In 1981, while on the operating table after being shot, President Ronald Reagan looked up at the doctors attending him and said “Please tell me you’re all Republicans.” If the shooting had happened today he would have said, “Please tell me you’re all in my network.”
Earlier this month, New Hampshire Public Radio’s Casey McDermott, a Monitor alum, aired a series of reports on the practice of balance or “surprise” billing by health care providers. McDermott interviewed Donna Beckman, a Seacoast area resident who, upon feeling ill, went to the Seabrook Emergency Room at Portsmouth Regional Hospital. She spent five minutes with a doctor who told her she was fine but should see her primary care physician, which she did the next day. The surprise came when she received a bill for $1,648, the highest possible rate for her ER visit because, though the hospital was in her insurance network, the attending doctor was not. He was working for a national company famous for its aggressive billing practices.
Most hospitals contract for physician services, primarily in four areas, emergency medicine, anesthesiology, radiology and pathology, specialties that are more likely to refuse to accept the prices negotiated by insurers. In some cases nationally, surprise bills have topped $100,000, McDermott reported.
Balance billing is extremely rare at Concord Hospital thanks to its contract relationship with specialty providers and when it does occur, bills are resolved through negotiation, a hospital spokesperson said.
Approximately 21 states have laws to protect patients from balance billing. New Hampshire does not, but two bills before the legislature would change that. One or both deserve to become law.
Last year, after lengthy study, the House and Senate Commerce Committee decided that balance billing of patients who are cared for in an in-network setting should be prohibited. It submitted a bipartisan bill that would do so. A similar bill was filed by Hopkinton Rep. David Luneau. It calls for holding harmless patients who are cared for at a facility that’s in their insurance network. Billing discrepancies would have to be resolved through negotiations between hospitals, clinics insurers and providers. If an agreement can’t be reached, the state’s insurance department would be called upon to decide whether a given amount was reasonable.
Researchers, writing in the New England Journal of Medicine found that though nearly all emergency department visits occurred within the patient’s network, 22 percent involved doctors who weren’t part of the network. And in some cases an out-of-network physician may be the only one available.
Outside of emergency situations, when time is of essence, it might pay to ask to have one’s x-ray read or biopsy analyzed by an in-network provider. The savings could be considerable. A Kaiser Family Foundation study in New York that surprise bills by out-of-network radiologists averaged $5,406 of which insurance paid $2,497. For non-network assistant surgeons, often called in without the patient’s knowledge, the average bill was $13,914. Insurance covered $1,794 of that leaving the patient with the balance, $12,020. And that was in 2011.
Health care billing is nearly beyond human understanding and those who profit by it like it that way. Banning balance billing would be one more step toward a more rational, transparent health care system. The bills are a good start, but they probably don’t go far enough. Lawmakers and Gov. Sununu should enact the bans, see how they work, and if necessary, expand them to cover other categories of providers like, for example, assistant surgeons.