You Can Bill Me Now

What is Balance Billing?  It is a controversial and sometimes illegal practice: doctors and other health care providers receive a discounted payment from the insurance company — an amount less than the fee they want to be paid — and then they bill the patient for the rest. Most states, including Illinois, have passed laws making balance billing illegal within an insurer’s medical network. And federal law prohibits balance billing by providers paid under Medicare. Which explains why many Providers refuse to take Medicare patients.

The idea under the Affordable Care Act now deemed "Obamacare" was to put the Insurers in command and in turn reign down the ever increasing costs associated with medical care.  Good intent, not going to happen unless all States agree to make the practice of balance billing illegal.

Insurance companies would love to see a nationwide shift  toward Medicare-based rates which allow a clear, objective method of calculating reimbursement. They say that premiums would be even costlier if reimbursements were more generous, and that exorbitant doctors’ fees are largely to blame. But few dispute that as the nation debates an overhaul aimed at insuring everybody, the new realpolitik of reimbursement is leaving millions of insured families more vulnerable to catastrophic medical bills, even though they are paying higher premiums, co-payments and deductibles. Most people simply see their Family Doctor but in those cases when Emergencies rise the sudden need for "out of network" providers becomes essential. And when you are being wheeled in on a gurney as I was, the options for choices become even more limited.

So suddenly bills arrive, they are vague, confusing and often piecemeal. That is the point. And as 40% of Americans are paying off medical debt they should kinda sorta know in detail for what they are paying. There are choices available and the new rise in medical negotiators that will do just that is one or you can take the time to find out what the costs are, if they in line with current Medicare/Medicaid payout rates, your average State medical costs in comparison to others or you can do what the 60% of Americans do and file bankruptcy.

I did find a site dedicated to transparency in healthcare billing.

FAIR Health is your source for transparent, current and reliable healthcare charge information. As a national, independent not-for-profit corporation, FAIR Health offers unbiased data products and services to consumers, the healthcare community, employers, unions, government agencies, policymakers and researchers.

So it pays to connect to them and see what is going on. Its also now post election and new and some old faces are being sent to both your State and National Congresses.  Ask them about the Medical Debt Responsibility Act, ask them about Balance Billing or Mediation laws that enable you the patient to negotiate and arbitrate over your care.  It all seems overwhelming but if you do nothing you get nothing and it further enables the fake non profits of Medicine to run this show and in turn your financial and emotional health into the ground. Why?

When I was rejected by Group Health over my entire bills as their in network provider, Harborview, I simply went to my Insurance Commissioner and was assigned Dan Connolly, who audited the bill and made Group Health comply with the law. Period. Much is made about the inefficiences of the State and sometimes you are right but in this case it was right and he was on my side. The joke is that the scum at Group Health rejected the claim AGAIN while still being audited.  Whoops! And they still had to pay! So there in some States actual Insurance Commisioners on the side of Consumers.. and if not you know what needs to be done there.

I thought this story was of interest and relatable. What it doesn't do is actually tell you what you can and should do... you should do this. Contact your Represenative, check your laws and make sure that the average person is getting what you voted for... REPRESENTATION. Its time the bill has come due.

Out-of-Network Bills for In-Network Health Care

By RONI CARYN RABIN

 The robo-call from the physicians’ billing service had the intended effect: I panicked. It sounded like a collection agency. I almost paid what it asked.

In fact, we didn’t owe a dime. By the time we got the call last week, followed by bills in the mail, our insurer, United Healthcare, had already paid most of the charges stemming from my daughter’s emergency room visit in late August, when she had a nasty fall shortly after returning to college. Cayuga Medical Center in Ithaca isn’t in our insurer’s network, but United handled the bills as though it was because it had been an emergency, paying the hospital nearly $900. We paid only the $100 emergency room co-pay.

The doctors were another story. Cayuga Emergency Physicians billed $563. Again, United treated the service as in-network, and the physicians agreed to accept the plan’s payment of $237.81.
But then the doctors turned around and charged us for the difference.

When there’s a difference between the charge and the insurance reimbursement, and a health care provider tries to collect the difference from the patient — that is balance billing. Critics call it a huge problem, even for people with relatively good insurance. The California Association of Health Plans reported in 2007 that 1.76 million state residents who visited emergency rooms over a two-year period were balance-billed $300 each on average. Sometimes the charges were legitimate and sometimes not, but about half paid the bills anyway.
Those bills can be enormous. A 2010 report by America’s Health Insurance Plans said out-of-network providers often charge exorbitant rates, as high as 70 times the Medicare reimbursement for a similar service. A report issued by New York State in March cited the case of a patient who went to an in-network hospital emergency room after severing his finger in a table saw accident. The finger was reattached by a nonparticipating plastic surgeon, and the bill was $83,000. The insurer estimated the going rate for the procedure was only about $21,000.

But balance billing does not occur only during medical emergencies. The New York State Department of Financial Services regularly receives complaints from consumers undergoing elective procedures who carefully selected surgeons and hospitals that participated in their health plans, only to be surprised by bills from nonparticipating providers — like anesthesiologists, radiologists and assistant surgeons — who became involved in their care without their knowledge.
In some cases, patients who are covered by health maintenance organizations, or H.M.O.’s, may actually be better protected against these kinds of charges than patients in flexible plans like preferred provider organizations that provide limited out-of-network coverage. New York State laws protect H.M.O. members from out-of-network provider bills as long as they follow the plan’s rules, said Elisabeth Benjamin, a co-founder of the Health Care for All New York coalition.
Patients are often surprised by bills after receiving services like anesthesia, pathology and radiology. Those specialists, who don’t hang out a shingle and may not rely on ongoing relationships with patients, often avoid signing up with health plans in order to set their own rates.
Illinois has passed a law holding consumers harmless from fees for certain medical services — like anesthesia — that are often provided by nonparticipating providers at in-network hospitals, Ms. Benjamin said. Her organization is working to pass a similar law in New York.
Such a law would mean that “providers and insurance companies would have to go to binding arbitration to resolve the dispute, and neither of them can go after the consumer,” she said.
State laws, however, do not resolve balance-billing problems for the many consumers who are covered by self-insured employer-provided health plans, which are exempt under the federal Employee Retirement Income Security Act.
The federal Affordable Care Act contains some provisions to protect patients from balance billing for emergency medical care, but they apply primarily to new health plans and only in limited cases to existing employer-provided coverage. It also sets standards for what health plans must pay out-of-network providers, the rationale being that if providers are paid adequately, they are less likely to balance bill.
So what’s a consumer to do?
¶ Know which hospitals are in your network in case of an emergency. Doctors who don’t participate in your network may work at the hospital, but it’s a start.
¶ If you’re having an elective procedure, it is not enough to choose a doctor who takes your insurance. Ask who else will be involved in your care, and insist that they all be in-network. Even if you have out-of-network coverage, it is likely that only a small fraction of actual costs will be covered if you wind up in an out-of-network facility.
¶ Carve out time to deal with the bills. Our insurer, United Healthcare, said we were not responsible for the difference between the emergency physicians’ charges and its payment because of a third-party agreement between them, but it took several weeks and half a dozen calls to the insurer and the physicians’ billing service to get the matter resolved.
At first, the person I spoke with refused to discuss my daughter’s account because of “medical privacy laws.” Then, she said I had to fax her a copy of the insurer’s explanation of benefits because they had no record of payment. When I asked to speak to her supervisor, the record was miraculously found.
¶ If you think your plan is not reimbursing you enough for out-of-network care, see the do-it-yourself-appeal packet at www.communityhealthadvocates.org. Check your state health consumer protection laws, though many large self-insured companies are not covered by these laws.
When you find yourself on the wrong end of balance billing, “the worst thing is to do nothing,” said Cheryl Fish-Parcham, the deputy director of health policy for Families USA, “because then it gets on your credit report, and it could be something you didn’t owe to begin with.”