DOCTORS' LOUNGE
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SURPRISE! YOU OWE US $350,000 FOR LIVING
C
AUTHOR Mary Barry, MD
ongrats, you survived the car wreck.
The truck that T-boned you is in the
junkyard, but you have managed to
claw your way out of the ICU, to the
ward, to the rehab center, and finally,
back to your own kitchen table. You
feel clearheaded enough, armed with
your cherished childhood letter opener (a gag
gift to a Cardinal fan: it says “Cincinnati Reds”) to tackle at last the
mountain of mail.
The get-well cards make you laugh. The bills don’t, especially the
ones from Cigna when you have Anthem! What is that all about?
And, especially the one with long pages of charges that are headlined
out-of-network and add up to an old but nice condo in Gulf Shores.
This is where you start to scream. You can walk again, you can
feed and dress yourself with your good arm in a cast, and your brain
swelling is long gone. Your time is your own again, not packed with
therapy appointments and waiting rooms. Just when you thought
you could take an easy breath, that truck has crashed your life again.
This time it has accomplices: the out-of-network balance billers.
In an emergency setting, patients frequently have no control
over their care: the ambulance takes them to the place the EMS
determines is the best, the one not on diversion, the closest or the
fastest. Since you are nearly always admitted to the hospital where
you were seen in the emergency room, you then have no control
over your hospital bill. According to the Kaiser data, one in six
Americans have received an emergency surprise bill.
The Affordable Care Act (ACA) recognized this as a problem
and made provisions for it. According to www.healthsystemtracker.
org, “This law provides partial protection for patients receiving
out-of-network emergency care. The ACA requires all non-grand-
fathered health plans to cover out-of-network emergency services
and to apply the in-network level of cost-sharing to such services.
Health plans are also required to pay a reasonable amount for the
out-of-network services.”
However, the ACA does not prohibit balance billing by facilities
or providers of this care. In contrast, in-network hospitals and doc-
tors are not allowed to bill for the balances not covered by the insurer.
They are required to accept the amount negotiated in the contract.
Texas is one of the leading states for patients to suffer this huge
shock – 38% of patients in emergency rooms by some surveys, as
contrasted to 4% for people in Alabama. In June, Texas Gov. Greg
Abbott signed the bipartisan Senate Bill 1264, designed to eliminate
such surprise billing (but as passed, only for people with insurance
plans regulated by the state of Texas, not with federally regulated
insurance plans). Way to go Texas! In Kentucky, Sen. Ralph Alvarado
and ranking Democrat Sen. Dennis Parrett have introduced SB24,
including this issue in a wide range of other health care proposals;
a previous bill KY SB79 is still sitting in the Banking and Insurance
Committee.
The Texas bill was backed by the Texas Medical Association and
the Texas Hospital Association, passing the House 146-0 and the
Senate 29-2. It carries three major components: reporting of the
surprise medical bills will be limited on consumer credit reports;
hospitals, clinics and doctors accepting state regulated insurance
plans must eliminate all balance billing; and mandatory mediation
of the amounts billed must be accomplished by a state arbitrator
who takes the patient out of the equation. Arbitration takes place
between the insurance plan administrator and the provider, only.
(continued on page 28)
AUGUST 2019
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