When his 5-year-old son suffered a burn injury, Michael Caraway took him to a local hospital emergency room. The hospital was in Caraway’s insurance network.
His son got successful treatment and went home. Caraway, of Grovetown, says that weeks later, he got the ER bill that he expected . . . and another one that he did not expect.
The surprise was from an ER doctor, who sent a bill for $725. Caraway found out that the physician was not in the insurance network. “I felt we were blindsided,” he says, adding that he’s still disputing the bill.
Such “surprise billing’’ has a special, painful meaning for many health care patients.
These bills can come from ER doctors, anesthesiologists, radiologists, pathologists and others who are not in a patient’s insurance network, even though the hospital where they work is.
A surprise bill can be the result of “balance billing.” This occurs when the patient is pursued for the balance after his or her health insurer pays its share to the medical provider. The problem is that the balance often turns out to be much more than the patient anticipated.
Two state lawmakers have introduced separate bills in the General Assembly to prevent these surprise bills. Other states, including Florida, recently have passed legislation to address the problem.
Physician groups, insurers and consumer advocates in Georgia all say they want to solve the problem – taking the patient out of the middle of the current tug-of-war. These situations currently confound and upset many consumers receiving medical care, leading to unpaid bills and harsh collection practices.
Medical bills often sting the most
Beth Stephens of Georgia Watch, a consumer watchdog organization, says issues with medical bills were the No. 1 reason why consumers called her organization in 2016.
A surprise medical bill “can be a few hundred dollars,’’ Stephens says. “It can be thousands of dollars.“
A huge bill for medical care can be a crippling load for a family to bear. A recently released report says medical debt is the No. 1 reason why consumers report being contacted by a collection agency.
Physician groups and insurance groups are at the opposite ends of the billing equation, says state Sen. Renee Unterman (R-Buford), who introduced legislation on surprise billing last year and is updating it this year. “It’s a very, very complicated issue.”
“The main goal is to take the patient out of the conflict between providers and insurance companies,” says Unterman, who chairs the Senate Health and Human Services Committee.
Both her proposal and a House bill on the issue call for greater transparency about which doctors are in an insurer’s network, and an estimated cost of the procedure.
Unterman says her proposal would create a database of reasonable charges for a procedure. If a bill is disputed, the insurer and doctor would have to work out a resolution.
Meanwhile, the chairman of the House Insurance Committee, Rep. Richard Smith (R-Columbus), says that under his bill, House Bill 71, any doctor who is credentialed to work at a hospital must also be part of that facility’s insurance network.
That way, Smith tells GHN, the insurer and provider must negotiate with each other ‘’in good faith’’ to resolve the reimbursement question. The patient, he said, is left out of that battle.
The aim of the proposals is to have the consumer paying reasonable rates, as though each provider delivering services is in their insurance network.
Among states passing legislation on the billing problem is Florida, where Republican Gov. Rick Scott signed a bipartisan bill that exempts patients from having to pay balance bills from out-of-network providers in certain situations.
The Florida law applies to patients who go to a health care facility in their health plan network and inadvertently receive services from a non-network provider, Modern Healthcare reported. Patients are responsible for paying only their usual in-network cost-sharing.
The Medical Association of Georgia, a physicians organization, says it’s working with legislators to address these billing concerns.
“The health insurer shell game is so murky that even the savviest patients have trouble navigating its rules,’’ says MAG’s president, Dr. Steven M. Walsh. “In case of an emergency, a lot of patients do their research and try to do the right thing and go to a hospital that is in their insurance network. But they generally don’t have any way of knowing when a doctor they need to see is in or out of the network. The system lacks transparency – and our patients pay in the end.
“Emergency department physicians want to be included in these networks,’’ Walsh adds. “The problem is that health insurers often offer physicians inadequate, take-it-or-leave-it deals – forcing them to opt out of the network. The insurers wash their hands of medical bills they should cover. This harms the patient and undermines the doctor-patient relationship.”
A group called Physicians for Fair Coverage is calling for use of an independent database of reimbursements to determine out-of-network rates for physicians, and for the patient to pay in-network rates.
Dr. Matthew Keadey, an emergency physician and president-elect of the Georgia College of Emergency Physicians, says there should be fair payment based on a database such as Fair Health, which is used in New York.
The recent trend toward more limited or “narrow’’ insurance networks has created more opportunity for surprise billing, says Dr. James Smith, an ER physician who works in Gwinnett County.
Such networks offer the patient a more limited choice of doctors, typically as a trade-off for charging lower premiums.
“If you’re clutching your abdomen [in pain], it shouldn’t have to cross your mind, ‘Is the ER in network?’” Smith adds.
The health insurance industry says it wants to work on a solution to the problem.
Graham Thompson, executive director of the Georgia Association of Health Plans, says insurers “are willing to work on a fair and reasonable reimbursement. There needs to be balance to it.”
Thompson says the problem is not caused by narrow networks, which are prevalent in the Affordable Care Act’s insurance exchanges.
“Balance billing was an issue before the ACA,’’ he says.
“This is a small group of providers‘’ sending surprise bills, Thompson says. “The consumer never chooses the anesthesiologist.”
The Georgia Hospital Association agrees that surprise medical bills “are of great concern.”
“Unexpected financial pressures can make healing physically and emotionally more difficult,’’ says GHA President Earl Rogers. “Georgia’s hospitals have a significant role to play in helping to educate our patients about their out-of-pocket financial responsibilities for the health care services they receive in our facilities.
“GHA is committed to working with Georgia lawmakers to ensure better health insurance network adequacy and transparency so that patients can better plan for their health care costs.”