|Date:||February 17, 2017|
A year ago, Lisa Ricks was rushed to Ochsner’s West Bank emergency room after accidentally stabbing herself in the eye with the end of a metal broomstick.
It was extremely painful, but she got expert care at her in-network hospital, paid a $200 copay and was back out at parades in time to enjoy Mardi Gras 2016. The eye patch she had to wear almost fit in with the zany Carnival costumes and soon her vision was back to normal.
She wasn’t blinded, but about nine months later, she was blindsided – by a $585 doctor’s bill.
“I call Ochsner; Ochsner says that's not from us,” Ricks said. “That's from another doctor's group. I said, 'Explain.' She said, 'Well, just because you were in Ochsner's emergency room, which is in my network, doesn't mean that the doctors are employees of Ochsner. Some of them are contract labor.”
Ricks sells supplemental medical insurance, so she knows the process. But she wasn’t prepared for something called “balance billing,” charges for uncovered services at in-network medical facilities. It’s a problem that’s getting more attention as more people with private insurance go on high-deductible health plans, forcing them to confront billing issues that used to be handled behind the scenes by insurance.
A recent survey by Yale University researchers published in the New England Journal of Medicine found that a whopping 22 percent of in-network hospital visits include some sort of out-of-network charge. Often, those bills come from independent physicians’ groups that provide anesthesiologists or other specialists to hospitals on a contract basis, to supplement in-house staff at emergency departments.
Illinois, Colorado, Texas, New York and Florida have managed to rein in this type of balance billing, but Louisiana lawmakers have been thwarted by the medical lobby, Insurance Commissioner Jim Donelon said.
“It is a self-serving, very anti-consumer system that I have called the greatest consumer abuse in the insurance world,” Donelon said.
While hospitals, insurance companies and physicians have fought in Baton Rouge to keep the practice going, when questioned about it, they are quick to say they don’t engage in balance billing.
“We make sure that … if we work with a physician at one of our facilities, that they're in-network, because we want to make sure our patients don't have out-of-network costs,” Ochsner CEO Warner Thomas told WWL-TV.
And yet, when the station confronted Ochsner with Ricks’ bill from an out-of-network ophthalmologist who saw her at Ochsner’s emergency room, it took just four days for the contracted physicians’ group to send Ricks a corrected bill, wiping out the entire $585 charge.
That physicians’ group is Schumacher Clinical Partners out of Lafayette, one of the largest providers of emergency room physicians in the country. Asked why the bill was reversed, Schumacher Vice President Maura Nelson said the company’s “client relationships and practices are proprietary.”
“We cannot comment on specific patient cases, but are always committed to working closely with hospital partners to help resolve any patient grievances or concerns,” Nelson said.
Ochsner maintains it doesn’t engage in balance billing and called Ricks’ bill an error. However, the hospital never acknowledged it was an error during the four months Ricks was challenging it, before WWL-TV questioned it.
Lisa Ricks said she was blindsided – by a $585 doctor’s bill.
Donelon called several aspects of medical billing “a racket,” and said public shaming can be the only way to get hospitals to back down. The Legislature did pass a bill in 2011 forcing medical providers and insurers to post notices telling patients that they may be charged for out-of-network services during visits to in-network facilities. But Donelon said the notices posted in hospital reception areas and on the backs of bills after-the-fact do not effectively warn the public about balance billing.
Louisiana Secretary of Health Rebekah Gee said she, too, is concerned with surprise billing and suggested the state might be able to use its leverage – as the largest payer of health care costs through Medicaid – to pressure providers to divulge their prices ahead of time.
“We need a lot more consumer-directed information and transparency,” Gee acknowledged.
And that would help with other kinds of surprise bills, too.
Like the one Ralph Leopold got from an in-network hospital when his dependent son was injured on a hunting trip in Iowa. The hospital charged an extra $110 for what was called a “contractual adjustment.”
The hospital said it had an agreement with Leopold's insurance company that allowed to charge a premium for certain services, even though Leopold was paying the bill himself as a part of his deductible. Leopold said he’s not a party to that contract and therefore shouldn’t have to pay it, but the hospital has not backed down and reported Leopold’s son to credit agencies as a slow-payer.
Donelon said there can be arcane language in insurance policies that subject policyholders to those kinds of agreements between insurers and providers, but Leopold said that’s underhanded.
“It's the only product or service I can think of, off the top of my head, that you go in and purchase without any idea what it's going to cost,” Leopold said.
Similarly, patients are often surprised by facility fees, which are sometimes added by hospitals to cover the costs of providing space, equipment and nursing during emergency care, and even for certain planned visits to the doctor.
The practice can vary widely. For instance, East Jefferson General Hospital says it charges facility fees only at its emergency departments, while Ochsner warns patients with posted placards that it charges the fees at affiliated clinics. But in an interview with WWL-TV, Thomas, Ochsner’s CEO, said those fees are only charged to Medicare or those without insurance, not to those with private insurance.
Meanwhile, Tulane Health System has an even more complex facility-fee policy. Tulane Medical Center is the hospital, and Tulane Medical Group provides the doctors who staff the hospital and various clinics around the New Orleans area. After patients pay Tulane Medical Group for services, they can also get a bill from Tulane Medical Center for use of its facilities, staff time and supplies, but only for certain services that are considered “outpatient procedures.”
“It's abusive, I agree,” Donelon said. “But there's no law against it.”
Louisiana Secretary of Health Rebekah Gee said, “We need a lot more consumer-directed information and transparency.”
Donelon and Gee say that when it's not an emergency, patients should protect against surprise billing by shopping around and getting quotes for all their medical procedures. They said once a medical provider quotes a price for a procedure, they are not permitted to tack on additional charges.
Whenever possible, they said, patients should ask ahead of time how much each aspect of a medical procedure will cost, if there is any additional facility fee and if everyone involved in providing care will be in-network.
And as Ricks learned, providers are – at times – willing to acknowledge an error or overbilling if patients fight hard enough.
“We need to speak up and just let them know, you're going to lose!” she said. “Because you can send people to collections all day long, you're not going to get these out-of-pocket fees. You're not going to win.”