As posted by: Wall Street JournalYou might expect to pay more if you choose a doctor outside your insurer's network. But what if you don't know a doctor's status -- or are in no position to ask? The result can be a nasty surprise known as balance billing.
Insured patients are sometimes hit with unforeseen charges after emergencies, when they are taken to the closest hospital regardless of whether the facility accepts their insurance. Consumers also may be billed after visiting in-network hospitals if they received treatment from medical providers who work there but don't participate in the same health plans. When that happens, insurers often pay part of the doctors' fees, and the physicians bill patients for the difference. This is the practice known as balance billing, and it can leave consumers battling both the insurer and the medical provider to get the charge reduced.
Tom Pritchard, of Hartwick, N.Y., knew the orthopedic surgeon who operated on his hand last December was in his insurer's network. So was the outpatient surgery center. But when a bill arrived weeks later, he got a surprise: The anesthesiologist didn't accept his health plan. After Mr. Pritchard's plan paid the specialist at its out-of-network rate, the anesthesiology practice asked the 57-year-old retiree to pony up the remaining $580.
So far, Mr. Pritchard says he has refused to pay, because he's upset no one warned him or gave him a chance to request an in-network doctor. "It never occurred to me to ask" about the anesthesiologist, he says. "Why would I?"
A growing number of state regulators are moving to crack down on balance billing. Mr. Pritchard testified in October at a public hearing held by the New York State Insurance Department, which is drafting proposed regulations that could force more disclosure by medical providers and insurers and shield consumers from unexpected charges. California regulators recently made it illegal for people covered by health-maintenance organizations to be balance-billed for out-of-network emergency services. And late last year Illinois put out a bulletin that protects many consumers from balance bills in certain situations if they make a "good faith" effort to use in-network doctors that provide Michigan Health Insurance.
If you're faced with an unexpected bill from a health-care provider seeking the difference between his fee and what your health plan paid, you should start by calling your insurer and the doctor's office. If you can't resolve the matter, you may want to turn to a consumer advocate for help.
"The patient shouldn't have to bear that burden," says Michael McRaith, director of the Illinois division of insurance. He says the problem may be growing partly because some doctors are feeling squeezed by insurers' reimbursement rates, prompting them to drop out of networks and bill patients instead.
It's not clear how much balance billing occurs in the U.S., but the practice appears to be widespread. A state survey last year by the California Association of Health Plans found that 16% of insured respondents who had visited an emergency room in the previous two years had been balance-billed. Based on that, the group estimated that 1.76 million Californians had faced such charges for emergency room visits in that period, with amounts averaging $300 each.
Physician groups say doctors have the right to refuse to sign up with insurers' networks, and regulators shouldn't bar doctors who don't participate in health plans from billing insured patients. They say that insurers' payments to out-of-network health providers are often unfairly small. "You can't turn it around and say it's the doctor's fault," says Nancy Nielsen, president of the American Medical Association.
Insurers counter that they shouldn't be forced to pay whatever fee out-of-network health-care providers demand. "You have a set of specialists who won't contract with health plans, and they want to bill whatever they choose," says Robert Zirkelbach, a spokesman for America's Health Insurance Plans.
Insurers also defend how they calculate payments they make to out-of-network doctors and hospitals. The size of the payments, known as reasonable-and-customary fees, is often derived from a database of medical-claims price information. Still, the New York attorney general's office is investigating the legitimacy of insurers' methods.
Ronald Eckert, a Las Vegas casino employee, says he can't afford to pay the approximately $8,200 charge from an out-of-network surgeon who operated on his fractured eye socket after he fell last year. Mr. Eckert says that when he arrived in the emergency room he asked a nurse to call his health plan and check for coverage. But by the time the surgeon came to his room, the 59-year-old says, he was semi-conscious and not in any condition to confirm that the doctor would accept his insurance.
"I didn't pick him. I was on a morphine drip when all of this was decided," says Mr. Eckert, who is working with the Nevada governor's office for consumer health assistance to negotiate a reduced bill.
There are ways to fight back against balance billing. When you are planning a procedure in advance, ask detailed questions about the potential role of out-of-network doctors in your care. Anesthesiologists, radiologists and pathologists are often the most likely to not accept many health plans, but they're not the only ones. If possible, you can request an in-network provider, or you can seek to work out terms in advance with the doctor and insurer.
After medical treatment, you should expect to have to pay out-of-pocket any co-payment or co-insurance fee, and any deductible that your plan requires. If you get a bill that goes beyond these, start by calling your insurer and the doctor's office for more information, as well as your employer if your health benefits are from your workplace.
Find out if you are being balance billed by a health-care provider who is in your network and for a service covered by your plan. If so, you probably don't have to pay. States generally prohibit such charges, which also typically violate your insurer's contract with the doctor.
If the doctor is not in your insurer's network, there still might be steps you can take. Some states have regulations that may protect you from balance billing in certain situations, most commonly emergencies. Check with your state's insurance regulator.
Your insurer also may be able to help; companies' responses to unexpected out-of-network balance bills often depend on the member's particular benefits package and whether the care was for an emergency or not. In any case, insurers say consumers should call them before writing any checks to the doctors. "You should not pay that bill and figure you're going to get it back in the end," says Wendy Sherry, vice president for product development at Cigna Corp.
Filing an Appeal
She says Cigna typically tries to "protect members ... when it wasn't a voluntary use of an out-of-network provider." Aetna Inc. says it will "attempt to work through the situation on the member's behalf." UnitedHealth Group Inc. says that if a member is billed inappropriately, it will generally negotiate with the hospital or doctor "to take the member out of the middle."
If your insurer and the doctor can't reach a compromise and you're still getting billed, you can file an appeal with your insurer to try to force the health plan to pay more. You can also try to negotiate with the health-care provider.
Leanne Suter and her husband, Mark Watters, a pilot, were socked with big bills for the emergency treatment Mr. Watters got after a helicopter crash last year off the coast of Florida. With injuries including broken ribs and back and punctured lungs, Mr. Watters says he was in no shape to ask questions after the accident, when an air ambulance ferried him to a trauma center. Ms. Suter, a local television reporter in Los Angeles, later checked that the hospital accepted their insurance. It did, so she assumed its doctors would as well.
But both the air service and the trauma surgeon who later operated on Mr. Watters weren't in the couple's insurance network. Ms. Suter hired a firm called Healthcare Advocates Inc. and appealed the initial charges. She got the health plan to increase the amount it paid for the treatment, though this still fell well short of the bill totals. Then she convinced the air service to reduce its approximately $5,600 remaining charge to $2,200, saying she couldn't afford any more. But so far, she says, the trauma surgeon's office hasn't backed down, and wants more than $16,000. "Where am I going to come up with the money?" she says.
