Hoping this bill will stop separate billing from physiatrists in hospitals who stop by your room for two minutes, but have no contract agreement with your insurance company. As an inpatient the burden should NOT be on me to ask every non family member that walks through my door whether they are a participating provider with my insurance company. Absurd.
29
Why are they only tackling surprise hospital bills? While those may be higher, many, many more Americans face surprise medical bills (and indecipherable EOBs) every day. I think it would be much more helpful to have transparency in regard to the bills I get every month than those I might get once or twice in a lifetime.
6
I’d just like to tell to people that this bill isn’t all “congresspersons doing good work.” There is a significant downside of this bill that will be a big holiday giveaway to insurance companies.
You see, in this bill there is a little-noticed provision called benchmarking, where insurance companies are salivating because they’ll be able to decrease physician pay 30-40%. They’ll offer you no decrease in insurance costs, so this is a direct wealth transfer from your paycheck to insurance company profits. That should upset 160 million Americans, but it needs to be reported on.
I know that a lot of people think physicians make too much, so NBD right? But the thing is we graduate from medical school with an *average* debt of $190,000 (some have much more!) and then have to do 4-8 years of very low pay (read: below median income) residency work. Cost of living and housing prices are at an all time high and physician salaries have generally been flat since the 1990s. So, given the fact that these are top-of-the-class graduates, it’s a real concern that people will just go and do something else. If it becomes too hard to pay a mortgage and your school loans, physicians will leave medicine.
15
@Dan D Could not have put this better. The problem here is that insurance companies have found it profitable to make physicians the bogeymen and women, and it’s working.
The reasons for seemingly inflated pricing is because most insurance companies arrangements are based on a percentage of charges billed. So although the physician or hospital may only require $350 for a particular visit the Blue Cross contract might state they will pay only 10% of fees billed, thus generating a $3500 charge. If the physician charged $350 they would get $35.
With the stated purpose of “containing costs,” insurance companies will tell physicians to either accept lower charges or go out of network. Even if in network, the companies will sell high deductible or co-pay plans to patients and then put the onus on physicians to then go collecting those deductibles and co-pays, making us the ones who have to now become bill collectors . Patients will then refuse to pay the deductibles or co-pays because they didn’t understand the complex plans they were signing up for, note that they have already paid high premiums (they have), and physicians either write off or accept vastly reduced reimbursements because we are the ones who have a relationship with our patients. All the while your premiums continue to line the pockets of your insurance execs and the congressmen they lobby to maintain the status quo.
9
The US has the most dysfunctional and crooked healthcare system in the world.
The private insurance companies are run by thieving jackals whose only desire is to make money for shareholders.
Patients be damned!
34
When we went on a trip to Australia, my wife spent several days in Royal Darwin Hospital. When she had a reaction to a medication several thousand miles away in Alice Springs, the hospital in Alice Springs was able to instantaneously pull up all of her Royal Darwin records so no tests needed to be repeated and they knew exactly what her treatment in Darwin was. Think of how much money and medical costs were saved. Why can't American hospitals be required to do the same thing.
We all know why. Because the competitive American hospital systems where 2 hospitals that are across the street from each other can not communicate pay off your congressmen and senators to keep the unworkable system as it is.
23
If a patient has no choice in choosing a physician or hospital as occurs in an emergency, (in distinction to an elective procedure) they should not have to pay more than if they had wound up at an in network hospital. However,insurance companies use the fact that no ER can turn down evaluating a patient who presents to them (this is a Federal law) to force ER physicians to accept sub-standard reimbursement. We cancelled our contract with
Anthem Blue Cross who is notorious for their low fee schedules and we never try to collect more from patients than they would have had to pay out of pocket if we were in network. This is not about greedy doctors (yes, some abuse the practice); we just want to be fairly compensated for our services which we provide 24/7/365.
By the way, the top 6 executives at Anthem Blue Cross received a total compensation of over $40 million and they get to sleep at home every night.
22
The current healthcare finance system is failing. An alternative:
Everyone pays out of pocket for medical care subject to their ability to pay. This is accomplished by setting a progressive deductible based on income. As an example a homeless person with no income has a 0 deductible and a wealthy person with huge income might have a deductible ranging into the 100's of thousands of dollars.
Once the deductible is met, anyone, rich or poor can tap into a personal lifetime pool designated for medical care that pays for expenses beyond their deductible. This pool would be a single, tax-payer funded national fund. The patient would be reimbursed and the money would again funnel through the patient to the provider, not through any other third party. Congress would set the size of the pool based on a public give and take prioritizing health care vs other valid societal priorities.
Consequences:
A true competitive marketplace. Patients are again the client of the provider rather than some third party payor. Elimination of a huge infrastructure now devoted to the administration of care, denial of care, billing to third parties for services, etc., etc.
Some believe the current system fails to force patients to take personal responsibility for their own health care and there is significant merit to this argument. Progressives believe that everyone deserves access to healthcare, an argument that also has huge merit.
A system as outlined above would satisfy both arguments
6
Medicare for All supporters. Please talk to some people who have Medicare. It's still an insurance scheme, and you pay 20% unless you get other insurance.
What we need is a public option, and, ideally, single payer.
It sounds schnazzy and is easily digested, and it's better than what you have if you're under the age of qualification, but it's not fixing the problems each and every one of us pays for.
However, the power of Medicare to negotiate does mean that some extremes are avoided.
6
@Susan Anderson a plan underwhich I pay only 20%, without a 7k deductible, sounds like heaven to me. I understand the shortcomings of Medicare, but I have to say that during the 18 months that I had BCBS and my I was handling my mother's expenses under Medicare, there was no comparison. She had much more health care and had almost no payments (other than her premiums) and almost no paperwork, while I had tremendous payments I'm still challenging and reams of confusing paperwork for significantly less medical care. I'd give anything under the sun to be on Medicare.
9
I just don’t understand why people don’t want ONE just one medical record that can follow them around the country? But until we get the college costs lowered docs will never go for it
I am a nurse at the VA and One medical record is fabulous Public health works
12
@Calleendeoliveira because the ACA isn't secure and many of us are still worried about being denied insurance due to pre-existing conditions. My medical tests are still done primarily "off the grid" for that very reason. As soon as any suspect test result gets in to my "permanent health care record" I'll have to worry about becoming uninsurable as soon as the GOP finishes destroying the ACA. (Mind you, so far I have had no actual diagnoses, but the risk is always there.)
9
The medical profession exists to serve patients and full disclosure is part of their duty of care.
My highly experienced hip surgeon in 2007 persuaded me to have a chromium cobalt rather than ceramic prosthetic on the basis that the latter might shatter when it was already known that metal was toxic. The former was made by Exactec which was later fined $6 million for bribing surgeons. Was his advice influenced by a financial interest that he chose not to disclose? His assistant surgeon did not take insurance but that was also not disclosed in advance. And, of course, one of the hospital services was out of network. I then went to rehab for a week and on arrival asked the case manager to check the insurance coy authorization. She failed and I ended up looking at a $55,000 bill for many months while the hospital and insurance coy played negotiation games at the expense of patient welfare. Complete disclosure of all prices and conflicting interests should be the law. Patients should never serve as a financial convenience to visiting doctors who should take the rough with the smooth.
14
Private equity investors have cause so much harm to this country. They need to be heavily regulated. But, obviously the so-called healthcare industry is not suffering if they have money to blow on lobbyists and advertising.
11
"But doctors there have said it has lowered their pay."
Good. That's how you know it worked.
22
Compare this to yesterday's story about Finland.
Only in America. No other nation tortures its citizens like this.
17
New York passed legislation as well regarding surprise billing. It is no surprise that the vultures of finance - private equity firms are fighting this change - they have no interests besides financial gains, screw everybody else.
12
Out of network charges are still covered by insurance, the employee just has a higher cost sharing arrangement. But the maximum out of pocket would put a ceiling on what one would pay, regardless of in-network or out-of-network.
Lots of comments here about automobile accidents (car insurance pays bulk of medical costs incurred) and situations where you were going to incur your max out of pocket no matter what (cancer treatment, surgery).
That is the reality of healthcare for most people, the costs are binary. 50% of Americans pay less than $500/year out of pocket. If you are healthy, no chronic conditions, and don't suffer a non-automobile accident; your costs are very low.
If you get sick (cancer, heart disease, etc), costs become high very quickly no matter what. Yet you have a ceiling on costs inn the form of maximum out of pocket.
Yes, for those without insurance, the costs will be high - but that is because they don't have insurance, not the network.
3
@James Many in this country have HMO plans with no out-of-network benefits. They are the ones getting slapped with the outrageous bills, often by drive-by doctors. I received a bill for $1,618 from a drive-by doctor when my son was in the ER. I have a POS plan (the pun did not escape me) that allowed me to negotiate that fee down. He literally said, "How is he doing? Better? Good," and walked away. He didn't even earn the $400-something I paid him.
10
@James Out of network is paid by insurance, yes. BUT, the patient is caught two ways. First, the insurance states up front that the "coinsurance" expected of the patient is considerably higher, usually 40% rather than 20%. Second, that "coinsurance" applies to the usual and customary charge, or the charge that an in network provider would have accepted. The amount over what the in network provider would have accepted is still due and payable to the out of network provider.
If the out of network physician bills $20,000, and the in network allowable is only $10,000, the insurance company will pay $6,000, and the patient will be expected to pay $14,000. With an in network provider, insurance would have paid $8,000, and the patient would be expected to pay $2,000. For major trauma situations, these figures of course would multiply many times.
I have noticed that physicians, including those who accept almost all insurance company payments, all seem to be quite well off. I haven't seen any of them in any welfare lines.
16
I live in Texas, and saw those ads by the "dark-money group". I was suspicious right away, but a lot of rural Texas voters (mostly Republican) probably saw them in a much different light. Typical for Texas, unfortunately.
13
One simple solution would be single-point billing. If you go to a hospital, then EVERY cost associated with that visit, from the ambulance that brings you there to any tests performed there to any doctor who looks at your chart, should be billed THROUGH the hospital, in accordance with the hospital's status as a network provider.
The current situation is like it would be if, when you go to a restaurant, you received separate bills from the hostess, the waiter, the chef, the busboys, and the mechanics who maintain the ovens - all in addition to the price on the menu. There is no other type of business in which this practice would be accepted - so why are we forced to accept it in healthcare?
32
@Happy retiree Because of the onerous contracts that insurers try to place on independent physicians. The bureaucracy and regulations placed on physicians is ridiculous and if you had privy to these contracts, I doubt you would sign them as well. So if the waiter or hostess could go to prison for not notifying their employer ( read insurer) of time consuming bureaucratic burdens, then they might not sign as well.
1
@Happy retiree Your analogy is apropos, with the caveat that some of those people actually do expect to be paid separately, in the form of a tip. So, that is another way businesses (physicians are in business) whack the consumer. I shouldn't have to pay separately for table service in a restaurant, that should be included in the menu price.
Perhaps a better analogy would be a visit to an automobile repair shop. The price quoted should be the price quoted. If the shop is paid, the cost is covered. The mechanic doesn't charge an additional fee over what the shop charges.
3
@Dave I agree with you completely about tipping, and I readily admit that the restaurant analogy is a bit of an oversimplification because of it. But at least with tipping, the customer knows going in who will be tipped and how much is considered appropriate. The is no "surprise billing" involved.
5
Oh the horror. Doctors might get less pay. No No No. They won't be able to have mansions, swimming pools and luxury cars. A pay cut? These doctors can't afford to have this happen. Their lifestyle would change. Their families in uproar.
7
@Chris Anderson Lets see you take 24/7 call for 2 weeks in a row and stay up all night delivering a baby and then have regular office hours the next day.
12
The current status of surprise billing is unacceptable by any metric. Adjustments and modifications will be needed to the proposed legislation, but ignoring the present problem is not an option. Cost containment in medical care is the greater issue that still has not been addressed.
5
I'm all for any progress, but spending this much time and energy on solving this one problem is like treating wide-spread cancer by operating on each individual lesion, rather than the disease as a whole. The patient will likely die in the process. Medicare for All can solve this, and also eliminate the uninsured and underinsured, allow drug price negotiations, cover dental, hearing, and vision care, remove deductibles, and separate health insurance from employment, plus lowering everyone's costs by about 10%. Why not do all of this in a single big move, rather than nickel & diming our way forward? Medicare for All Now, Medicare for All forever!
9
@Chef George what exactly does Medicare for All mean? It’s a nice slogan but the devil Isco always in the details
3
@Desmond We should have something like the UK's NHS, or Canada's government coverage. When I was last in Canada, I had to visit a physician. When I registered, I was asked for my health card. Of course, I did not have one. The clerk was surprised, and I had to tell her I was from the U.S. I was charged $100 for the visit. The Canadians who were there paid nothing. And, they pay far less for health insurance than American's do.
4
@Desmond you know that plan we have for disabled people and those 65 and over? It would apply to all Americans. If that is not what you meant, please clarify the question.
1
Hospitals need to be held responsible for surprise bills as well. Why are hospitals employing outside physicians, especially in the emergency room, that send their own bills? Hospitals created this problem and hospitals can put a stop to it. What happened to ethics in medical care?
25
@JRL
Because: some hospitals fly physicians in from outside of town so that adequate coverage exists at that hospital for specialty and other care. However, just as you can’t force a restaurant or store to accept American Express or Discover, currently physicians cannot be forced to accept insurance terms from every pre-existing arrangement that exists at every hospital. We can debate whether or not that is ethical, but the fact remains that at the moment, physicians (like others) are free to determine for themselves where the want to work and under what terms.
Unfortunately, this means that some hospitals are forced into arrangements with providers that aren’t a part of their standard insurance coverage plans, and without these many hospitals, particularly rural ones, would not have adequate staffing to remain open or would be forced to transfer patients out to bigger cities at additional expense and inconvenience.
The solution has to require hospitals and physicians to be 100% transparent about their pricing and what is/isn’t covered, and for insurance companies to be 100% transparent about what “coverage” they are actually selling. At the moment most insurance products are too complex for the avg consumer to understand. It is not the fault of the patient if they were misled by their insurance carrier, but nor should it be the fault of the physician if the patient has been paying for an insurance product that doesn’t cover the care they need.
3
@James Your response completely misses the point. If the hospital chooses, for whatever reason, to bring in another doctor from outside, that is the hospital's decision and the hospital's responsibility. The patient has nothing to say about it. The patient does not choose this doctor, the patient does not have say in the matter, so how can you demand that the patient be responsible for whatever insane charges that doctor submits? The patient has fulfilled his responsibility by choosing an in-network hospital. EVERYTHING after that is between the hospital, the doctor, and the insurance company.
14
@JRL Not all physicians are hospital employed, especially the surgical specialists. Requiring a doctor be on your insurance plan may result in no doctor being available to treat you. How's that for a surprise. Getting the government out of healthcare is the answer, not fascist tactics by the government.
3
Surprises also come from another source; "Emergency Care" facilities that look, inconspicuously like "urgent care" or other walk in medical centers.
No one should ever walk into any "Emergency Care" health provider unless they are actually having a heart attack or other real emergency. These new facilities bill patients at far greater rates, usually not covered by regular insurance, because they claim, falsely, that you, the patient, have chosen to have emergency treatment by emergency room physicians or specialists. The claims of "Emergency Care" facilities that are NOT hospital associated emergency rooms are false, dishonest and void of valid claims. It is the ultimate bait and switch scenario that brings in money claiming that specialists provided high level medical care found only in hospital emergency rooms.
This scam has not been addressed. If you have a rash, a cold, fever, a bladder or urinary tract infection you will be billed as an emergency patient. A surprise bill is in the mail as most insurance companies will refuse outright to pay the extraordinary and outrageous charges of "Emergency Care" facilities.
If you are sick and need assistance go to an urgent care or walk in facility or seek an appointment with your primary care physician but, under no circumstances never, never use "Emergency Care" unless it's part of a hospital.
One more thing, if the care is not a real emergency, ask ahead of time if the facility will accept your insurance. If not, run!
17
As deplorable as getting sucker punched for out of network fees is, I'm not sure that it makes the case for Medicare for all.
I can't explain why some people are very disturbed by sharing the costs of medical care for people who are careless of their health: are fat, smoke, drink, take drugs legal and prescribed, eat unhealthy objects, cut themselves and do or do not survive suicide attempts ; others are not.
There never seems any suggestion on how to build personal responsibility into such universal care. Seems like the success of education in other areas hasn't encouraged a hope for that.
I'm all for reforming a situation typical of market operations: fine print and long contracts that have the effect of putting the responsibility for self preservation on the purchasers of what is willingly offered.
One possibility is to require medical service organizations to call patients insurers at the earliest opportunity so they can monitor the use of their funds. I offer this out of ignorance; correct me if you can.
I suspect in the old days, when people died at home, many were quietly, often lovingly but secretly cut short. The modern world's dark corners contain many kept going without regard for what they think of it, as the bills accumulate.
4
@William Agreed. Why should my current medical insurance rates be so high because of people who smoke cigarettes and drink pop? I don't do any of those things so why should I have to pay? Why do insurance companies have to make a profit too? 35 cents out each dollar of my premium does not go to any health care related aspect.
3
@Ernest Ciambarella
Insurers could be allowed to rate risk based on smoking and other habits, but getting insureds to answer honestly poses an issue. And what habits will be included? Will playing high school sports lead to higher premiums? Will we be rated based on our occupations?
@Ernest Ciambarella I am retired, and have insurance from my former employer. Each year, the benefits department requires that I certify that I do not smoke. Otherwise, I would have to pay a premium for the insurance.
1
Not all "out of network" billing is done by big networks. There are independent self employed docs that refuse to sign the onerous "in network" provider agreements. Maybe one of those could be published here, so commenters can see what they contain. I agree that patients should know the costs involved up front, and Trump has proposed that transparency, but hospitals are against it. Why? Because they will be exposed for the top heavy, costly administrative bureaucracies that have ballooned over the past 2 decades. Everybody wants a piece of the pie, especially the relatively easy administrative bunch who want to tell doctors and nurses how to practice medicine.
5
@Kay Daniel
Fair enough, but getting paid the same as an in network provider without having to jump through all the hoops of one should be fair compensation. But one problem is that in network providers sometimes earn additional funds based on results, efficiency, etc. So, how does that get factored in?
1
What business besides the healthcare industry doesn't show you prices until after the service is done? NONE.
Healthcare needs to have a price list like a restaurant has on a menu.
11
This sounds like a good idea in theory but in practice is not workable. For example, you may be in the hospital recovering after surgery.
While there may be ways to predict certain fixed charges (cost of anesthesia, surgeon time, OR services etc), there are many variables that cannot be anticipated and which may affect your bill.
For example: you may develop shortness of breath the night after your surgery. If a chest x ray was ordered, the cost of the chest x ray would be whatever the hospital charges for it...you wouldn’t be able to, at that moment, perform a google search to find the cheapest chest x ray around, leave the hospital, have it done, and return. Maybe you need to be monitored in the ICU. Maybe you develop some other issue that requires consultation from a specialist - maybe it’s on the weekend and there’s only one such specialist on call. There are an endless series of variables that explain why the healthcare industry is different with respect to charges appearing only after you’ve received the services.
There is also the part that no one wants to talk about—when you’re sick and trying to get care, the last thing anyone wants to be spoken to about are the costs of your care and whether or not you can afford it. Maybe that needs to change.
3
@James, Clearly, you are a provider, and write with a provider's perspective. But, I wonder why in Europe the things you propose here as unworkable are done all the time, no difficulty.
3
@Dave actually, I never said these things are unworkable...they are workable in a single payer system where one entity sets the prices for everything. Those are the systems you reference.
4
Re: "A dark-money group funded by private-equity-backed physician staffing firms has spent tens of millions of dollars in television and direct mail advertising in a bid to scuttle the legislation."
Yep. That's the other portion of so-called "health-care" costs. We pay some people to help us, and we pay other people to attack us.
18
The Upshot claims: "Solving the problem has been a priority for both Republicans and Democrats in Congress — as well as the White House."
Since when have Republicans ever made a priority of reducing healthcare costs, or protecting patients from exorbitant bills? The GOP opposed Medicare, with Ronald Reagan calling it "socialism," opposed Medicaid, opposed the ACA. Republicans were in charge of congress for how many years, all without moving on this problem.
Since when has it been a GOP "priority"? We'd all like to now.
18
@Sean Medicare IS socialized medicine. Medicare is NOT health insurance. You have no contract as with a traditional insurance company. You cannot challenge healthcare decisions - those decisions will be made within the parameters of what the government bureaucracy approves. If you fall outside those limits, and many do because they are individuals, tough luck. But you may never know what test, treatment, you really needed unless you have a family friend or relative who is a doctor, nurse, etc. And then even if you do find out you need additional care, you cannot pay out of pocket, unless you can FIND a doc/agency that doesn't participate in Medicare
1
@Kay Daniel "You cannot challenge healthcare decisions - those decisions will be made within the parameters of what the government bureaucracy approves. If you fall outside those limits, and many do because they are individuals, tough luck. But you may never know what test, treatment, you really needed unless you have a family friend or relative who is a doctor, nurse, etc. "
Just replace the words "government bureaucracy" with "insurance company" and you have described EXACTLY the situation that now exists. Do you honestly believe that your healthcare decisions now are being made by anyone OTHER THAN the insurance company's accountants? Do you actually believe that your doctor is telling you "what test, treatment, you really needed"? If so, you have absolutely NO idea how the current insurance model works. Any doctor who has a contract to be a "network provider" with an insurance carrier is prevented by the terms of HIS contract from discussing any options with you other than those the insurance company permits.
13
@Happy retiree sorry but docs call all the time to insurers to have supposedly disallowed items to be covered. Also, I’m free to seek out any service that is recommended, but may not be covered and pay for it out of pocket. To some people, their life is worth paying out of pocket. I just want the choice to do so.
2
Air Medical bill of $34,000. I was in an automobile accident and knocked unconscious at the scene. I was told at the hospital that a helicopter delivered me to the Hospital - 15 miles away. The hospital released me that day and told that my injuries would mend over a couple months. The Air Medical bill is higher than the sum of all other costs of the accident. Yes, Congress needs to get involved.
17
@Gary In an automobile accident, your (or the other driver's) car insurance policy would cover the medical costs, not your private health insurance.
5
Not so long ago it was illegal for medical practices to be owned by non-physicians or for profit businesses. For reasons of transparency and consumer rights, when you register at the counter in any medical office or facility the law should require you to be notified of any relationships of the office/facility and the doctors with private equity groups or other for profit business entities.
11
"The legislation would also raise the minimum age for legal tobacco purchases to 21."
Ah, what it takes to get buy-in from the bluenoses. Maybe, just maybe one of these days somebody will notice that there's a small item in the constitution about applying the laws to all equally.
The argument that if you can vote and be drafted, you should not be prevented from buying certain items until 21, is still valid. Just because liquor has some special status in the constitution doesn't mean that other things can be similarly restricted.
Sooner or later somebody will challenge the "21" rules. And they will win.
6
Tying this to the mean of in-network providers is crazy. The insurer makes out like a bandit on the back of the MD. We have a problem with insurers all the time that they send money to patients. Sometimes a lot. Patient cashes the check and I am out money.
NY has done it well- hold the patient responsible for what their liability would be had the provider been in-network, and then an arbitrator decides if the doctor and insurer do not come to an agreement.
But by all means, mandate that the reimbursement get sent to the physician, not the patient.
8
@Ny Surgeon Public health care for all - even surgeons!
2
@Ny Surgeon, If the patient is only responsible for what he or she would have been if the physician had been in network, then that is fine. But most physicians who are not in network want an absurdly greater amount than that.
3
This is only one example of how difficult it will be to de-privatize our health care system. Wait till they try to reduce drug pricing and costs of insurance policies or reduce the many levels of paperwork for medical claims. Billions will be spent by the for profit groups to maintain the status quo. People love their private plan until they get that unexpected bill. With the rising costs of health care, there will be a lot more out of pocket charges.
8
As the lobby money sources are discovered and as the senators and congress members who accept it are revealed, all that information should be widely published. Investigative reporting should be able to shine a light on dark money sooner or later.
5
Yes to Bernie Sanders and Elizabeth Warren and Medicare for All based on the Nordic models of care. The system cannot be any more broken than it is now and these small steps are too incremental to bring so many out of bankruptcy due to Wall Street profits.
15
Private Equity...translation: Money Mafia Middlemen.
or
Rich people with money who don't create or sell anything but love raising prices on all services and goods.
11
There should be a default understanding that all billing should be agreed upon in writing between the patient and all providers before it is rendered. That would put an end to the ambush billing that follows those "please sign here" papers put in front of patients just prior to entering the hospital for care. If a health care provider isn't willing to accept the amount that the insurer will pay, then that person should be replaced by someone who will. Enough of this nonsense!
10
@Bill McGrath except that in many cases the hospital can't find other or enough physicians to staff- so they make a deal that allows doc to bill outside the hospital's arrangements....patients have to strike the pertinent language on the paper
1
@Bill McGrath
This does happen currently. You or a family member sign that you agree to pay charges you will be sent shortly after you arrive. The problem is- it is unrealistic for this alone to be a reasonable approach: you’re sick when you arrive so to some degree under duress, the tests and doctors you need to see are not always known up front depending on your medical condition so you can’t possibly anticipate every potential charge (the source of most surprise bills), and what is the recourse if you don’t agree? Get your emergency handled elsewhere? In most rural communities the place you’re at is the only place.
Two things are clear: medicine cannot be managed “like the private sector” because it’s not the same as buying an iPhone; physicians/hospitals and patients both have a responsibility to charge fair prices and pay for care and services they have already received.
2
But what about those among us who "love private insurance?"
6
@Jason We still love it. 50% of Americans have annual out of pocket health expenses below $500/year. Get your annual physical (included in premiums) and a flu shot ($20) is all that a healthy young person typically needs.
I haven't seen a proposal for Medicaid for All that would actually lower my contribution to health care (most would have one pay more and more as you become more successful).
@James , So, what you are saying is that if 50% are not being abused, then it is ok to abuse the other 50%. I don't know anyone whose health care costs are under $500 a year, and that includes my very healthy daughter, son-in-law and their school aged children. They have insurance through an employer, which costs north of $10K for each of them (most is paid by the employer). So, before any one of them even walks in to a clinic or hospital, the cost is $9,500+ above what you claim.
Anyone over 50 who has health care costs under $500 annually is not taking care of his or her health.
4
@Jason how about considering what is best for ALL Americans, and not just those of you lucky enough to have reasonable, affordable insurance? I consistently vote for people that would raise my taxes because I understand that would benefit others who need help, our infrastructure, education, defense, etc. If you believe that eliminating private insurance would really HURT most Americans, then by all means, make your points; however, I do not find persuasive any argument beginning with "what about me?"
2
What exactly needs to be arbitrated?
1
Missing from this discussion is what private equity firms offer the markets. Why are doctors selling out to them? Why is it profitable for the equity firms?
They do so when they can manipulate the market. In this case e.g. they bought up the anesthesiologists in NYC, took them out of networks, and charged whatever they wanted for surgeries to proceed. They bought dermatology practices because they can send cheap PA’s into nursing homes where they trim precancerous lesions that most elderly have, and charge medicare. Or they set up Cath labs so anyone with chest pain gets a stent. Or they set up a “phatma” company that just buys drugs, and then price them through the roof and fight off generics (lookin at you idalimumab).
This kind of nimble financial engineering adds no value but will run circles around insurance companies and government regulators.
This legislation only weakly protects one form of abuse, and likely last-minute changes will lock in enduring advantages in arbitration and legitimize the fundamentally fraudulent activity of unagreed, unconsented, and uncontestable health services.
Like democracy, we have market competition and consumer protection in name only. Private equity is a way for the seriously dirty money of our enemies to feed and grow off the mutual self-interest assumed when the open society was embraced. Let’s hope this legislation is the first step in comprehensively attacking the abusers of openness.
11
@we Tp - Excellent post, thank you.
1
hard to believe, at the end of the day, the GOP will pass anything that helps the people at the expense of their corporate masters.
11
As the article says, this is the business model for private equity controlled groups. It is predatory.
8
Do away with surprise bills by all means but don’t make it another vehicle to tie patients in an arbitration model that favors the biller! There is a lot more going on in the “surprise” billing area than surprise and misunderstanding and that’s FRAUD! Hospitals engage in it hourly. It is so prevalent and lucrative thatI would be willing to bet that not one hospital bill goes out without at least one fraudulent charge.
It’s time for all these legislators who enjoy taxpayer covered health care to tackle these issues head on and enact legislation that will subject CEOs to jail time and personal fines for these practices. Enough is enough.
6
What about balanced billing? Won't doctors resort to that to recoup the lost funds?
@ Colin Barnett
Albuquerque NM53m ago
"How is "surprise" defined. Is it a technical term? If the patient is told in advance of all the charges, no matter how outrageous, does make all the charges not surprise charges?"
I don't know of ANY hospital/ambulance at which you are routinely told in advance of your charges. I asked re charges for Holter monitoring and the hospital looked it up and told me, but neglected to mention that the fee disclosed was for putting it on and using it. The fee DOUBLED for interpreting it.
One common surprise is that your hospital is in your insurance network, but it contracts with ambulance services, ED doctors, radiologists, anesthesiologists, etc., who are NOT in your network and they don't have to accept your insurance's negotiated rates. Also, it has even happened that while your hospital and surgeon for a planned surgery are in your network, the surgeon's assistant surgeon is not and bills you many times more than your insurance would pay. And neven though you are insured, and get stuck with the bill.
6
Our health insurance is broken, no where online can you find what medical procedures cost. No prices are posted anywhere for the public to see.
The same is true for dental procedures, no dentist in America posts the costs of dental procedures online. Many people here without dental insurance go across the border to use English speaking dentists in Mexico at a third of the cost in the United States.
It is possible to find dental procedures from Mexican dentists online and you will find similar care across the border.
I was reading another article on medical costs on the NY Times website and how procedures done by young residents or interns was billed by a doctor, who never even saw the patient.
6
I regularly have blood tests at Quest. They do a decent job efficiently.
The original bill is for about $300. They actually get paid about $30 by Blue Cross, Blue Shield, no co-pay from me.
How can they justify charging private patients $300 when they can still make a profit at $30?
(At $30 it's a bargain in my opinion. )
7
@norman0000
Who says they are making a profit at $30? This is simply what Blue Cross has agreed to pay them. Likely they are just breaking even at that price or losing money. In actuality, the profit is frequently only realized in the setting of a combination payer mix (such as other insurance companies that may reimburse higher, private/self pay patients, and the “patient responsibility/deductible” component of the $300—ie a part of the remaining $270—that the physician/hospital is responsible for collecting on their own—which many patients simply ignore). In other words, the system is built to maximize profits for insurance, drug, and device companies, while leaving hospitals, doctors, and their patients on the hook for finding ways to collect on costs, negotiate prices, and subsidize care from those who can pay wherever they are able. The system should change!
4
As a Canadian who currently has been dealing with major medical problems, after reading about what you Americans go through, I am so thankful I was born in Canada. If I lived in the so called land of the free, I would probably be bankrupt. I have heard stories up here of people working for big corporations and good insurance, having to sell their house because of a cancer.diagnosis.
it is so not right. Why are Ameticans so duped by the right wing that public medical insurance is a bad thing. Everything up here is not free. There is not universal pharmacare. BC has coverage for the low income and most dental care is not covered. Some in hospital dental care is.covered as is care for disabled people. Some physiotherapy is covered not all.
7
@bcer Americans are duped by the right-wing because the vast majority know almost nothing about other countries. I can't tell you how many times, while in Florida on a winter escape, I've had to correct misinformed comments about our health care system.
2
A few months ago I wen to the emergency room of a hospital that advertizes itself as being in-network. A few weeks later to my surprise I received a bill from a doctor indicating that the payment from my insurance company was inadequate and requesting the I pay a substantial additional amount. This came as a surprise since I was unaware that a physician can use the facilities of a hospital and not abide by its standards. Since the hospital promoted itself as being in-network, I was under the impression that all services provided would be in-network. Moreover, on checking-in, no one warns you of this trap. It is time for legislation to be introduced to control this scam.
31
@Chances_R Balk at paying. Tell 'em why. Offer to go to court if they want to sue (but no arbitration.) They'll make a good deal or drop it.
2
Many rural hospitals will close. as will helicopter and private ambulance services. Many will not be replaced and people will have to travel to metropolitan facilities for their care. I guess that is what people want.
2
@Steve people want affordable healthcare. People don’t want to be ripped off my greedy insurance companies, hospitals and ambulance services. Many people, like myself want Medicare for all.
6
@Steve I, for one, do not want Medicare for All. There seems to be little understanding as to what Medicare is. It's not health insurance. There is no contract between you and an insurer. You have no rights, when care is not approved by the government. Medicine is not a "cook book" to be followed, but Medicare follows that model. If you don't fall in the government allowed parameters, then tough. Doctors and Hospitals are fined if they dare step out of line and guess what, the Medicare enrollee cannot pay out of pocket for any other recommended tests or care, unless you can find a doc to treat you that is not participating with Medicare.
1
@Kay Daniel Sorry, but most medicine is "cookbook." That's the definition of "quality medicine," that's measurable and repeatable. Are there "outliers?" Of course, but Medicare allows for that. And in most circumstances, i'd want providers fined or sanctioned for providing "quackbook" medicine.
4
@skeptical1
I completely agree. I have spent HOURS researching Medicare options, comparing companies, coverage, and prices. It is ABSURDLY complicated, and I have decades of experience in the health care system. My coverage will be better at less cost to me than private insurance, but it is a tortuously difficult process to settle on what works best for you, and I don't know how anyone who is not knowledgeable, or literate, or persistent manages at all.
11
@colorado You know that Medicare is NOT insurance. You have no contract with an insurer that gives you rights if a procedure or test is denied. And believe me, to save money, Medicare only allows treatment if you "fit" in it's parameters. You will be denied treatment and tests if you don't fit the government approved parameters - and believe me, people are individuals and should be treated that way. Everybody wants "healthcare" for free but when doctors and hospitals have no incentive to stay past 5pm, they won't and you or some other unlucky patient will be out of luck and you will die "assured" that your healthcare was free.
@colorado You know that Medicare is NOT insurance. You have no contract with an insurer that gives you rights if a procedure or test is denied. And believe me, to save money, Medicare only allows treatment if you "fit" in it's parameters. You will be denied treatment and tests if you don't fit the government approved parameters - and believe me, people are individuals and should be treated that way. Everybody wants "healthcare" for free but when doctors and hospitals have no incentive to stay past 5pm, they won't and you or some other unlucky patient will be out of luck and you will die "assured" that your healthcare was free.
@colorado You know that Medicare is NOT insurance. You have no contract with an insurer that gives you rights if a procedure or test is denied. And believe me, to save money, Medicare only allows treatment if you "fit" in it's parameters. You will be denied treatment and tests if you don't fit the government approved parameters - and believe me, people are individuals and should be treated that way. Everybody wants "healthcare" for free but when doctors and hospitals have no incentive to stay past 5pm, they won't and you or some other unlucky patient will be out of luck and you will die "assured" that your healthcare was free.
How is "surprise" defined. Is it a technical term? If the patient is told in advance of all the charges, no matter how outrageous, does make all the charges not surprise charges?
1
@Colin Barnett You miss the point that many people are taken to an Emergency Department, not choose to go there. Or that IF you go to a hospital and your surgeon recommends a procedure, you aren't told clearly, and in advance, and with enough time to make other arrangements that the anesthesia team, a radiologist, or outside pathologist who isn't in network will be sending a bill. And those bills are not negotiated down with agreements with your insurance company.
It is that kind of thing that needs fixing, and soon.
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@Colin Barnett
No one is told in advance of any total charges. That is what is most outrageous.
7
@Donna President Trump has proposed that hospitals be transparent with their costs. The Hospital Association has sued to prevent that.
1
I actually heard a Wall Streeter claim that cancer and other diseases is good for business. Took great restraint to simply walk away from that but it was very revealing.
Pull the insurance companies from the stock market and watch how fast things change when our health care system no longer cares about ROI's and their investors.
9
Can someone with knowledge clarify? The out of network charges will still be covered by insurance, but the patient has a higher shared cost responsibility, correct. In other words, the maximum out of pocket expense is the ceiling on what i may have to pay (which admittedly can be $15k or so).
@James
In NY, the patient is now removed from the process of "surprise billing" and it is between the doctor and insurer. BUT, the patient is responsible for the amount up to what they would have had to pay had the provider been in network. So, no surprise, just what the patient's policy stated in advance that they had to pay.
2
@James many insurance programs pay little or nothing for any "out of network" care you receive, so limiting what that charge will be (since you will be paying all or most of it) is important.
We would not need "vital protections" if healthcare was a right and provided to everyone equally.
18
It's about time . There's nothing more frustrating than getting hit with big surprise doctor bills when you go to a hospital or facility that is supposed to be in your insurance company network of preferred providers.
8
Surprise high medical bills for patients who diligently go to hospitals within their insurance network are outrageous.
A fair solution to this problem would NOT be to require non-participating doctors to simply accept the payments for services provided dictated by insurers.These payments are often below market rates. The insurers have to get haircuts too. Or the hospitals need to subsidize the doctors. Our ER group did not participate with BlueCross because the payments they offered did not cover our costs. Primary care or subspecialist doc,s get something from participating with insurers - for example patient referrals or expedited payments. Hospital based doctors don't get these benefits. All they get is a demand to accept 50% of what their usual charges are.
10
If your costs can’t be covered by the outrageous costs I have paid to hospitals then you don’t deserve to be in business and have a cost structure that needs to be reigned in. When you are the root of the problem you cannot see any different than what you believe.
5
@Jim Your recommendation is a bit simplistic. The hospitals would love to pass these extra costs onto non-employed doctors. ( Hospital employed docs would not bear the brunt of these changes as they are on the payroll.) But self- employed, independent individual doctors and groups are essential. They can afford to stand up to top heavy administrators and bureaucrats who only are looking at the bottom line. FYI, hospital administration has grown by over 1000% in the last decade. Just what we need more bureacracy.
1
@semaj II Your definition of your costs is a problem, but the greater problem is that there are too few physicians to compete with you.
2
Given that outrageous physician pay is a big part of why the US spends so much more on healthcare than other developed countries, I find the news that the California law reduces physician's pay a confirmation that it is working as it should.
21
@DMC You're quite right. I'm a 4th year medical student who will graduate with >100,000 USD of educational debt (which will balloon to far more before I can pay it off), so there's a selfish part of me that doesn't want to see physician pay come down too far (although unethical billing practices have to go regardless of how it affects physician pay, no doubt about it). But, at the end of the day, it's very hard to ignore the data; US physicians make so much more than physicians make in other wealthy countries that I cannot imagine that this disparity is just or sustainable. Additionally, this extra cost is a huge barrier to expanding access to care, as M4A is hugely expensive if prices don't come down at the same time.
If physician pay is going to come way down, though, can we please do something to reign in our grossly inflated finance sector as well? Otherwise I fear we'll lose even more top minds to such unproductive endeavors than we already do.
23
It’s hard to feel sorry for someone who chose to go into debt to earn a degree that moves them into a salary that is more than $100,000 per year and probably closer to $150,000. Get someone to help you with a budget and don’t move to a major metropolitan area and you’ll do just fine.
2
@Jim —a little compassion would go a long way. You should reread the prior comment: the responder was essentially agreeing with you while also admitting a smidge of self interest. And re the salary debt issue: yes, it will—as the commenter him/herself stated—work out, but the first few years probably will be a challenge. Compassion. It’s a beautiful thing.
7
Corruption is corruption.
Organized crime under a corporate logo is still organized crime.
Humans are not born to be milked and bred into infinitely veiled forms of enslavement.
23
We all know where this will go--at the last second, the GOP will side with private equity. Please, someone site an example in the last 20 years where where the GOP has taken the side of citizens over corporate interests.
22
Physician here - the need for this legislation is insane. The very fact that thousands of hours of time and millions of dollars need to be spent on these complex issues surrounding healthcare demonstrates the total craziness that is our current single payer healthcare system.
I say single payer, because in the end, you can look in the mirror. YOU are the payor. You must realize that your premiums, copays, deductibles, and other costs are affected by this and other profit-centered negotiations. Every hour and every dollar spent on this irrational system is completely wasted. Look to the Nordic countries for a more rational solution.
I understand you may not want to pay more in taxes - but isn't that better than paying even more in premiums, where some of those dollars are spent on this exact sort of issue, thereby fattening the 401k's of lobbyists rather than providing YOU healthcare?
61
You are correct on that. Until rookie look at their total cost for health insurance which includes the part your employer pays plus all of the expenses you pay there cannot be any rational decisions on it. If people knew their total cost would be fixed army $X per year the cost (tax) would be a lot more palatable.
7
Why don’t they listen to us in the healthcare field? I have written many examples of how
Public healthcare is better but I feel the GREED card drowns is out
2
@Nicholas Browning I've been wondering the same thing. Why is it that the proponents of various single payer proposals don't add up all individuals and businesses are paying FIRST and then compare it to the necessary tax increase? For many if not most, it's a decrease, and for the few middle class people who would pay more, many would admit either that "the peace of mind is worth the extra cost" or "what's best for the most Americans is what I need to support." You know, like I do when I pay my very high property taxes for education, though I have no children?
3
If true, I love it.
...but I find it a little hard to believe that the party that has done everything it could to make healthcare (and every other real problem) worse would go along with Democrats to make some part of healthcare better. A deeper dig into what's in it for them needed, I think.
17
Cheers to Ms. Sanger-Katz for being the first to finally acknowledge that insurers have been behind the attempts to benchmark physician payments. Brookings Institute's biased analysis is no shock, given their heavy roots and donations from the healthcare insurance industry.
Cutting emergency physician salaries by 20% and still holding them accountable for this nation's foibles via EMTALA and unfunded mandated care for those it fails to ensure is heinous. That money would just go right into insurer pockets, cause more physician group consolidation under such private equity groups as private groups would go under, and would unlikely to cause any benefit to insurance premiums or payments.
Cheers to Congress for not giving insurers the keys to the kingdom and all the power in negotiations against your local neighborhood physicians with six-figure debt. AND for following the data for what worked in New York. AND for keeping patients out of the middle of billing negotiations.
5
A neighbor brought her son to the local ER that was in her insurance network, where a doctor set his broken nose from a baseball game injury. Turns out the dr was not in the same network and he sent her a bill for $28,000. Yes, this bill is needed.
44
@Jeff After receiving a bill like that I would have broken the doctors nose.
8
It's amazing that this actually counts as a win when it comes to healthcare costs in the USA.
Somewhere along the way, this country became all about how much money big business can extract from people. Just full-on exploitation of the citizenry by corporate interests. We're living in a right-wing dystopia with no end in sight.
31
When I learned about the cause of surprise billing, I was flabbergasted and angry. Patients are burdened with a phone book of rules that determine if your insurance claim will be covered. If you missed the rule stated on page 113 of your guidebook, then, sorry, no coverage for you. But by now, most people get the in-network/out-of-network rule & realize it's almost better to die than rush to an out-of-network facility for medical care where you'll be billed for every dollar you'll ever make in a lifetime.
I pictured myself interviewing each doctor on their insurance affiliation to make sure they were in my network before they laid a hand on me.
When you follow the rules & go to a facility in your network, it's a crime & a sin to present patients with an out-of-network doctor unbeknownst to them. Surprise billing is actually well known as fraud & deception. What's the point of paying for this outrageously priced insurance if it can be so easily subverted? Why wouldn't a doctor, knowing his or her insurance does not line up with that of the facility, inform the patient or family and give the patient the right to opt out? (That would really open a can of liability worms for providers & insurers, wouldn't it, if patients began refusing care because their in-network facility couldn't provide in-network medical personnel!)
19
The way it is now, unless you’re very rich or very poor, if you go to the doctor or suffer a medical event, you will need to make a payment plan for the deductible and/or co-pays. Of you don’t make a payment plan you will be at risk of losing your home and job as part of the collection process. It’s a rigged system and the only way to win is to die.
8
Envision, as an example, supplies ER physicians, radiologists and anesthesiologists, just to name a few services.
So imagine a person falls hiking, resulting in a compound leg fracture. He is scooped up by an ambulance and taken to a hospital that his insurance covers. He is seen in the E/R, sent for an X-ray and the surgeon is called in. He finds that the surgeon, room, the OR and the tylenol are covered; the E/R admitting doctor is not, nor is the radiologist and the anesthesiologist. Fully insured, he is presented with a $15K bill.
Of course, he should have asked before transport, and shopped around for an ER which was covered.
Yes, this should be a bi-partisan effort. Financially raping the sick and injured is a matter we should all be concerned about.
36
The fact that this is even one bit contested is an incredibly disturbing indictment of the American healthcare industry. What other business thinks that surprise billing is some kind of normal business practice?!
19
"The solution is similar to one passed in California three years ago. That law appears to have substantially reduced the number of out-of-network bills in relevant medical specialties. But doctors there have said it has lowered their pay."
GOOD, because your ridiculous pay was the problem.
16
@chad
Physicians actually count for a fairly small amount of medical costs. Much more goes to useless administrators and paperwork, yet they escape your ire. This is why doctors and nurses are quitting left and right and leaving the field.
4
Another article to remind me how much I appreciate our healthcare system in Canada.
25
Does anyone under the age of 55 believe in scary, fear inducing advertising any more?
Everyone I know laughs at ads like the ones the lame private equity group sponsored.
8
Finally, our government coming together to do the right thing.
1
Fixing our broken system one out rage at a time will probably not succeed. It’s a game of whack a mole until we take on the corporate interests that are literally sucking the life out of people. For example, who’s going to fix this one? My friends husband had a heart attack while driving. He was airlifted to a primary medical Center. He died after a few weeks. His emergency care was covered by his insurance except for the $65,000 bill his widow received from the helicopter company but airlifted him.We need a government run healthcare system that recognizes society as a whole must care for all of us. That’s what Medicare for all means
19
As a Real Estate Appraiser I see that the most expensive,luxury homes in my area are often those of doctors. I have little sympathy for Doctors being paid less.
9
My sentiments exactly
3
@Displaced yankee
Really? We can't hire doctors or nurses because they can't afford to live here. Presumably you live somewhere rural. The big money is in software and finance, and they don't take as much school.
1
"Private Equity" - yecch.
My veterinarian told me recently that a huge chunk of the vet business has been taken over by private equity. The little place down the street with 2 vets and 2 exam rooms is now owned by corporation in Texas, with ever higher prices to match; they're no longer an independent practice.
She told me that most of the independent practices in the Bay Area have been bought up - apparently the capitalists realized that it was a safer place for their money than bogus mortgages; and because people love their pets, it's a good way to squeeze more money out of their wallets.
45
That’s another area that needs insurance and legislation, imo. Vet expenses can be as costly as human medical expenses, with little to no relief. If it’s a devastating injury or illness, you either pay or euthanize. That’s a horrible choice to have to make, and devastating in a whole other way
People nowadays are opting to have pets (fur babies) over human children. I see car decals that exclaim the driver is a grandparent of a fur baby and they love their granddog. But the law recognizes the animal as property; so why not have insurance for pets the same way we have car insurance, or at least be covered under homeowner insurance?
Sorry, I know this thread is about medical insurance for humans...but since it was brought up, I thought I ‘d throw in my 2 cents
3
@Reneé Google 'pet insurance' for some options.
1
More proof that Medicare for All is the only real solution. And this article provides a clear demonstration of who will be fighting that the hardest: the 0.1% who control private equity. For a picture of what "socialism" and "socialized medicine" looks like, see yesterday's NYT article about moving to Finland.
54
The real problem with the entire US Health Care system is all the rent seekers piling on to the doctors and nurses and technicians at the coal face who actually heal the patients. It's well past time for the entire "industry" to adopt the Hipocratic Oath, under oath, and
do no harm. Ask your doctor if the entire private equity racket is right for your relationship. It's not. This is a system ripe for a technological change back to the past when you just paid your doctor directly, cash price, no mumbo jumbo billing desk coding the bills, begging insurers, and running up the costs. Back to basics.
29
"A dark-money group funded by private-equity-backed physician staffing firms has spent tens of millions of dollars in television and direct mail advertising in a bid to scuttle the legislation."
I think this says it all. The opposition to truth-in-billing legislation is not because it would hurt the patient somehow, but because it would slow or stop a gravy train.
Can't stop them there gravy trains, now can we?
46
@Alternate Identity
The thing you’re not getting is the details. I’m a doctor. I’m not a dark money whatever but we’ve been lobbying hard to have a slight change, which some senators are receptive to and some aren’t.
My group has not been out of network with an insurer for 30 years. Now an insurer wants to cut our reimbursement 30%. The reason they want to is because of this legislation, and how it will allow insurance companies to set a low benchmark rate for what they pay physicians.
This represents a wealth transfer from your paychecks to insurance companies: they pay doctors less but give the insured no discounts. Everyone should be outraged at that.
Moreover, my group is facing a 30% cut. Who in the world is taking a 30% cut lying down? Auto workers? Bus drivers? Congresspersons? Tech workers? Insurance agents? No one goes back to work at the same job where the pay was just docked 30%
Doctors have experience in science, data analytics, complex systems organization, strategy, design, and personnel management. Many if not most of us have monetizable skills in the “real world.” For me? I happen to love serving people in a real and tangible way: making it so that when they wake up after muscles have been flayed and viscera exposed, that they have a.) survived without complications or harm and b.) are reasonably comfortable. You can of course add to this list innumerable items that we do daily. This has *real* value.
4
This legislation is badly needed at the federal level, since state legislation cannot protect those with employer-based health insurance which is federally regulated under ERISA.
As a medical-claims supervisor for an employer-based health plan, one of the hardest things for me to explain to plan participants is why they have zero protection from their insurance company or the government from the predatory surprise-billing of out-of-network doctors who provided care in an ER or in-patient hospital setting.
Since the charges billed by these doctors were far higher than what insurance would cover as 'reasonable and customary', the patients were blindsided by balance bills for hundreds (if they were lucky), or thousands, or sometimes tens of thousands of dollars.
Of course these doctors (who never join PPO networks) blamed allegedly low levels set by insurance as 'reasonable and customary,' but in these cases the amounts billed above what they know insurance will accept were so high that they amounted to highway robbery.
In my experience, the doctors who do this commonly use very agressive bill collectors to go after their patients. That was their business model. They knew the patient's had no choice about who would show up, no control over anything.
74
@Joshua Ireland I completely agree. I was in Maryland when I received a surprise bill from a surgeon. I had come in through the emergency room and then was hospitalized. The hospital and the ER were in network, my surgeon was not. What is the patient supposed to do, question every doctor before they allow them to touch us? When I questioned it, the hospital said, "everybody does it."
This law is a long time coming.
96
If the physician is out of network they shouldn’t even be able to step foot in the facility.
Should be if you work under their roof, you are considered in network, and accordingly
12
Is it possible that an important piece of legislation, crafted and approved by both Democrats and Republicans, could result in an inflection point in the widening gap between the two parties? That could be more important than the bill itself because even legislation passed by both houses would be in jeopardy of failure to successfully enact, so dismissive of the Constitution and our laws is the president and Republicans.
7
This article fails to mention the role the insurance companies have in surprise billing. This legislation will lead to even less contracting with physician groups as the bill will automatically be a median payment. Why should insurance negotiate any contracts after this is passed? They will continue to charge the same premiums or higher. This does not help consumers and harms physicians who have gone through great personal and financial hardship to obtain the training to provide quality care to individual.
12
@Rt808 No law is perfect and insurance companies are a part of the problem too. But I shouldn't go to the ER for a medical emergency and, while I'm bleeding to death, need to check that all doctors who treat me take my insurance; because if I don't, I might get a $10,000 bill. That's plain wrong no matter what downsides we can think of for doctors.
77
@Rt808 Patients are told to go to an in-network facility to honor the conditions of their coverage. There is nothing in these rules that even warn patients that there my be out-of-network doctors treating them whose bills will not be covered by insurance. Patients are not even given the right to be informed at the facility of the presence of out-of-network doctors so that they can opt-out of their care. We pay an arm & a leg for these policies & still, even when we follow all the rules, we are slammed with unanticipated costs. How is that fair?
41
Sound of smallest violin.
1
"A dark-money group funded by private equity-backed physician staffing firms"
If the physicians with their influence are getting squeezed by the private equity firms what chance does the average American have against them?
Now more then ever Medicare for All.
119
This is a much needed consumer protection bill. Next, I beg these Committees to curb the confusion caused by private health insurers marketing various packages of benefits to people kn Medicare. It can only be deliberate, because chance could not possibly create the misleading information offered on the websites of United Health Care, Humana, and Blue cross in New York (I have not looked at others) . Too little, or too much, or not clearly differentiated data is given. I have a PhD in economics and it took about six hours to figure out and verify on the telephone the best Supplementary medical care plan and prescription drug plan for me. I am not sure I succeeded, before time ran out. Also, data was removed from United Health Care website on the last day of enrollment. It results in higher costs for consumers, is threatening to their mental health, and justifies tossing out the insurance system entirely.
100
@Skeptical1
You hit the bull's eye in the last sentence. Surprise billing was a few opportunistic physicians' immoral response to the immoral acts of insurance companies. It's bad, but only possible in the environment of widespread chicanery that's the US insurance system.
Fixing this is important, but if fixing this sabotages fixing the entire system, then it's not worth it.
4
I have seen these ads and could never find any information on the sponsors (Doctor/Patient Alliance, I think). I would never have guessed this was the issue the ads were addressing. They did use scaremongering language. They referred to the legislation as a 'scheme' put together by Congress. There must have been some deep pockets behind this because the ads played frequently.
62
@Helen You can thank John Roberts and Citizens United. for that.
27