Tag Archives: medical bills

New York Fighting Over Medical Billing

Surprise medical bills have long been a battleground issue for Andrew Cuomo, both before and after he became governor. This year’s budget includes consumer protections against surprise bills from out-of-network providers. The new law takes effect in April.

But four months before implementation, the law still is a work in progress. Two of the health care industry’s most influential playersphysicians and insurersdisagree on final rules, which have yet to be issued by state insurance regulators. The state Department of Financial Services declined to comment for this story.

Providers and insurers are still exerting influence over how the new law will be implemented, with concerns over who has responsibility to disclose what providers charge, and how to benchmark reasonable fees. Fighting among providers and insurers has derailed similar legislation in Maryland and Colorado, said Jack Hoadley, a research professor at Georgetown University’s Health Policy Institute. Policy experts hope New York won’t be next.

“New York has a chance to try something and make it work, and that really hasn’t happened before,” said Mr. Hoadley.

The challenge with out-of-network fee legislation, he added, “is to make sure that you’re not left with either the provider or the insurance company completely holding the bag.”

Pressure for a law in New York intensified in 2012 after the state Department of Financial Services issued a report that examined the issues underlying some 2,000 annual complaints about medical billing.

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Jeffrey R. Ungvary President

Jeffrey R. Ungvary

Tips You Should Know to Avoid Hefty Medical Bills

Jeffrey Craig Hopper is a probate attorney and Little League coach in Austin, Texas, so he knows all about following the rules. Still, accidents happen. Last June on the Little League field, an errant baseball smashed into his face.

His wife, Jennifer, remembers rushing to the field.

“His eye was swollen shut enough that we weren’t sure if he could see,” she says.

Even in that moment of panic, Jennifer Hopper realized that there are rules when it comes to using health insurance that can hugely influence the size of the medical bill. Care providers who are “in network,” she knew, cost much less, so she made absolutely sure to drive Jeffrey to the emergency room of a hospital in Austin that is part of their insurance network.

That sounds straightforward, but, as the couple soon learned, it doesn’t always work out that way — some patients still get slapped with big bills, even when they try to play by the rules.

In the end, Jeffrey was OK — the ball broke some facial bones around his eye, but they healed and his vision was fine. Jennifer, however, was surprised by what happened next. After she’d already settled with the hospital, paying the copayments for the ER, the ER doctor sent the couple a separate bill for more than $700.

“It felt kind of random,” she says. “How do I know who’s going to charge me, and who’s not going to?”

Like many patients, Hopper assumed that if she went to a hospital that the insurance company had designated as being within her network, the doctors who work there would also, of course, be in the network.

But that’s not necessarily true. Emergency room doctors, radiologists and anesthesiologists often don’t work for the hospital. They work for themselves, often in large practice groups, and it’s up to them to sign their own deals with insurance companies.

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Jeffrey R. Ungvary President

Jeffrey R. Ungvary

The Obama Adminstration Setting Standards for Health Plan Networks

The Obama administration and state insurance regulators are developing stricter standards to address the concerns of consumers who say that many health plans under the Affordable Care Act have unduly limited their choices of doctors and hospitals (mostly individual, not group plans), leaving them with unexpected medical bills. Carriers are looking to further stratify their networks in their 2015 plan offerings, so plans are available at numerous price-points to attract consumers with varying needs.

Federal officials said the new standards would be similar to those used by the government to determine whether Medicare Advantage plans had enough doctors and hospitals in their networks. These private plans, sold by companies like UnitedHealth and Humana, provide comprehensive care to 16 million of the 54 million Medicare beneficiaries.

States are free to adopt additional standards of their own, and Washington did so in late April.

“I heard from many consumers who were upset to find their health plan no longer included their trusted doctor or hospital,” said Mike Kreidler, the insurance commissioner of Washington State. “Some people discovered this only after they had enrolled.”

Mr. Kreidler said the new standards were needed to deal with “an emerging trend toward narrower networks of medical providers.”

If a network is viewed as inadequate, patients may need to seek care from doctors outside the network, incurring thousands of dollars in costs not covered by insurance.

New York adopted a law this year to protect consumers against such “surprise medical bills.” Before treatment, doctors must tell patients what insurance they accept. If an insurer does not have a doctor with the expertise to treat a patient’s problem, the patient can go to providers outside the network at no additional cost.

The National Association of Insurance Commissioners, representing state officials, is updating its 18-year-old model law to add new consumer protections, after finding that some insurers tried to cut costs by excluding children’s hospitals and academic medical centers. Cancer treatment centers say they, too, have been excluded from many health plan networks.

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Jeffrey R. Ungvary President

Jeffrey R. Ungvary