one with a network of good doctors and hospitals. One recent study suggests that narrow provider networks may offer as good care as wide networks; it’s all about the providers in your community and the quality of the providers in the narrow network. Check with your doctors to make sure they are in the health plan’s network and have good things to say about the health plan. To keep your costs down, you want to be able to see in-network doctors in the event you need costly care. And, if possible, set aside money or make a plan to cover your deductible and out-of-pocket costs. Too many Americans end up foregoing needed care because, even with insurance, out-of-pocket costs can be huge.

    Here’s more from Just Care: