Proposal would insure you against surprise medical bills

Jan. 28--Before his wife had an outpatient medical procedure, Robert Laubscher made sure the facility accepted their insurance. He asked again the day of the appointment and again was assured everything would be billed as in-network.

Then they got socked with a $700 bill from the anesthesiologist, who was out-of-network.

"It's just crazy when you ask them and they say, 'Yeah, yeah, yeah,' " said Laubscher, of Bangor. "If you're going to say you take Blue Cross/Blue Shield, make sure everybody in here accepts it."

He told me he refused to pay the bill and the practice waived most of it after he threatened to publicize what happened. He shouldn't have been forced to take that stand, and a recent proposal would prevent him and others from having to in the future.

The Pennsylvania Insurance Department said last week it wants legislation to address situations such as what happened to Laubscher. People who seek treatment at a health care facility that is in their insurance network, but are seen by an out-of-network professional, then wouldn't be responsible for paying that professional an out-of-network rate.

Under the proposal, patients could be charged only the amount they would have been charged if that out-of-network professional were in-network.

So if your co-pay or deductible were $50 for an in-network physician's services, that's what you'd pay the out-of-network professional. Then the doctor and your insurance company would negotiate over how much of the balance of the bill would be paid by your insurance. If there were a dispute, they could go to binding arbitration.

"The goal of this proposal is to take consumers out of billing disputes between insurers and health care providers," the Insurance Department said.

The department is seeking public comment on the plan or alternative suggestions that would achieve the same goal. After considering the feedback, a final proposal will be drafted and the department will seek legislation to enact it.

The provisions would not apply if you went to a facility that wasn't in your insurance network. Then you'd be on the hook for the entire bill, though some insurers already make exceptions for emergency care.

There are many reasons why you could see an out-of-network health care professional working at a hospital or facility that's in your insurance network. Many professionals who work in those buildings aren't employed there. They work for outside practices. They may not have been invited to join health insurance networks, or they chose not to join.

Last week's proposal was drafted based on input the Insurance Department gathered at a public hearing in October.

Carolyn Morris, the department's consumer services director, testified then that dozens of consumers had contacted her office because they were "devastated after doing everything right and receiving thousands of dollars in medical bills."

"They followed the rules of their health plan by using participating doctors, surgeons and hospitals only to learn that an anesthesiologist, radiologist, pathologist or other provider not participating in their health plan's network provided treatment," Morris said. "These consumers had a reasonable expectation to receive full in-network benefits from their health plan."

Several people who got stuck in situations similar to Laubscher's testified at the hearing or submitted written testimony.

One woman complained about her in-network doctor using an out-of-network pathologist to analyze her test results. Another woman told of her son's going to an in-network urgent care center and hospital and being seen by out-of-network doctors.

This isn't a new issue, and it's about time it gets addressed.

I wrote nearly six years ago about a Monroe County man who went to Palmerton Hospital, which was in his insurance network, and was treated by out-of-network physicians who sent him unexpected bills.

Those bills were waived after I contacted the hospital, which told me it required all physicians who practice there to participate in the same insurance networks as the hospital. That's a good policy. I wish all hospitals would use it.

At the October hearing, many witnesses said health care providers should inform patients in advance of the potential for out-of-network professionals to be involved in care, and insurers should publish up-to-date lists of professionals in their networks for consumers to reference.

Others cautioned that any legislation must be fair to everyone, not just to patients.

Forcing insurers to pay the full charges billed by a provider "would send insurance premiums skyrocketing," Patrick Gillespie, Cigna's director of state government affairs, said in written testimony.

But it also would be unfair to force health care professionals to accept as full payment a discounted rate they did not agree to, the Pennsylvania Society of Anesthesiologists said in written testimony.

"There is no legal basis to require the provider to do so," the society said.

If you'd like to comment on this issue, you can send your thoughts to [email protected]. Comments are due Feb. 29. You can read the Insurance Department's full proposal at www.insurance.pa.gov. Any comments that are submitted will be published online after the deadline.

The Watchdog is published Thursdays and Sundays. Contact me at [email protected], 610-841-2364 or The Morning Call, 101 N. Sixth St., Allentown, PA, 18101. I'm on Twitter @mcwatchdog and Facebook at Morning Call Watchdog.

___

(c)2016 The Morning Call (Allentown, Pa.)

Visit The Morning Call (Allentown, Pa.) at www.mcall.com

Distributed by Tribune Content Agency, LLC.