It shouldn’t take a Harvard expert in health policy to understand a doctor’s bill. But sometimes, it does. In August of last year, Liz was a medical student whose doctor found a lump on her tonsils. Her primary-care physician referred her to an in-network ear-nose-and-throat specialist.
Liz, who asked to go by her first name, expected the usual $20 copay. Instead, she was charged $219.90—wrongly, in her view—for separate physician and facility fees. Under the terms of her plan, Liz says, she should not have been responsible for those charges. After a polite letter to her (“Thank you for your recent grievance...”), Anthem Blue Cross upheld the charges.
A few months later, Liz convinced Anthem to wipe much of the bill. But here’s the thing: By that time, she was studying health policy as a master’s student at Harvard. “It took me hours of going over the insurance policy and hours of arguing with the insurance company over that insurance pamphlet,” she said. (Later, Liz realized she had been doubly insured that month—her Harvard insurance had already kicked in—and she got the other plan to take care of the remainder of the balance.)
“I’m in a privileged position, but the tides were very much against me,” she said. “Other people aren’t as privileged and don’t have as much time.”
Liz is, like the roughly half of Americans who have decent insurance through their jobs (or grad schools, in her case), comparatively fortunate. But her experience reveals the persistent frustration, for people with all types of insurance, of trying to avoid surprise medical bills. Even generous insurance plans don’t always shield patients from puzzling bills. A simple trip to an in-network facility—with a referral!—can combine all the mental anguish of tax season with all the physical anguish of, well, physical anguish. (...)
A major reason for medical sticker-shock is that many facilities bill patients separately for each service they provide. “Imagine going out to eat and receiving separate bills from the restaurant, host, waiter, cook, and busboy, some of whom were willing to negotiate discounts or accept coupons, while others were not,” wrote Stacey Pogue, from the Texas think-tank Center for Public Policy Priorities, in a September report on surprise medical billing. (...)
Even when a hospital is in-network for a given plan, one or more of the doctors whom a patient sees while there may not participate with that plan. Occasionally, this discrepancy results in balance billing, a situation in which a provider charges the patient for the portion of the bill the insurer didn’t pay. These bills can amount to thousands of dollars, especially for long or complicated hospital stays. (...)
In Dallas recently, I met a man whose personal account exemplifies how balance billing typically works. (He requested anonymity because of a legal case he says he is building, so I’ll call him Steve.) Three years ago, Steve had a stroke, and the paramedics who rushed to the house suggested they take him to Medical City Dallas Hospital, a top hospital for strokes in the area. At the hospital, he was given a clot-busting drug and spent the weekend in intensive care. He recovered and went home.“Our system is so convoluted that most providers don’t even know how patients are billed.”
Steve had an Aetna PPO plan, but he says that in the weeks to come, he received bills totaling several thousand dollars above what his insurance covered because of various diagnostics and providers that were billed out-of-network. Six months later, Steve had another stroke. He said the same thing happened with a different hospital, Methodist Richardson Medical Center, which was in-network for Aetna.
In separate statements, both hospitals said that while they encourage their doctors to accept the same insurance plans as the overall facility, the doctors do bill separately for their care. It’s conceivable, in other words, that these other providers did not accept Steve’s plan.
Steve told me he couldn’t find his bills, so I could not independently verify his account.
Which brings the total opacity of American health care full circle: Hospitals don’t tell patients how much they charge. Patients don’t know how much their insurers will pay until they get their bills. And the information in the bills isn’t publicly available, so there’s no way to know exactly how, why, or to whom frequently surprise billing is happening.
Liz, who asked to go by her first name, expected the usual $20 copay. Instead, she was charged $219.90—wrongly, in her view—for separate physician and facility fees. Under the terms of her plan, Liz says, she should not have been responsible for those charges. After a polite letter to her (“Thank you for your recent grievance...”), Anthem Blue Cross upheld the charges.A few months later, Liz convinced Anthem to wipe much of the bill. But here’s the thing: By that time, she was studying health policy as a master’s student at Harvard. “It took me hours of going over the insurance policy and hours of arguing with the insurance company over that insurance pamphlet,” she said. (Later, Liz realized she had been doubly insured that month—her Harvard insurance had already kicked in—and she got the other plan to take care of the remainder of the balance.)
“I’m in a privileged position, but the tides were very much against me,” she said. “Other people aren’t as privileged and don’t have as much time.”
Liz is, like the roughly half of Americans who have decent insurance through their jobs (or grad schools, in her case), comparatively fortunate. But her experience reveals the persistent frustration, for people with all types of insurance, of trying to avoid surprise medical bills. Even generous insurance plans don’t always shield patients from puzzling bills. A simple trip to an in-network facility—with a referral!—can combine all the mental anguish of tax season with all the physical anguish of, well, physical anguish. (...)
A major reason for medical sticker-shock is that many facilities bill patients separately for each service they provide. “Imagine going out to eat and receiving separate bills from the restaurant, host, waiter, cook, and busboy, some of whom were willing to negotiate discounts or accept coupons, while others were not,” wrote Stacey Pogue, from the Texas think-tank Center for Public Policy Priorities, in a September report on surprise medical billing. (...)
Even when a hospital is in-network for a given plan, one or more of the doctors whom a patient sees while there may not participate with that plan. Occasionally, this discrepancy results in balance billing, a situation in which a provider charges the patient for the portion of the bill the insurer didn’t pay. These bills can amount to thousands of dollars, especially for long or complicated hospital stays. (...)
In Dallas recently, I met a man whose personal account exemplifies how balance billing typically works. (He requested anonymity because of a legal case he says he is building, so I’ll call him Steve.) Three years ago, Steve had a stroke, and the paramedics who rushed to the house suggested they take him to Medical City Dallas Hospital, a top hospital for strokes in the area. At the hospital, he was given a clot-busting drug and spent the weekend in intensive care. He recovered and went home.“Our system is so convoluted that most providers don’t even know how patients are billed.”
Steve had an Aetna PPO plan, but he says that in the weeks to come, he received bills totaling several thousand dollars above what his insurance covered because of various diagnostics and providers that were billed out-of-network. Six months later, Steve had another stroke. He said the same thing happened with a different hospital, Methodist Richardson Medical Center, which was in-network for Aetna.
In separate statements, both hospitals said that while they encourage their doctors to accept the same insurance plans as the overall facility, the doctors do bill separately for their care. It’s conceivable, in other words, that these other providers did not accept Steve’s plan.
Steve told me he couldn’t find his bills, so I could not independently verify his account.
Which brings the total opacity of American health care full circle: Hospitals don’t tell patients how much they charge. Patients don’t know how much their insurers will pay until they get their bills. And the information in the bills isn’t publicly available, so there’s no way to know exactly how, why, or to whom frequently surprise billing is happening.
by Olga Khazan, The Atlantic | Read more:
Image: Lauren Giordano
