The way the game is played, the providers of ambulance services now are ruled by Wall Street sharks,
who bill as much as they believe they can get away with.
Price-gouging by ambulance services is a disreputable business, preying on people who suffer emergency illnesses or injuries.
Insurers fight back by reimbursing patients a set amount, threw patients under the bus: ambulances use shady collection
companies to force patients to make up the difference between the insurers’ rate and the ambulance’s and use specialized ambulance charges
collection for this purpose, such as infamous
Revenue Guard
In accordance with the above, if the insurance contract provides major medical or similar comprehensive-type coverage, it must
include coverage for prehospital emergency medical services for the treatment of an emergency condition when such services are provided
by an ambulance service issued a certificate to operate pursuant to section three thousand five of the public health law. The insurer
must provide coverage for emergency ambulance services based upon the rates negotiated between the insurer and the provider of such
services. If no participating provider contract exists, the insurer must pay for the services at the usual and customary charge,
which shall not be excessive or unreasonable.
Once the insurer makes payment at the usual and customary charge, the provider must accept such payment as payment in full. The
provider may not bill the patient directly for emergency ambulance services for the balance of a bill, except for the collection
of copayments, coinsurance or deductibles that the insured is responsible for under the terms of the insurance contract.
Please note that N.Y. Ins. Law §§ 3216(h)(24), 3221(l)(15) and 4303(aa) (McKinney Supp. 2006) are applicable only to insurance
contracts that provide major medical or similar comprehensive-type coverage. Thus, if such a contract is not involved, these
provisions do not apply and there is no prohibition in the Insurance Law against the ambulance company billing the insured directly.
In addition, these provisions do not address a situation in which a New York authorized insurer or HMO has denied payment entirely
for emergency ambulance services (i.e. where the insurer or HMO states that coverage was not in effect or that treatment was not
medically necessary). In such cases, the ambulance company may bill the patient directly, subject to the remedies available to the
patient.
If the ambulance company or patient disputes a payment made by the insurer or HMO as not constituting the usual and customary
charge or disputes the fact that no payment was made, the ambulance company or patient may raise the issue with the insurer or HMO
and/or file a complaint with the Department's Consumer Services Bureau.
Lastly, the New York Attorney General's Office has conducted an investigation on balance billing by ambulance companies.
For further information, the inquirer was directed to contact the Attorney General's Office at (518)474-7330 or access their web
site which is located at http://www.oag.state.ny.us .
This opinion does not provide an analysis of the No-Fault Insurance Law, which would result in a different analysis and conclusion,
since the inquirer already had OGC Opinions on this subject. 1 Please note also that this opinion is limited to an interpretation
of the New York Insurance Law. No opinion is rendered on any other laws.
For further information you may contact Associate Attorney Pascale Jean-Baptiste at the New York City Office.
The technical term for this practice is Balance Billing and it is legal for most states. There
are only six states that currently provide limited protection from this practice (and maily for HMO providers customers, not PPO customers
like CIGNA).
How to handle surprise medical bills
It is better to try to avoid them abut with ambulance services this often is not possible and you are taken fot he ride, even if
this is not a life threatening emergency. One typical scenario is suspicion that you have a heart attack. Your wife or husband
calls 911, then 911 dispatches the ambulance and here we go.
In most case the trip to ER room in a family car is faster
and safer (you need both ECG and blood test to exclude the possibility of heart attack), but if you have a real hart attack movement
is detrimental even if you take aspirin and nitroglycerin (which for patients at risk should be reality available in all situations
and carries with them all the time), so unless you use an office chair to move to the car or use neibours help (you should, if this
is a possibility), you take some (minimal in most cases) additional risk. Patients at risk should have portable EKG at home, just
in case.
AliveCor Kardia Mobile ECG for Apple and Android devices is just $74 on Amazon,
Heal Force 180D is $157
If you do get a surprise bill, take action. Check with your state insurance regulator to see if your state has any consumer
protections against surprise bills. Many states have laws that require HMOs to protect consumers from surprise bills, especially
with respect to necessary ER services.
Fewer states have similar protections for other types of health plans, such as PPOs and EPOs.
At present, California, Colorado, Connecticut, Florida and New York do have such protections against unexpected balance bills
— either for out-of-network ER situations alone or for additional types of surprise bills. Generally, these laws provide that
the consumer is required to pay only the amount he or she would owe for the services if provided in-network. States have different
mechanisms for settling the balance, but they generally involve the insurer and the provider, not the patient.
If your state does not provide protection
If your state does not offer protection against surprise bills, check first to make sure the provider is really not in your
network. Back offices and billing companies deal with many plans and sometimes make mistakes. Providers who are in your network have
to accept the insurer’s contracted rate.
If the provider is out of network, do some research on an independent website, such as
fairhealthconsumer.org, to estimate what the procedure typically costs
in your locality. If your plan’s reimbursement is based on an amount that is less than the typical charge, you can use this
information to ask the plan to pay the provider on the basis of at least the typical rate. If the out-of-network provider’s charge
is higher than the typical rate, you might be able to negotiate with the provider to reduce your costs. You can try to persuade the
provider to reduce the charge, or to discount an excessive balance bill, by showing the provider that his or her charge is above
the typical market rate.
If neither the insurer nor the provider is willing to budge, do not be afraid to seek help. If you get your insurance through
your employer, your human resources department may be able to intervene. Call your state representative or your local consumer protection
office. With the right assistance, you might be able to reduce the bill, if not make it go away entirely.
Robin Gelburd, JD, is the president of FAIR Health, a national,
independent nonprofit with the mission of bringing transparency to healthcare costs and insurance reimbursement. FAIR Health oversees
the nation’s largest repository of private healthcare claims data, comprising over 21 billion billed medical and dental charges that
reflect the claims experience of over 150 million privately insured Americans. Follow on twitter
@FAIRHealth
Get organized. Create a spreadsheet to track all bills and all correspondence. Use registered mail only for communication.
Send letter to the collection company which sent you the bill with the request to put you bill on hold while insurance company
proceed your appeal.
Appeal of the insurance company initial decision. Your insurance provide should at least pay "in-network" fee for
the service. It will do nothing more, but it should not do less. Typically on $5K ambulance bill this is around $1.5K, sometimes
less. At this point you are left with $3.5K to foot.
If you are customer of PPO like CIGNA you are in substantial disadvantage even if you live in the state that provides some
customer protection. And you need to understand that. PPO sucks as for balance billing. See Tips.
Check the state laws contacting the state department of insurance. In some states they provide meditation or dispute
resolution process.
Try to talk with your HR department. They might know something about such cases, or have a similar case in the past. You
might also have a low charge legal help service from your company
Ask billing company to provide you itemized costs for the service.
What should be included:
In an emergency, the ambulance provider that services the location typically will respond immediately to a call. The
dispatcher will determine if only emergency medical technicians are needed, for basic life support, or if paramedics are needed,
for advanced life support.
The ambulance crew will assess the patient's medical condition and check vital signs such as pulse, blood pressure and
respiratory rate, and will determine if transport to a nearby hospital emergency room is needed.
If so, the crew will provide needed care during the ambulance ride.
Basic life support care, typically for non-life-threatening emergencies, includes minor treatment, continued
monitoring, and possibly administration of oxygen.
Advanced life support care, for life-threatening emergencies, also can include CPR, administration of
medication, breathing tube insertion and other needed treatments.
Additional costs:
Medical supplies -- for example, sterile gloves, needles, IV supplies, catheters, and saline -- used during the trip
can add hundreds or even thousands of dollars to the final bill. For example, providers in Los Angeles County[3]
can charge $24.75 for an oxygen mask, as well as for bandages, dressings ice packs; they can charge $45.25 for
a burn kit or obstetrical kit; and can charge $80.25 for an infusion pump or pulse oximeter.
If a critical care nurse or respiratory therapist is required during an ambulance ride, it can add hundreds of dollars
to the cost.
Discounts:
Some providers will negotiate a discount of up to 20% or more for uninsured patients who pay cash or pay within a certain
timeframe. For example, Lincoln County Ambulance Service[4]
in Kansas offers a 20% discount for payment within 30 days and a 10% discount to uninsured patients.
Woodburn Ambulance Service in Oregon offers a 10% discount for payment made within 30 days of service.
If you can get it, use Medicare Part B reimbursement as the baseline. See
Cost of an Ambulance - Consumer Information —can give you
estimates of how much health care services should cost in your area. Your insurer’s website may also provide a tool that will
allow you to compare costs.
Consider using
Medicare rates as a guide; the federal health system for people 65 and older typically has the lowest reimbursement rate for
hospitals and medical providers. They will never agree to charge you Medicare fee, but this figure is a good starting point
for any negotiation.
The American College of Emergency Physicians Foundation[5]
offers a guide to when to call an ambulance in an emergency. In a 9-1-1 emergency, the ambulance provider that services that
location will respond; in some locations, there is more than one provider and it might be possible to request a certain provider.
For a scheduled transport, a hospital or physician should be able to provide a referral for an ambulance service.
Or, the American Ambulance Association[6]
offers a provider directory by state and city.
Get in touch with professionals.
Talk to lawyer specializing in civil cases to see if you can use small claims court for this case. Attorneys often
charge 30% of the savings they achieve. Initial consultation is usually free.
You can try to use companies that promise to cut the bill for a fraction of costs (typically one third of savings).
The advocacy firm Copatient.com, charges 30% of what it saves
you
If this is only a part of your trouble try to contact the fraud division of your insurance company that investigates overcharging
and improper billing. Try talking to them, too. But usually insurance company just pays a part of ambulance bill and let
you hang dry. Only if you get additional charges like unnecessary cardiac stent ( see
Overuse of Cardiac Stents
) they can jump into action.
Here is an advice from Anne Marie Bryn Mawr, Pa.
July 12,
2011
As a practicing physician who is fed up with the way insurance carriers have managed to take over the delivery of health care
in this country, my comments, I warn you, will be brutally frank.
The way the game is played, the providers of health care bill as much as they believe they can get away with.
That's because they are in business to make money - that's why it's called "for profit" health care. The insurance carriers
try their damn best to find excuses to not pay as many of these charges as they can. Same reason. These two conspirators become co-conspirators
when they play the game of "crap runs down hill".
That's when they come up with things like "co-pays", "deductibles", "co-insurance", and a whole host of creative ways of attempting
to coerce the patient to pick up the tab.
So here's my advice. Don't pay any "balance billing" no matter what they choose to call it. Activate the pump that sends the
crap back uphill. Write letters to the provider asking for specifics as to the balance billing.
Don't accept their response. Write again. Write to the insurance carrier and appeal.
Then write the provider with the appeal number from the insurance company. Keep it going round and round.
If contacted by a collection agency, write back explaining your appeals and that your financial condition won't allow you to pay
without getting a disposition from your claim, and a better explanation from the provider as to why the procedure wasn't covered.
Tell them to not contact you again.
Tell them that you refuse to pay until you get a decent explanation. Dare them to sue you. CC a law firm on all correspondence.
Make the providers get hurt enough to fight against the carrier.
Bust up their friendship. Neither will hire a lawyer to get you. The publicity is the only thing they are afraid of.
Non-profits hospitals are actually wolfs in sheep skin. Hospital administrators are basically
real estate developers, and that is where the profits go. They have become monsters, quite
uninterested in serving the public good. The average CEO makes well more than an order (or two)
of magnitude more than the average physician and has much less time and money invested in
training. Most of the CEO's are grossly over compensated.
It is time to rein in aggressive tactics used by nonprofit hospitals to collect unpaid bills,
including suits and garnishing of wages. The fees are not published. The rates for procedures are
unknown until you get the bill. The bill, when it finally arrives, has absolutely stupid figures
on it, such as $700 for 1 bag of intravenous saline. Which actually costs about $1. At such
prices any discout is meaningless and actually is a cruel joke on sick people.
It is asinine that hospitals don't provide pricing information before you have treatment
(obviously, emergencies would be an exception).
Nonprofits in 2016 received an estimated $9 billion in federal tax breaks
Another issue is why those people do not have health insurance. With Medicaid expansion and
liberalization there is no excuse for not having it. The one thing Obamacare did was give people
the opportunity to get insurance. There is a difference between "can't" pay and "I want to spend
my money on something else besides my medical insurance."
Maryland recently added new restrictions on
hospital debt collection , after a state report said hospitals wiped out less than half of
their charges to patients who were eligible for free care under state law in 2018.
Washington state's attorney general sued hospitals over patients' access to financial aid.
Under a 2019 consent decree, nonprofit hospitals refunded about $1.6 million to patients.
Hospitals nationally face ongoing scrutiny for their billing and pricing practices, with new
rules this year
requiring hospitals to publish prices they have previously
negotiated in secret with insurance companies. The Trump administration policy sought to
boost transparency for consumers, but
many hospitals haven't complied . According to Turquoise Health Co., a startup working with
the newly public pricing data, Ballad hospitals have generally complied with the new
transparency regulations.
Hospitals can sell unpaid bills to debt buyers in the secondary debt market, where RIP
Medical Debt typically buys portfolios for pennies on the dollar. Terms of the deal with Ballad
weren't disclosed.
... ... ...
Federal requirements for nonprofit hospitals to provide financial assistance and inform
patients about it are limited. Nonprofits have freedom to set eligibility as they choose, and
can also create their own process and forms, said Jenifer Bosco, an attorney at the National
Consumer Law Center. They are supposed to take steps to alert patients, including making their
policies widely available on their websites, Ms. Bosco said. State rules for nonprofit hospital
financial aid vary.
Please not that stent insertion is often unnecessary procedure performed not to save the life of the patient but to earn money.
The system is criminal indeed.
Non-profits hospitals those day are also governed by Wall-street sharks.
Please note that Abdominal CT scan with insurance like CIGNA would cost you $300-$600 out of the pocket depending on the
facility.
Notable quotes:
"... abdominal and pelvic scan at Avera St. Luke's cost $6,422, the highest out of a wide range of rates the Avera hospital charges for that service ..."
"... Some dominant local and regional nonprofits, including Mass General Brigham, based in Boston, and Avera, based in Sioux Falls, S.D., billed the uninsured at their general hospitals some of their highest prices while also setting some of the most restrictive financial-aid policies for free care nationwide, according to tax filings, Turquoise data and patients' medical bills. ..."
"... "It's really criminal, the mess that our current system is in," said Mary Daniel, chief executive of ClaimMedic, which helps patients negotiate payment with hospitals. "It is a deliberate attempt for these hospitals to gouge the uninsured." ..."
"... for expensive procedures like angioplasty and drug-coated stenting, the difference in the cash price within a single county can be over $100,000. ..."
"... The cash prices for patients who must pay for their own care can be equal to the sticker prices or sometimes represent a percentage lopped off that top rate. Sometimes, those cash rates are also applied to people who have some form of insurance but get a service that the insurance doesn't cover. ..."
"... The quarter of hospitals with the most generous free-care policies write off the entire bill for those with monthly incomes under about $2,600 a month, and even up to roughly $6,400 a month, for a one-person household, the Journal found. ..."
"... Those that rank in the quarter of hospitals with the most-restrictive policies draw the line at or below about 160% of the federal threshold for poverty, disqualifying for free care patients with monthly income of more than around $1,700 for a one-person household, according to a Journal analysis of nonprofit hospital tax filings. ..."
"... A patient paying cash at the hospital for the stenting procedure is charged $84,792. Local insurer Fallon Health spends $36,755 for the procedure under one of its health-maintenance organization plans. A Medicare insurance plan from Aetna, part of CVS Health Corp. , pays $16,648. ..."
"... Patients who don't qualify for financial aid at nonprofit hospitals also aren't protected by pricing limits under federal law. The Affordable Care Act requires nonprofit hospitals to cap prices for patients who qualify for financial aid. ..."
"... Hospitals apply financial aid and discount policies inconsistently, say consumer advocates and patients. Offers may be one-time-only, or discounts may emerge only when a skilled negotiator is pushing for them. ..."
"... In January 2018, Joannie Berthiaume spent two days at Broward Health Imperial Point hospital in Fort Lauderdale, Fla., and got emergency surgery to remove her appendix. She was uninsured and the hospital charged Ms. Berthiaume its highest prices. Her bill totaled about $42,000, including a $6,033 abdominal CT scan. For that same scan, an Aetna subsidiary gets a 24% break, according to the newly public data from Broward Health. That discount would have meant a fee of around $4,600 for the scan, based on the price charged in 2018. ..."
"... "If you charge me $42,000 and your costs are justified, how can you knock it in half in a matter of minutes," Ms. Berthiaume says. "You must be overcharging." ..."
"... High cash prices inflate bills that uninsured patients often struggle to pay. Hospitals collected 5% of the amount they billed uninsured patients before writing off bills after a year of seeking payment, according to Crowe LLP, an accounting, technology and consulting firm, based on an analysis of 600 client hospitals. That is compared with collecting 40% of bills sent to patients with insurance for amounts owed under deductibles, copays and other out-of-pocket costs, based on a separate analysis by Crowe of about 1,500 hospitals. ..."
"... Hospitals closely track their "payer mix," or the mix of patients with commercial insurance, Medicare, Medicaid and the uninsured, who might be unlikely to ever pay for their treatment. That could play a role in how hospitals set prices. ..."
"... Resolve also offered about $8,000, or slightly more than the company estimated Medicare would pay, for Mr. Macias's $24,800 emergency-room bill at Avera St. Luke's, Mr. Pan said. The hospital said no, and despite denying financial aid, offered to reduce the bill by 50%, Mr. Pan said. The amount excluded another $34,994 he owes Avera's heart hospital. ..."
"... Have you or someone you know faced a challenging hospital billing situation? Tell us about your experience in the form below. ..."
The 32-year-old's abdominal and pelvic scan at Avera St. Luke's cost $6,422, the highest out of a wide range of rates the Avera
hospital charges for that service based on the new data. The price billed to Mr. Macias was roughly three times the best deal negotiated
by an insurance company.
Another scan of his chest came to $4,194, approximately $280 to $2,800 more than any prices negotiated between St. Luke's and
an insurer. The prices for identical scans performed at Avera's heart hospital were also among the highest that the hospital charged. His total hospital bills came to $59,800.
... ... ...
Services including emergency-room visits, imaging scans and procedures such as an angioplasty and stenting often performed on
heart-attack patients have been identified by researchers and federal data as commonly needed in emergencies by those without insurance.
The Journal analysis looked at the 1,550 hospitals in the Turquoise data that released both insurance and cash-payment rates.
Among the Journal's findings:
Hospitals routinely bill uninsured patients at their highest rates. About 21%, or 319, of the hospitals did so for the majority
of the services included in the analysis. At 171 of those hospitals, the cash rate was higher than all of the rates billed to
insurers, or tied for the highest rate, for every service in the analysis. That was true at some hospitals owned by major systems
including Sanford Health and Yale New Haven Health System.
On average, across the 1,166 hospitals that included rates for Medicare Advantage plans in their disclosures, the fees for
uninsured patients were 3.6 times the average rates paid by the Medicare Advantage plans. Medicare rates are typically set by
the government to at least cover hospital costs and are considered a baseline for comparing prices. Rates for Medicare Advantage
plans, which are administered by private insurers, are generally close to these mandated prices.
Some dominant local and regional nonprofits, including Mass General Brigham, based in Boston, and Avera, based in Sioux
Falls, S.D., billed the uninsured at their general hospitals some of their highest prices while also setting some of the most
restrictive financial-aid policies for free care nationwide, according to tax filings, Turquoise data and patients' medical bills.
Cash prices, which haven't been available publicly to help patients choose where to seek medical care, often vary widely even
among hospitals in the same county. In the 270 counties where at least two hospitals have disclosed their cash prices, the average
spread between the lowest and highest rates for a complex emergency-room visit is $1,852.
In Shelby County, Tenn., home to Memphis, the spread for that type of ER visit is $2,054. It would cost an uninsured patient $884
at any of the three Baptist Memorial Health Care hospitals; $1,480 at Regional Medical Center; $2,653 at Saint Francis Hospital-Memphis;
and $2,938 at Saint Francis Hospital-Bartlett.
... ... ...
Hospitals that offer additional discounts for the uninsured don't always automatically make the cuts to patient bills, leaving
cash-pay patients with significantly higher charges, the Journal found. It can take long negotiations, often by hiring lawyers or
professional advocates, to bring about reduced charges.
... ... ...
Those discounts slash bills by an average of 85% off its top price, the company said in a recent statement to the Journal. But
patients must apply to receive the discount. The vast majority of cash prices for emergency services at Tenet hospitals reviewed
by the Journal instead reduced bills by 20% to 30%.
"It's really criminal, the mess that our current system is in," said Mary Daniel, chief executive of ClaimMedic, which
helps patients negotiate payment with hospitals. "It is a deliberate attempt for these hospitals to gouge the uninsured."
The differences between the prices for uninsured people and insurance companies can be wide.
At Ephraim McDowell Regional Medical Center in Danville, Ky., an uninsured person getting a stent after a heart attack could be
billed around $66,226 for the procedure. An Anthem Inc.
health-maintenance organization plan would pay just $17,895 at the hospital, and the insurer's Medicare plan even less -- $12,445.
Ephraim McDowell Health said the cash prices are the highest rates but that it offers discounts and bill forgiveness for those
who qualify for financial assistance. In a written statement, the hospital system said, "it is rare that an uninsured patient would
pay the total gross charge amount due to the variety of financial assistance programs available."
Eligibility under the program cuts off at three times the federal poverty level, according to the hospital system, which is an
annual income of $38,640 for a single person.
Prices typically haven't been publicly available before now. Yet for expensive procedures like angioplasty
and drug-coated stenting, the difference in the cash price within a single county can be over $100,000.
The reasons for high cash prices are complex and, even to many healthcare experts, baffling.
Hospitals typically have a sticker price, often called the "chargemaster" price, that can be the starting point for negotiations
with insurers. Discounts off that sticker price tend to be steeper for those that bring large volumes of patients. Insurance plans
offered under government programs like Medicare and Medicaid get even lower rates, tied to prices mandated by federal and state agencies.
The cash prices for patients who must pay for their own care can be equal to the sticker prices or sometimes represent a percentage
lopped off that top rate. Sometimes, those cash rates are also applied to people who have some form of insurance but get a service
that the insurance doesn't cover.
Will Fox, who advises hospitals on pricing as an actuary with Milliman Inc., says hospitals often keep cash prices above the rates
negotiated by big insurers.
"They don't want to give away too much of a discount because they really want the best discounts to go to these larger volume
negotiated insured rates," he said. "Somebody walking off the street, we'll give you a 20% discount, but we're going to give our
favorite customer, who sends us millions or even billions of dollars in business, we're going to give them a much bigger discount."
Yale New Haven Health offers cash prices that represent a discount off sticker rates, but it keeps them above all of the prices
negotiated by insurers, says Pat McCabe, the system's senior vice president of finance. "We didn't want there to be that tension,
for an insurer to look at that data and say, 'you're providing better rates to uninsured patients than you are to our insureds, how
do we justify that to our members and/or employer partners?' "
For individuals who struggle to pay, financial aid is hard to get at some hospitals with high cash prices, the Journal analysis
found. That is true even among the nearly 3,000 nonprofit hospitals that get tax breaks on the condition they give back to the community.
Hospitals typically set household income limits for financial aid, with free care for patients below a cutoff.
The quarter of hospitals with the most generous free-care policies write off the entire bill for those with monthly incomes
under about $2,600 a month, and even up to roughly $6,400 a month, for a one-person household, the Journal found.
Those that rank in the quarter of hospitals with the most-restrictive policies draw the line at or below about 160% of the
federal threshold for poverty, disqualifying for free care patients with monthly income of more than around $1,700 for a one-person
household, according to a Journal analysis of nonprofit hospital tax filings.
Brigham and Women's Hospital, affiliated with Harvard Medical School, falls in this most-restrictive group, with income cutoffs
for free care at $1,610 a month for a one-person household. For 12 of 17 emergency services at Brigham and Women's reviewed by the
Journal, its highest rates are for uninsured patients, and insurance companies pay significantly less.
Brigham and Women's Hospital, in Boston, Mass., is among the group of nonprofit hospitals with the most-restrictive income cutoffs
for free care.
A patient paying cash at the hospital for the stenting procedure is charged $84,792. Local insurer Fallon Health spends $36,755
for the procedure under one of its health-maintenance organization plans. A Medicare insurance plan from Aetna, part of
CVS Health Corp. , pays $16,648.
Mass General Brigham, the system that includes Brigham and Women's, said in a written statement it has policies to prevent
someone without insurance from paying full price.
Some hospitals, including Brigham and Women's, also partially discount patients' bills for some who earn too much for free care.
Others write off bills that are large relative to a patient's income. But policies vary widely. The most-restrictive quarter of hospitals
cut off discounts at 2.5 times the federal poverty level, the Journal found.
Patients who don't qualify for financial aid at nonprofit hospitals also aren't protected by pricing limits under federal
law. The Affordable Care Act requires nonprofit hospitals to cap prices for patients who qualify for financial aid.
Hospitals apply financial aid and discount policies inconsistently, say consumer advocates and patients. Offers may be one-time-only,
or discounts may emerge only when a skilled negotiator is pushing for them.
In January 2018, Joannie Berthiaume spent two days at Broward Health Imperial Point hospital in Fort Lauderdale, Fla., and
got emergency surgery to remove her appendix. She was uninsured and the hospital charged Ms. Berthiaume its highest prices. Her bill
totaled about $42,000, including a $6,033 abdominal CT scan. For that same scan, an Aetna subsidiary gets a 24% break, according
to the newly public data from Broward Health. That discount would have meant a fee of around $4,600 for the scan, based on the price
charged in 2018.
Ms. Berthiaume, who is Canadian but was living in Florida at the time of her illness while finishing graduate school, went in
person to Broward Health to ask about the bill. She was told it could be cut in half, to about $21,000 total -- if she paid in full
right then. Ms. Berthiaume, then working in a part-time bookkeeping job, says she couldn't do that. The hospital later continued
to seek the full amount, including in letters sent by a law firm and reviewed by the Journal.
"If you charge me $42,000 and your costs are justified, how can you knock it in half in a matter of minutes," Ms. Berthiaume
says. "You must be overcharging."
Ms. Berthiaume hired attorney Jacqueline Grady to negotiate on her behalf, and in October 2019 the hospital offered to accept
$20,000, in addition to $2,000 she had already paid, if she paid within 16 days. Ms. Berthiaume declined.
Broward Health declined to comment on the details of Ms. Berthiaume's case, although she signed a consent form allowing the hospital
system to do so. The hospital system said that U.S. citizens and people with a permanent U.S. residence who come to its hospitals
for unplanned care, and don't qualify for its financial assistance program, are offered a discounted rate.
In the pricing data files Broward Health has disclosed under the federal transparency requirement, the cash prices are shown as
Broward's highest rates. However, the hospital system pointed the Journal to a consumer tool on its website that displays lower prices
for self-pay patients. Broward Health said in a written statement that the tool "provides the most current pricing for consumers,"
and "discounted prices may not be reflected" in the data files. The system didn't respond to questions about the reasons for the
discrepancy.
High cash prices inflate bills that uninsured patients often struggle to pay. Hospitals collected 5% of the amount they billed
uninsured patients before writing off bills after a year of seeking payment, according to Crowe LLP, an accounting, technology and
consulting firm, based on an analysis of 600 client hospitals. That is compared with collecting 40% of bills sent to patients with
insurance for amounts owed under deductibles, copays and other out-of-pocket costs, based on a separate analysis by Crowe of about
1,500 hospitals.
Hospitals closely track their "payer mix," or the mix of patients with commercial insurance, Medicare, Medicaid and the uninsured,
who might be unlikely to ever pay for their treatment. That could play a role in how hospitals set prices.
For Mr. Macias, debt from Avera hospitals plus other bills related to his November hospitalization amount to about 75% of his
annual income, according to Resolve Advocates, one of a growing number of companies that patients hire to negotiate hospital medical
bills on their behalf.
Mr. Macias, a superintendent for a construction company, suffered a potentially life-threatening tear in the lining of his largest
artery. He said he has largely recovered.
Avera's hospital in Aberdeen charged him the highest price for some emergency room services, according to a review of medical
bills for Mr. Macias and the Journal's analysis of Avera's negotiated rates with insurers.
Avera in some cases has multiple contracts with a single insurer and said the prices it made public are the average price it charges
an insurer for each service.
The Avera Heart Hospital of South Dakota, in Sioux Falls, gave Mr. Macias a 20% discount. Even with the discount, some of the
heart hospital prices were in the top third of what the hospital charged patients with insurance for some services.
Mr. Macias, a superintendent for a construction company, earned too much for free care at Avera, where the income cutoff is among
the lowest nationally for nonprofit hospitals, ranking in the bottom quarter, according to the Journal analysis.
But he appears to qualify for other financial assistance, such as a partial discount based on income or because Mr. Macias's medical
debts are large when compared with his household finances, said Resolve's chief executive, Braden Pan.
Avera rejected the request, saying that Mr. Macias could have had workplace health benefits but didn't enroll, according to Resolve.
Mr. Macias said in an interview that he missed the sign-up after miscommunication with his former employer. Buying insurance in the
marketplace was too costly, he said.
Avera also rejected an appeal, after factoring in his assets alongside his income, according to Resolve. Mr. Macias said he needs
his years of savings for a house down payment.
Resolve also offered about $8,000, or slightly more than the company estimated Medicare would pay, for Mr. Macias's $24,800
emergency-room bill at Avera St. Luke's, Mr. Pan said. The hospital said no, and despite denying financial aid, offered to reduce
the bill by 50%, Mr. Pan said. The amount excluded another $34,994 he owes Avera's heart hospital.
Mr. Macias, citing his unhappiness about the fight, told the Journal he wouldn't give Avera permission under federal privacy laws
to speak about his interactions with it.
"Health care delivery comes with a cost -- and when individuals have the means to pay, it allows us resources to help those
most in need," Lindsey Meyers, a spokeswoman for Avera, said in a written statement. "We have thoroughly reviewed the case you
have mentioned and identified that all processes were followed as described, and we made every effort to work with the patient."
Mr. Macias said he has largely recovered with new blood-pressure medication and months of rehab exercises he devised on his own.
He now lives in Austin, Texas, with his fiancée and their children, ages 6 and 3. Avera's debt collectors call constantly, he said.
"They're still blowing me up."
This Is Why Hospitals Can Charge $6,000 Or $60,000 For The Exact Same Procedure
BY TYLER DURDEN
SATURDAY, FEB 13, 2021 - 17:00
Several months back,
we
pointed out
how new disclosure laws would be forcing hospitals to disclose the cost of services and rates negotiated by
insurers. Now, the numbers are starting to trickle in - and they're ugly.
Roughly 6,000 hospitals across the nation are starting to reveal the rates they negotiate with insurers for a number of
procedures. The figures show how widely prices vary for the same procedure depending on who is paying, as highlighted by a
new
Wall
Street Journal report
.
For example, the report found that a C-section can cost between $6,241 and $60.584 - all depending on which insurer covers
it. Niall Brennan, chief executive of the Health Care Cost Institute said:
"It is
shining a light on the insanity of U.S. healthcare pricing. It's at the center of the affordability crisis in American
healthcare."
The rates are a key driver of the massive healthcare costs in the U.S., some of the highest in the world. It was a Trump
administration rule that shed light on the differences in procedure pricing - some of the widest gaps in pricing of any
U.S. industry. Gerard Anderson, a healthcare economist at Johns Hopkins University, commented: "These price differentials
are unique to the healthcare and hospital industry."
The prices have a direct effect on consumers, as they push up premiums and
deductibles
. And, in a stunning revelation, "total U.S. expenditures on private health insurance have increased
50% in the past decade through 2019, according to federal figures," the
Journal
wrote.
The report found that a Northern California system of 24 hospitals had sometimes "extreme" pricing ranges for procedures.
One cardiac procedure varied between $89,752 to $515,697, depending on insurer. For those paying out of pocket, the
procedure cost $325,703. The system, called Sutter Health, did $13 billion in 2019 revenue is is known for drawing an
antitrust suit from the California state AG in 2018. The system paid $575 million to settle the claims.
Sutter Chief Financial Officer Brian Dean commented: "We enter into negotiations with every health-insurance company or
payer in good faith and with the end goal of providing access to quality, affordable care for patients."
"The variation in the data reflects robust competition in the markets for commercial insurance," he argued.
One former insurance executive told the
Journal
that they could expect the same
types of wide ranges for pricing across the country:
"The California system's pricing spread for the procedures reviewed by the Journal are likely at the upper end, but
similar patterns will be found at many hospitals around the country, said Alan Muney, a former
Cigna
Corp. executive.
"This is probably typical of what you're going to see across big delivery systems," he said.
Prices paid by private insurers in the nation's $1.2 trillion hospital sector are often far higher than the amounts paid
to hospitals by the Medicare program, which are set by the government. Plans offered by insurers under Medicare or
Medicaid often get rates tied to those mandated prices."
Insurers have a better chance of winning better rates if they can drive more
patients to a certain hospital, another former insurance executive said
. Hospitals, meanwhile, sometimes set their
prices with "little bearing on the actual cost or value of a service", the report says. Rather, hospitals set prices based
on their own targets for margins and according to what the market will pay.
Privately insured patients drive margins typically - and hospitals that boosted margins generally didn't cut costs, but
rather raised revenue by increasing rates billed to commercial insurers, one study found. Economists have found that
quality is generally no better at more expensive hospitals. Michael Chernew, the Leonard D. Schaeffer Professor of Health
Care Policy at Harvard Medical School, said: "We have not found evidence that price is a great signal for quality."
The new data will draw the eyes of insurers and hospitals, moreso than consumers. Elizabeth Mitchell, chief executive of
the Purchaser Business Group on Health, which represents major employers, said they will use the data to help choose which
hospitals to use and how to negotiate with insurers.
The Journal examined one cardiac code for cardiac-valve procedures involving catheterization performed on patients with
risk factors. It confirmed that the largest spreads on pricing were in procedures that cost the most:
Seven insurers pay the lowest negotiated rate, $89,752, for their Medicare plans. The lowest price for a
commercial-insurance plan, the type offered to employers, is $197,900. At the top end, the charge is $515,697 for
patients whose health plans don't have the hospital in-network.
For hip- and knee replacements, Medicaid and Medicare plans paid the lowest prices at the Modesto hospital, $3,264 and
$16,349, respectively. The lowest price paid by a commercial insurer totaled $51,895. The highest rate reached $81,617,
again for patients whose insurance didn't include the Modesto hospital in-network.
Recall,
we
first brought up
President Trump's plans to institute these transparency plans back in January.
The $1.2 trillion industry comprising some 6% of the country's economy is now subjected to more transparency than it has
seen in decades. The point of instituting the disclosures, according to the Trump administration, was the hope that good ol'
fashioned market dynamics will kick in, and help lower prices across the board.
Previously, hospital pricing was negotiated confidentially between hospitals and the employer groups and insurance
companies that pay for care.
Many criticized this system for obscuring market rates and helping drive up the cost of health insurance premiums paid by
employers and workers.
Rising hospital prices accounted for about one-fifth of the
nation's health spending growth over the last 50 years.
Now, we will see first hand if a free and open market can help solve some of the industry's problems.
At
least, until President Biden reverses the new rules.
Yves here. We've written regularly on Eileen Appelbaum and
Rosemary Batt's important investigations into how private equity has taken over more and more
of hospital staffing, including of emergency rooms. This in turn has allowed them to override
patient efforts to have only in-network doctors assigned to their case, as well as to engage in
other practices that greatly inflate patient charges (so-called surprise billing).
The legal fig leaf that allows private equity firms like Blackstone and KKR to play doctor
is that their deals are structured so that MD or group of MDs is the nominal owner of the
specialty practice, even though the business is stripped of its assets and the operating
contracts are widely believed to strip them of any say. The now-notorious incident of
Blackstone's TeamHealth firing whistleblower Dr. Ming Lim confirms who is really in charge.
By Eileen
Appelbaum, the Co-Director of the Center for Economic and Policy Research and visiting
professor, School of Management, University of Leicester, UK and Rosemary Batt, the Alice Hanson Cook
Professor of Women and Work, Cornell University ILR School. Produced by Economy for All , a project
of the Independent Media Institute
Doctor Ming Lin is the first emergency room doctor to be fired for going public with his
concerns about poor hospital emergency room safety practices and shortages of medical supplies
and protective gear for health workers. He won't be the last.
Like many hospitals in the US, PeaceHealth St. Joseph Medical Center in Bellingham
Washington, where Ming Lin worked for the past 17 years as an emergency room doctor, has
outsourced the management and staffing of its emergency rooms. So, Lin works on-site at the
hospital's emergency room, but he is employed by a physician staffing firm that runs the
emergency room. These staffing firms
are often behind the surprise medical bills for emergency room services that patients
receive after their insurance company has paid the hospital and doctors, but not the excessive
out-of-network charges billed by these outside staffing firms.
About a third of hospital emergency rooms are staffed by doctors on the payrolls of two
physician staffing companies -- TeamHealth and Envision Health -- owned by Wall Street
investment firms. Envision Healthcare employs 69,000 healthcare workers nationwide while
TeamHealth employs 20,000. Private equity firm Blackstone Group owns TeamHealth, Kravis
Kohlberg Roberts (KKR) owns Envision.
Care of the sick is not the mission of these companies; their mission is to make outsized
profits for the private equity firms and its investors. Overcharging patients and insurance
companies for providing urgent and desperately needed emergency medical care is bad enough. But
it is unconscionable to muzzle doctors who speak out to advocate for the health of their
patients and co-workers during the global pandemic that is rapidly spreading across the US.
Yet, that is what Blackstone-owned TeamHealth just did. Why would an experienced emergency
room doctor be fired in the middle of a pandemic? One clue may be that Blackstone's CEO,
Stephen A. Schwarzman, is part of President Trump's inner
circle . He may not want to risk that relationship by allowing TeamHealth's doctors to
inform the public about Washington's mishandling of the allocation of supplies and protective
gear. The President might conclude that TeamHealth doctors didn't appreciate him enough, and
where would that leave Schwartzman?
PeaceHealth St. Joseph Medical Center may have the distinction of being the first hospital
to have a doctor outsourced from a physician staffing firm unceremoniously fired for telling
the public the truth. But it won't be the last. Hospitals are now telling doctors treating
coronavirus patients
they will be fired if they speak to the press.
The American Academy of Emergency Medicine protested Dr. Lin's ouster and
questioned how TeamHealth is allowed to provide hospital services when the law requires
that physician practices must be owned by a licensed medical practitioner. TeamHealth skirts
the law by owning all the assets of the physician practices it acquires -- the real estate,
offices, equipment, supplies, inventory, and even accounts receivable.
On paper, the physician practices are owned by a doctor-led organization that TeamHealth has
set up to comply with the law. But what does it mean to own a physician practice if the
practice has no assets and no possibility to exist on its own?
The furor over patients hit by surprise medical bills revealed that TeamHealth controls the
billing for the doctors it supplies to hospital emergency rooms. The firing of Doctor Ming Lin
pulls back the curtain and reveals that TeamHealth controls the doctors as well.
So anyone who works for TeamHealth or Envision needs to stay home until the virus subsides
Or until PE is out of ER. Right now is the time to be going after them hard. If they come out
the other side of this with no changes to PE control of ER, it will be a missed opportunity
to bring them to heel.
Way back when, an American banker named Paul Erdman tried to start an American bank in
Switzerland, and wound up taken down, tried, and convicted under by a charge in Swiss law
called (IIRC, this whole comment is IIRC basically) untreu Gesellshaftshandlung . He
went on afterwards to write popular novels about what -- meanies -- Swiss bankers are. The
one I read is really pretty good.
Anyway, although it would be really heavy lifting creating an American law against untreu
Gesellshaftshandlung in the face of the modern American concept of business, a law like
that could have excellent effects. It could penalize people who destroy the businesses they
are pretending to manage. Think how wonderful that would be.
In what ethical system is profiteering on the sick and injured who are having a health
emergency morally correct? What kind of people are these Blackstone owners? The kind of
people who rob the dead and wounded on a battlefield, apparently. Ghouls. Morally depraved
scum.
That Peace Health, which is owned by the Catholic Church, has contracted with these
looters, is indicative of how low the Church has fallen in its mission in the world. They
kicked out the nuns from any oversight of the hospital and brought in these Blackstone
demons. Is it any wonder the moral authority of the Church is a thin thread when rather than
supporting their flock they prey upon them? When did the Church start subcontracting to
Satan?
ambrit's suggested reset brought to mind another frame, the role of the tribunes in early
Roman society. I've enthused about them before here, re their ability to block measures
deemed harmful to the people, and the oath sworn to protect them, whereby anyone laying a
hand on them would be hung by the rightfully enraged citizenry.
What we're seeing going on now between the administration and some of the governors is a
loose fit. They are speaking out against the administration's deadly neglect and acting
against it, while, hopefully, having a degree of immunity against reprisal. We'll see about a
hanging, electoral or otherwise.
"What kind of people are these Blackstone owners?"
Steve Schwartzman is on the list of billionaires who supposedly urged Trump to reopen as
soon as possible.
Given Blackstone's medical investments, that is quality talking-your-book.
For the modern era, I would say john Paul II. He largely had free reign to control the
bishop selection process (which for a long time was tied to local governance) and stamped out
any opportunity for good or not heinous bishops to serve as counter examples or exist as
threats to leadership.
Blackstone was a firm that was behind the stealing of houses from American homeowners in
the foreclosure fraud heyday since 2008's financial crisis, I believe. I think they were
owners of document-forging firms.
tonycat,
I didn't think Blackstone had anything to do with document forgery, that was primarily the
realm of LPS, ( lender processing services), who changed their name to Black Knight Services.
Owned by Fidelity National , yes, the title insurance company.
Blackstone bought tens of thousands of foreclosed homes, the ones with irretrievably
corrupted chains of title, formed a subsidiary to do so, and rented them all out.
If you could let me know who you have reason to believe Blackstone owned as far as document
processors , or forgers, pls respond to me thanks-
Before the information is taken down, search for and file save
the board of directors. Save as a file on your hard drive. Guarantee that these same people
will pop up like moles in future disasters and national looting. https://www.blackstone.com/the-firm/our-people
Never (let them) forget.
That Peace Health, which is owned by the Catholic Church, has contracted with these
looters, is indicative of how low the Church has fallen in its mission in the world. They
kicked out the nuns from any oversight of the hospital and brought in these Blackstone
demons."
How does the Catholic church contracting with them still allow their tax exempt status?
Care to comment?
PeaceHealth System Services
1115 SE 164th Avenue
Vancouver, WA 98683
360-729-1000
When did the Church start subcontracting to Satan?
I believe it was around 325 A.D., when they made a deal with the Emperor Constantine. It
may have been earlier, when the tax collector, Saul of Tarsus, said, "Can't get new converts?
Hold my beer."
Where I live our local hospital emergency room is staffed by doctors and nurses that
aren't hospital employees. They are employed by a private group. This has been the case for
at least a decade. There are signs telling people that they will get separate bills from the
doctors. My wife and I both are on traditional medicare and a supplemental policy.
Fortunately this group is part of my supplemental network. Also the hospital sold its
dialyses unit to a private company. They used to do their own laundry now it is done by a
private company. The same is true for the janitor services. The head of the hospital used to
be a doctor. Now the head is an MBA. This hospital is considered a nonprofit hospital. Since
all of these changes has been happening I have noticed that care has become just another
business transaction. Tho corporations own everything , even doctors who are now employees.
If you need to see a doctor immediately you now have to go to one of two walk in clinics.
Health care in my area has become just another money making business. This is a county in
upstate NY with a population of about 100,000 people. There are only 2 corporations providing
all of the care. Both operate with the same business plan. My doctor of 13 years decided to
move out of the area. Instead of the health care organization hiring a replacement his
patients were left out in the cold to find a new doctor. My wife has had 5 primary care
doctors in the last 2 years. Health care has become just another money making business with
no real competition.
There are lots of dimensions to the outsourcing going on in American hospitals. My
experience last summer is instructive. My husband (on Medicare) got sepsis from a carpet
tack, he's diabetic so it was very dangerous and I took him to the ER on instructions from
his podiatrist. The ER hemmed and hawed, tried to confirm with the podiatrist who just
happened to turn off his beeper so the ER called Bill'r regular doctor. His regular doctor
was playing the system like a violin: because he gets bonuses for any cost saving measures he
achieves. This was one – so instead of getting Bill on an emergency IV, his doctor sent
him home with some crappy antibiotics, which he threw up; we lost a good 24 hours which could
have been the diff between life and death. I was furious and I called all the people I knew
on the board of the new hospital to complain. We returned to the ER the next morning and I
was already a cat-5 tornado. They got Bill on an IV and they literally hid from me. After 10
days he was cured but his nitwit doctor (to cover his own ass) recommended some expensive
anerobic antibiotics for another 7 days – by mouth. The gave me a prescription to get
filled. No pharmacy in town had the stuff – it was special order only and took up to 3
days. Long-short when I finally got my hands on the pills, I called the hospital complaint
line and told them how inept they were to let a patient go from the hospital with an
un-fillable prescription – and she told me that that was not hospital policy, that
hospital policy was to send such a patient home with a 3 day supply for the interim. So I
only wish I had had the phone number of the person paying Bill's doctor his bonus for
endangering his recovery in such a callous and insouciant manner. I tried to get through to
Medicare to complain about him but I was blocked every time. It's a shame because that's
first class malpractice in my opinion – and the system that encourages it is
unconscionable. All those cost cuts by the system are death by a thousand cuts for patients
– and an equivalent amount of profits in the pockets of the corporation.
>. . . But what does it mean to own a physician practice if the practice has no assets
and no possibility to exist on its own?
Public sector pension funds are investors in Pirate Equity, in case anyone has forgotten,
so you could ask them or at the Trump's press conference today, ask him. He would know.
Pensioners don't have much, if any, say in how the people who run the pension funds do
what they do. The long look we have had at CalPERS gives some idea of the corruption and
malfeasance that's going on, protecting the "fees" and extractions of the "advisers" who in
turn get their spiffs from the "market."
Not sure what your point is. The structuring of the "deal" obviously seems to be to
maximize all looting possibilities and to shed any possible "legal" avenues of either control
or redress by any of the institutions of governance.
Luring the public sector pension funds into private equity was the historical turning
point. Private equity has now lashed itself to the ship of state, its main goal.
Instead of calling them private equity "firms" and "executives ", we should start
consistently labeling them in the same way The New York Times labels the dictators we don't
like with unflattering terms.
Since they have a long and questionable history in medicine, I nominate the term "private
equity leeches".
A doctor in Boise was fired for wearing her own M95 mask that she needs because of her own
health problems. Listen to the runaround she got! This doctor wasn't afraid to speak out
because she works for herself!
"The list included: if you wear it, everybody will want to wear PPE and we don't have
it,"
In her termination phone call, Buckalew asked to see the policy saying she couldn't wear
a mask.
"I need to have it in writing that you are asking me to leave because I want to protect
myself," Buckalew said.
Still, she said nobody has been able to show her that policy. She was informed though
that she was officially labeled as insubordinate, incompetent, and unethical for her
actions.
I wonder how the hospital would handle mass death? Financially of course seeing as ethics
don't matter.
The most telling sign that we are firmly in the post-truth era is the non-response
statement from Encompass Health:
"We are continuing to tap every resource available to provide personal protective equipment
that meets the needs of our patients and staff [ bla, bla, bla]".
Corporate PR considers not addressing the issue and spewing some unrelated sugar coated BS a
normal operating procedure these days. Before you think that corporations are bad people,
think about bad people inside the corporations. There are thousands of middle class employees
who are writing these kinds of statements on behalf of their paymasters. Humanity has a lot
of rot in it.
Keep every letter, every email, better yet, email them back and ask for clarification
about who authorized, authored, directed the policy. If you phone, record the call. Look up
the board of directors, save the webpage, their names.
This will be useful in the future for potential prosecutions at the judicial and activist
level.
Sorry Billy, it IS good advice, but others have suggested similar, like "when signing the
authorization for treatment, include a statement about in-network only ".
While logical, in every hospital, doctors office, clinic, etc, in my network, you sign all of
these authorizations on a "signature pad" attached to a computer. No addendums or changes can
be made by the patient, and the staff are not authorized to alter it either.
Anything you want as a hard copy, they tell you you can print from the "patient portal"
on the web THEIR version, of course, perhaps not the same as the one you signed.
In the case of any legal actions, their politically connected 18 lawyer team will select
their preferred judge, who will promptly throw out all of your careful documentation
MBAs and automation/IT run amok.
With 8b$ in the bank a 'non-profit" Atrium compensates the top well:
Atrium Health 's top 11 executives made a combined $27.6 million in 2019, the
Charlotte-based health system said on Friday. That's a nearly 15% jump from a combined $24.05
million in 2018. Atrium CEO Gene Woods was at the top of the list with $7.25 million in
compensation in 2019.
Here's a trick they used to get to that Executive pay which was stopped in 2018–
The Department of Justice announced a settlement with Atrium Health, formerly known as
Carolinas HealthCare System, that prohibits Atrium from using "anticompetitive steering
restrictions" in contracts between commercial health insurers and its providers in the
Charlotte, North Carolina metropolitan area. The settlement, revealed Thursday, also bans
Atrium from seeking contract terms or acting in such a way as to prohibit, prevent, or
penalize steering by insurers in the future.
SUprise billing is just a pluticrat swindle that will increase by millions when Biden gets
in; Bernie was right and every body knows
it. Consider every advanced country has medicare for all BUT not
here in plutocrat heaven; Bernie was totally right!!!
Other countries have systems different from Medicare for all, especially some of the
European ones. But they are heavily regulated which eliminates all of the efficiencies and
improvements you get with a free market .. I assume that is why we have such an inexpensive
and effective system compared to the heavily regulated ones.
From a Canadian perspective I don't understand why the vast majority of Americans don't
support political candidates which promote universal single payer healthcare.
Maybe healthcare isn't something most people think about until they have the misfortune of
accidents or illnesses.
If there is one positive outcome from the current pandemic, it might be that many more
Americans will be shown how badly broken their health care is, including the per capita death
rate compared to other countries.
However right wing parties are masters of deception, and they are likely working on some
dog whistle issues to change the focus away from health care after the pandemic settles
down.
Because most have been brainwashed since birth and couldn't imagine better governance
exists elsewhere.
From a Singaporean perspective, US is such a crappy place in terms of income versus
overall cost of living + public safety + government efficiency + convenience that it makes me
LOL whenever I hear Americans dissing us as "an authoritarian nanny state". Well, I say they
have the freedom to keep believing whatever that floats their rotten boats.
What is mind boggling is the dysfunction that can be wrought by lawyers.
It seems to me that the fulcrum under private equity's; arrogance,greed,uninhibited vile
existence leading to the takeover of the public medical infrastructure ; rests on peoples
ability to "BS" some excuse to a bunch of lawyers . and have it "cleaned" up into some legal
footing that can be defended. Not because of the merit of the idea . but because of some
standing granted to a "legal framework" of some kind.
The reality completely divorced from the effort to promote the scheme.
On all sides.
Not only the vile, morally repugnant private equity types.
But the people on the other side of the negotiation, who are enticed to make a quick buck ,by
selling out the ship the passengers without a lifeboat, are floating on.
And all of this dealing is made "right" ,by lawyers .
Is it because there is some contagion in law school? that divorces people from "right and
wrong" Or is it partly, sociopaths finding a setting where they fit right in?
Whether it is the prosecutors all over the country, "legally" screwing nominally guilty
people of all kinds of things, making money for their systems by taking it from the general
public
Or the ones who fight to allow every scumbag with a dollar to get non disclosure agreements ,
so they can "pay off" justice and continue to go about damaging society.
Or the ones who allow these medical ownership rule "work-arounds" by saying to private
equity," now , we all know that you are looking to plunder a population but hey . we can just
say "you're helping them on to their final journey" and "it all meets the requirements" . so
sign here how about a round of golf ,down at the club?
Great comment. That is the real cancer we are facing in this society. I note Joe Biden is
a lawyer, I believe he said he was at the top of his class at Syracuse, and Sanders is not a
lawyer. Americans seem to want lawyers as leaders because they know how to make everything
look fine and they can keep a straight face saying it.
"WASHINGTON (AP) _ Sen. Joe Biden claimed during a campaign appearance in New Hampshire
last spring that he finished in the top half of his law school class, although records
indicate he finished near the bottom."
Whatever else is going wrong, at the root we are experiencing a crisis of integrity. Such
a word, "integrity." It requires that we say it like it is. "The state of being whole and
undivided" the dictionary says. It is not, of course, a state that we, being human, can fully
achieve. But it is something that we, as humans, must aspire to achieve. Our huckster society
places no value on the simple virtue of telling the truth. It is a loser's creed, a false
refuge of Pollyannas, we are told by the grizzled veterans of economic warfare. In fact,
though, it is the lubricant that ensures the smooth functioning of all of society. We are
awash in falsehood, victims of Bill Black's "Gresham's Dynamic." We can get back on course by
punishing false representation, starting at the highest levels, where the greatest damage is
done by those entrusted with the greatest responsibility, who should be punished accordingly.
We should do this not out of a sense of retribution against the bad guys (a class which, in
fairness, may include many of us), but as a necessary means of survival.
Former SIGTARP Neil Barofsky was interviewed by Bill Moyers earlier this week. Barofsky
expressed his concern that we have developed a culture of casual lying at every level of our
society:
It is different. They lied then. They lied now. That hasn't changed. But the way those
lies are perceived, and how people have their alternate realities, I think that's very
different, and very scary as we go into this next crisis.
The human race is entering its extinction event, and there is no longer any such thing as
long-term thinking. Personal honor was the first casualty. Many people suddenly feel entitled
to "get theirs" at the expense of everyone else.
That is a symptom of civic decay, not a cause. Once moral relativism is acceptable in
"choices", then it becomes so in civics, then contracts then the entire society. You reap
what others have sowed and you casually accepted.
As far as I can tell the story is:
Once an organisation gets large enough (private or public) then it starts to attract
management accountants (often MBA degree holders). The management accountant believe they can
improve efficiency using the tools that (often) worked in improving efficiency in
manufacturing. Process flow-charts and statistical analysis leading to the use of Key
Performance Indicators (KPI). Sadly the management accountants are often lacking in knowledge
and they are often insecure so they don't dare to ask questions. Their understanding of
statistics is either bad or they simply decide to torture data to get their preferred (or
indeed any as they need an) answer.
The end result is often KPIs which are seldom Key and often not even Indicators of
Performance.
(Their own KPI is billable hours which can and often does affect the quality/usefulness of
their work)
In medicine then it might result in something like providing a doctor with a KPI of number
of patients seen during a day. Seems reasonable, right?
The problem with that KPI is that the patients differ, some visits are short and some take
longer. That might lead to a doctor deciding to call in patients who might as easily have
been helped over the phone. The doctor needs the quick and easy visits to meet the KPI, the
patient might end up with a two hour trip for something that might have been resolved over
the phone but the doctor might have no choice but doing this to meet the KPI.
Or alternatively, if the KPI is about resolving queries over the phone then patients who
needs to come to the office are instead refused to come in and instead treated/diagnosed (or
as it happens, not) over the phone.
The drive for efficiency can lead to more waste and worse outcomes, when it comes to
management accountants then my opinion is: A little knowledge (and that is all they have, a
little) can be a dangerous thing. Their lack of knowledge has caused and is continuing to
cause a lot of waste and a lot of problems for many people.
What struck me about the story is that the hospital(s) are every bit as guilty as the
PE's. Why would they sign these contracts? There must be some sort of kickbacks for them.
Ultimately, it's nothing but a way to squeeze more blood out of the turnips – and that
seems to be exactly the way they think of patients.
Technical question: are hospitals legally responsible for the quality of care and honesty
of billing in their own emergency rooms? Seems to me that question should be settled by a
big, expensive lawsuit by cheated patients.
My guess is that the hospital first tried outsourcing the canteen and the outsourcing of
the canteen might have worked well so they then decided to outsource something else. Why the
ER was chosen for the outsourcing might be related to wanting to be able to blame the
outsourcer for things that might cause bad publicity. Surprise-billing in the ER might cause
bad publicity. By outsourcing the ER the hospital might get more money from the ER and
deflect blame for the surprise-billing to the outsourcer.
And I would not be surprised if another reason for signing those deals might have generated
some personal benefits for the people who signed the agreement on behalf of the hospital.
Probably not a common occurrence but there is a risk that it could happen.
I have worked for an industrial catering firm and properly managed by the contracting
organization contracting out a peripheral function such as as food services can work well.
Contracting out your key business is madness.
I have been operating under the hypothesis that the escape from legal liability was key to
these subcontracting deals.
I am not an insider and have not direct knowledge of such a mechanism, but JTMcPhee may have
some insight, if he thinks about it for a few
There's probably no way a hospital, as a business entity, can avoid being sued In a
malpractice situation. The law on this is murky and fact-driven. Plaintiffs' attorneys sue
all deep pockets where there is a "colorable claim" and assets and insurance behind the
defendant. The hospital corps have deep pockets that fund the best lawyers and expert opinion
providers that money can buy. They can drown many victims in paper and procedure. So your
lawyer can sue the hospital, but will have an uphill battle piercing through to the
imposition of liability on the hospital.
Here's an article discussing the issue of entity liability in malpractice:
Often a case against the hospital turns on whether "vicarious liability" can be
established. As you note, the structure discussed is an effort to maximize the distance
between the hospital entity and the physician. And of course the PE real-party-in-interest
owners of the profitable part of the business are even further removed.
I've got to say, firing Dr. Lin was maybe unwise since it establishes a much closer link
between the PE entity as controlling the physician's practice and thus makes it easier to
establish agency, direct employee and vicarious liability by the PE entity. Though of course
those snakes are very careful to revise their own trench-warfare defenses against personal
liability in constructing their shells and disconnects.
Yves, I don't get it. Why would a hospital not hire these docs in the ER and give up that
revenue stream to a private company? If it's so profitable, why would a hospital just give
that money away? I can see why a small rural hospital or single site facility might not have
the consistent ER volume to justify multiple ER docs, but larger hospital groups can move er
docs around in a geography to cover greater needs.
As a doc the answer is management and cost control. If they have a lot of doctors they get
a hefty discount on malpractice premiums which can be in the hundreds of thousands or they
self insure with umbrella coverage. ER billing is a huge issue. It requires full time people
and a lot of phone calls and follow up and tons of paperwork. Don't forget the insurance
carriers see their job as looking for loopholes to not pay and the doctor groups see their
job as bypassing those loopholes. If it is a large group and someone goes on vacation or is
sick or can't make a shift coverage has to be maintained. A large pool of doctors makes that
possible. A lot of ER doctors chose the specialty because they did not want to be tied down
to an office and a business. They want to do the job and then have time off. For that they
are willing to take a substantial cut in pay. Overhead costs could easily be over 50%. Pay
for doctors has really not kept up with inflation over the last 30 years .unless they cheat
.and the more the payers cut them the more that happens. And consider the risk of seeing
children with fevers brought in to ERs by non English speaking people often without insurance
at 3 in the morning. One case of meningitis, and a certain small percentage will have it, and
you could be wiped out. The lawyers are all over it. Think about the two febrile kids who
died with ICE a few months ago as they were brought over the border by the parents. Combining
these sorts of high risk cases with our legal system is more than a single doc or small group
can handle. For example, I alway saw the problem with the asylum wave to be more the legal
risk of holding these folks than anything else. I think there were hefty settlements in those
cases and I am sure the doctors did not do much wrong .just bad luck .but their careers might
well have been significantly impacted. The only answer is a national health system with
significant tort reform in medicine. Doctors should be on government salary just like
firemen. There is no reason the payment structure should change between the most important
moments of care like 911 and the next part after you go through the swinging doors of the ER.
If health care is a government guaranteed right then it should be free of profiteering and
should be provided by the government and that goes for the pharma and hospital industry as
well. The recent primary suggests that Americans like the health care they have and the way
it is done. It is no accident the health insurance stocks bumped up to 30% the day after
Super Tuesday.
I commend your healthy lifestyle choices that have kept you from an ER visit over the past
10 years or so and from the out-of-network double billing that is now endemic.
Everywhere.
People have developed an exquisitely tuned sensitivity to some swindles, such as when the
oil companies collude to increase gasoline prices, with or without justification. They even
invented a phrase to describe the practice called "price gouging", and demand action from
their elected representatives. Everyone becomes a raging, full-throated socialist when being
squeezed by this particular variety of market leverage. Yet when faced by other, even more
egregious looting, such as described in this post, they fall in line like compliant sheep
being led to the slaughter. I don't get it. Maybe someone can explain this.
I am not going to claim to be able to explain it, but:
I *think* it's the horrible cross-pollination of the complexity issue vs the dire outcome
of the wrong choice.
You can, although most won't, find a way to save gas. It's pretty understandable, your
vehicle gets X MPG and you drive so many miles. You can adjust the second usually, and also
occasionally adjust the first. You have a chance (even if your in negative territory you can
buffer that period with a credit card) to somehow buy time while you make the
adjustments.
How the heck do you figure out if you really need to be cut open (your GP choice), who to
actually cut you open (references?) and where to have him/her do it (if the surgeon works
across hospitals).
Medicine is a massive example of market failure, for the reasons your example outlines. So
all that stuff about "choice" and "markets" is just self-serving BS.
The University Hospital Complex system is the most corrupt part of the economy, and as we
now see it is the weapon being employed. The curtain comes down.
Government essentially guarantees private corporate revenue, so those corporations can
focus on minimizing costs, which are labor. The non-profits sow up the trap with legal
exemptions, generating profit that is not taxed. The three-headed hydra is the least common
denominator of herd behavior, distilling labor.
That money supply chart is essentially an implosion ripe for explosion. You want to
harness that and direct parts of that energy toward some useful function.
Is there a place on the web where these relationships and transactions are published /
researched? State boards of medicine? State Attorney's General? Or is this another opaque
backwater where the details don't see the light of day?
Private equity is like someone standing between you and the milk at the grocery store
where you say "excuse me I need to get a gallon of milk" and he says "Ok, that will be six
dollars" and you say "but it says four dollars right there" he says "well I say six dollars
is the new price take it or leave it".
It's about time we told these a$$hole$ to get the hell out of the way.
A little anecdote from my Army basic training experience that might be a potential
scenario as all this goes "healthSouth:"
Troop barracks used to be these two-story buildings with "Open plan" layout -- ten double
bunks down each side, a latrine (bathroom facilities with a row of unenclosed toilets and
sinks and gang showers.) If you have seen "Full Metal Jacket," you remember the drill. In any
event, forty males on each floor sharing everything including microbes.
My experience was at Ft. Leonard Wood ("Fort Lost-In-The-Woods, in the state of Misery",)
in the fall and early winter of 1966. Meningitis started in the troop population, so the
Commanding General mandated that all the windows were alternately to be kept open 9 inches,
top and bottom, to air the place out. This with outside air temps being in the 20s.
So despite the window-open attempts to limit the spread of this infectious disease in a
pretty bad kind of social propinquity situation, one of the guys in in my barracks, a draftee
farm kid from Iowa, started having really bad headaches and a stiff neck. He was finally
allowed to go to "sick call" at the dispensary, the equivalent of the Emergency Room. He
went, they gave him Tylenol, and sent him back to duty. This was repeated for three days.
On the morning of the fourth day, his squad members found him in convulsions with a raging
fever and he was carted off by a GI ambulance. He died that night in the base hospital, from
meningitis. We troops were then made to remove his gear and bedding which was burned, and
also to "GI" ("deep clean") the whole barracks with some nasty disinfectant from a 55-gallon
drum in GI green.
A week or so later, the guy's father showed up with a shotgun. He'd collected his son's
body Earlier, but someone had told him about his son's failed efforts to get treatment. He
wanted to find the NCOs, officers and the sick bay doctor and staff that were responsible.
The MPs showed up in force and hauled him off to the stockade (jail).
I wonder if there have been episodes like this happening in our current looting-based
system? For sure, they are not likely to be reported very widely.
And the corporate scum have done a pretty good job of insulating themselves from
visibility, let alone responsibility and liability. Kind of unfair to shoot the ER doctor or
the mope in the billing department that was "just following orders."
Thanks. Yep, and the higher ups who allowed that probably got promoted. Whereas commanders
(and now doctors and nurses) who do the right thing to save lives get fired.
Expect COVID-19 case numbers to spike upwards soon along with deaths attributed to it.
Trump rejected re-opening Obamacare and therefore hospitals will rely on Federal CARES
dollars for reimbursement of Covid testing and care. So they will have every incentive to
test everything but a dog or cat that walks through their door to ensure they will get paid
because they will only be assured of being paid by the Feds if it is Covid.
About a third of hospital emergency rooms are staffed by doctors on the payrolls of two
physician staffing companies -- TeamHealth and Envision Health -- owned by Wall Street
investment firms. Envision Healthcare employs 69,000 healthcare workers nationwide while
TeamHealth employs 20,000. Private equity firm Blackstone Group owns TeamHealth, Kravis
Kohlberg Roberts (KKR) owns Envision .
About a third of hospital emergency rooms are staffed by doctors on the payrolls of two
physician staffing companies -- TeamHealth and Envision Health -- owned by Wall Street
investment firms. Envision Healthcare employs 69,000 healthcare workers nationwide while
TeamHealth employs 20,000. Private equity firm Blackstone Group owns TeamHealth, Kravis
Kohlberg Roberts (KKR) owns Envision .
Same Envision as envisionrx -- or is envisionrx owned by something else? https://envisionrx.com/
The whole story here is that for-profit medicine won't work. And in the U.S. of A., ALL
medicine is for-profit, including our beloved (which has always required supplemental
insurance, and now with "Advantage" plans is increasingly crapified) Medicare system.
As a Canadian, I had to stop reading this article when I got to the paragraph about Dr.
Ming Lin working for a staffing company. I. Can't. Even.
The entire US healthcare system is complete and utter insanity! I don't know how anyone can
even try to have a rational discussion about it.
Privatization and for profit craziness is creeping around the edges of Canada's system and
has f'd up our long term care system (certainly in Ontario where I live). It scares the
bejeezus out of me to think that anyone in Canada would want to go down the US road and I
hope I never live to see the day.
The head or our provincial, Conservative, gov is quite to the right (fun fact : he is the
brother of the crazy Toronto drug using mayor, Rob Ford, whose notoriety some of you may
remember from a few years back) his mother-in-law is apparently in long term care, where
Covid is hitting hard here in Canada and Ontario. I am hoping (faint though the hope might
be) that this personal experience wakes him up to the complete and utter wrong that is profit
in healthcare.
I have long been aware that the only way the American Healthcare system could be reformed
was if it totally collapsed, which is happening now.
Lots of unnecessary pain and death.
As many of you know I have in excess of $300K in medical debt accrued in roughly 18
months, the last trip to the Hospital ran $88K and change for a 32 hour stay.
If I had any easily ascertainable assets I'd have been sued multiple times already.
Fortunately every spare penny for the last 5 years has gone to my Daughter Rosetta's 529
plan, between that and a very nice scholarship she will graduate debt free.
And yes, that really is her name.
She's cool with it and we're planning to get matching Mohawks when I'm done with Chemo, I'll
likely go with the same cobalt blue I did when I knew Chemo was on the way.
A man's gotta do
All of that medical debt would be $0 if you lived in Singapore and opted in to pay ~USD300
per year in cash premiums for upgraded govt insurance, assuming you are in the 30-40 age
bracket Even if you didn't opted in and without employer insurance, you most likely won't
fork out more than USD 20K cash copay cash after all is said and done.
Also, you would probably pay only <1% of your total yearly income in income taxes and
not be blowing some USD 2-3K in rent every month.
So frankly I have NO idea how you Americans can tolerate living in that "exceptional"
sh!thole called the US.
In Pagan days human sacrifices were thrown into the fiery pits to appease the Mad Gods
& Big Nature. We may want to revisit that in the present terrible circumstances. High on
the list of nominees would be the Werewolves of Wall Street & all those Hedge Fund
Hooligans.
In Europe, doctors are facing difficult life and death decisions they are not prepared
for.
US doctors are fully prepared to make difficult decisions.
Do you have health insurance?
If not, get lost.
That's what I like to see.
Markets forces at work.
If you can't afford it, you get nothing.
Healthcare I had wondered why the Senate
(Schumer) had backed off on legislation controlling surprise billing. It turns out there is a
House bill also and I am sure they are going back and forth on this. Recently, two bills have
emerged in the House and one from the Senate. Medscape , "House Committees Advance
Bills to Address Surprise Billing."
Of course if Congress's butt was on the line, a solution would have been found quickly and
enacted in 2020. At the end, see which one I would back.
The House Ways and Means Committee bill passed by a voice vote bipartisan bill. It seeks to
establish more use of third-party negotiators ( arbitration) for settling certain disputes
about payment for out-of-network care. This bill has the support of the American Hospital
Association and the American College of Emergency Physicians. The American Medical Association
also praised the committee's reliance on mediation for disputes on bills.
The House Education and Labor Committee advanced a hybrid proposal seeking to use
established prices in local markets to resolve many disputes about out-of-network bills. Key to
this bill is the use of arbitration above a certain cost. Bills greater than $750 or in the
case of air ambulance services $25,000; clinicians and insurers could turn to arbitration for
an independent dispute resolution. House Education and Labor passed this bill in a 32-13 mixed
vote with some Republicans and Democrats opposing and in favor.
The latest Senate Health, Education, Labor and Pensions (HELP) Committee of legislative
proposals also addresses surprise medical billing. The HELP bill called for mandating that
insurers reimburse out-of-network costs on the basis of their own median rates for in-network
providers.
The Education and Labor Committee bill is estimated to save $24 billion, the Senate HELPS
bill is estimated to save $25 billion, and the Ways and Means' bill would save almost $18
billion all over 10 years. It is suggested the greater use of arbitration in the Ways and
Means' bill will result in less savings.
Read on about the private equity involved and providers.
Outside Opponents of Legislation
The
American Hospital Association : "Setting a rate in statute gives insurers few incentives to
develop robust networks with hospitals and physicians, and paying for emergency care at the
median in-network rate would surely underpay for these services and create an incentive for
insurers to avoid paying fair reimbursement for these services. This approach is an obvious
windfall for the insurance industry without any assurance that health plans will pass these
savings on to consumers through lower premiums."
Other physician organizations have joined the fight to make balance billing appropriate; the
American College of Emergency Physicians, Envision Healthcare, US Acute Care Solutions and US
Anesthesia Partners -- gave roughly $1.1 million in 2019 to members of Congress, according to a
Kaiser Health News analysis of Federal Election Commission records.
Doctor Patient Unity
: "We support a federal solution to surprise medical bills that makes insurance companies pay
their fair share and supports patients' right to quality medical care."
"We oppose insurance-industry-backed proposals for government rate setting that will lead to
doctor shortages, hospital closures and loss of access to medical care, particularly in rural
and underserved communities."
Early on in 2019, Doctor Patient Unity spent more than $28 million on ads opposing
legislation without disclosing its staff or its funders. It was later revealed its
largest financial backers are two private equity backed firms Team Health and Envision
Healthcare. Together they own physician practices and staff emergency rooms around the country
according to spokesperson Greg Blair. Blackstone Group owns Team Health and KKR owns Envision
Healthcare
As is typical of political ads being run to influence people, they do not tell the whole
story and omit references to surprise bills. Instead, they warn of "government rate setting"
harming patient care and doctor/patient relationships.
The Direct Providers
ER doctors, anesthesiologists, radiologists and other specialists who typically charge
out-of-network prices are among the highest-compensated practitioners. I have found this to be
true during my hospital visits. Doctors, 3rd party contracting companies, and hospitals
complain Healthcare Insurance Companies have the upper hand due to size and can pay the
increased costs of out-of-network pricing.
The argument by doctors, the 3rd party contracting companies, and hospitals has been made
the healthcare insurance companies control the market and are able to secure better pricing
from providers which is not passed along to the insured. In markets where both
providers and insurers are highly concentrated, insurers have bargaining power to reduce
prices for hospital admissions and visits to certain physician specialists. The Market
Concentration chart for insurers and providers reveals the concentration (concentration chart)
for providers is greater than it is for insurers overall. Furthermore and if we are talking
about ACA policies, additional moneys gained must be used for treatment or the excess beyond 15
and 20% overhead and profit is refundable. It can be said also, when the total cost goes up,
the portion (15 or 20%) of the total price increases in real dollars.
ER doctors, anesthesiologists, radiologists and other specialists who typically charge
out-of-network prices are among the highest-compensated practitioners. I have found this to be
true during my hospital visits. If the insurance company can not convince them to take a lesser
rate, you are stuck will the bill. I have been tempted to ask at the time of need whether they
are all in network and employees of the facility I am visiting that day. Countering the
argument by insurance, doctors, and hospitals complain healthcare insurance companies have the
upper hand due to size and market control and can pay the increased costs of out-of-network
pricing. As shown chart 1, their claims are not precisely true and the market for healthcare
has become less competitive as hospitals and ACOs buy up the competition.
"Providers are more concentrated than insurers in almost 60 percent of US metro
areas . Health plans hold an edge in only 6 percent of local markets. National and state
level studies reveal a steady rise in concentration among specialist physicians, primary care
providers, and hospitals alike. As Brent D. Fulton notes, concentration of
insurers fell slightly from 2010 to 2016, while concentration rose for both specialist
physicians and hospitals. The evidence suggests provider organizations will retain significant
bargaining leverage even after out-of-network billing reform, leaving little scope or incentive
or capability for insurers to push prices down sharply. "
Meanwhile, the naysayers are battling constructive resolution with $millions in countering
ads and intense lobbying of Congress to delay and/or deny resolution of overpriced surprised
billing of patients of which had no choice, many more are still being hit with bills there is
little explanation for except greed. We do need Single Payer. Nough said . . .
Congress has till February 22nd to resolve the deadlock before the current temporary bill
expires. I would take the Education and Labor approach, which is also backed by the House
Energy and Commerce Committee, and the Senate Health Committee. It would set the payment rate
based on the median amount paid for that service in the geographic area with the option of
going to arbitration for some higher-cost bills. It result in greater savings.
steve , February 18, 2020 5:25 pm
We (anesthesiology) are par with everything that our network accepts. I am not a fan
of surprise billing, but I dont think you grasp all of the issues here. Medicare
reimburses at much lower rates than does private insurance in my specialty. If you work
in a place with a high percentage of Medicare (or Medicaid which is worse) like we do,
you cannot come close to earning market salaries. So we, many years ago, ended up working
95th percentile or worse hours (over 70 per week) while earning in the 15th-20th
percentile in income. We lost a lot of staff. The hospital had to make up the difference
so that we could hire and retain people. We were fortunate that our hospital had the
resources to do that.
Up north of us another hospital faced a similar situation, but they didn't have the
resources to subsidize their staff. So they fired a good team and brought in another.
Told them it was OK to not bill in accordance with what the hospital accepted, like the
prior group did. That let the new group earn enough, for a while, to hire and retain
people. Hospital eventually failed anyway and had to be bought out.
I think most of the groups that I know are surprise billing are pretty greedy and
sleazy, so I stay away from them. However, there are other cases where groups are in a
tough situation and pretty desperate. Especially smaller rural hospitals that have
trouble finding staff to begin with.
Thank you for this post. This is an important topic that needs to be discussed.
Again Dr. ZDogg: "Guess what's going to happen to her insurance premiums next year?
They're going to go up by 10%, 15%, 20 percent. And what will happen at employers around
the country who are paying most of the bill? They're going to drop or keep wages flat
(happening today). Healthcare becomes a financial albatross with collusion between
healthcare providers charging a bunch of money and insurance companies paying it, hospitals
overbuilding, overcharging, and doing stuff we don't even need. The results of these money
games are a minority of people getting rich and everybody else's wages staying stagnant. 1
in 5 Americans have collection agencies coming after them for medical bills that are
inflated and unnecessary.
BTW this is the same price inflation dynamic that we observe in body shops and car
insurance companies. Kind of evil symbiosis that develops. So this is a more general
phenomenon than just healthcare.
This is the same spiral of cost inflation that we observe in dealing with repair shops and car insurance companies. They form
symbiosis that prosper by mutual inflation of costs.
Notable quotes:
"... The Insurance company must apply 80% of healthcare insurance premiums to actual care. and 20% to Overhead and Profit. Dr. ZDogg states most of the tests were not needed such as a Pan-Viral test when a rapid-strep swab would do. Dr. ZDogg contends this was a virus and the most one should do is the swab the throat or just wait to see what develops . . . this sounds familiar to me as a patient too. ..."
"... The hypothetical? Lets say at the most, what was done should be about $1000 or $800 to actual care and $200 to Overhead and Profit. Multiple this by 26 and see what it amounts to. In Dr. ZDogg's words: "What if we make the pie bigger and 3% of a bigger pie is more money? What if we actually let people overcharge for procedures they don't need? Then all we have to do next year is raise the premiums to cover the actual medical cost, which is now higher, and then we make a higher amount of profit." That was the untoward side effect of the government policy on this, which, by the way, happens with many policies that are top-down. You can't predict what happens and then it happens. " ..."
Going to her PCP located in Manhattan, a woman complains of a sore throat. Forget the
Manhattan part of this as various versions (surprise billing) of this situation are happening
everywhere. The doctor swabbed the throat, sent it off to the lab, ordered some tests, and then
gave her a prescription for antibiotics. She took her meds and went on vacation feeling
better.
The tests came back negative. She later received a bill for ~$26,000.
The lab was out of network which usually results with insurance only paying a portion of the
bill and the patient the balance unless the insurance negotiates a lesser charge (hospital 3rd
party employees) which they will pay. This is another version of Surprise Billing, not in a
hospital setting, which we have heard so much about, and the patient gets screwed with the
balance of the Surprise Billing.
More Information
The lab was out of network but it was a part of the employer the PCP worked for also.
Usually doctors use the hospital they are affiliated with to run tests or do lab work which are
also in network (today). I suspect more hospitals will relegate lab work to 3rd parties to cut
costs and improve profits.
There was a time when I had catastrophic insurance which only paid 50% of costs. I had
pneumonia and really could not afford to go to my PCP at $150 (then) as I was out of work. My
PCP was not sympathetic and wrote me script to take to the hospital for imaging and another
test. I called the U 0f M hospital and talked to a clerk there about cost. He finally told me
to go to Quest (outside lab) and they would be half the cost in doing imaging, etc. U of M has
some major Overhead to pay for today.
By the way, Blue Cross Blue Shield paid almost all of the bill for this lady with the sore
throat.
Even More Information and a Hypothetical
The Insurance company must apply 80% of healthcare insurance premiums to actual care.
and 20% to Overhead and Profit. Dr. ZDogg states most of the tests were not needed such as a
Pan-Viral test when a rapid-strep swab would do. Dr. ZDogg contends this was a virus and the
most one should do is the swab the throat or just wait to see what develops . . . this sounds
familiar to me as a patient too.
The hypothetical? Lets say at the most, what was done should be about $1000 or $800 to
actual care and $200 to Overhead and Profit. Multiple this by 26 and see what it amounts to. In
Dr. ZDogg's words: "What if we make the pie bigger and 3% of a bigger pie is more money? What
if we actually let people overcharge for procedures they don't need? Then all we have to do
next year is raise the premiums to cover the actual medical cost, which is now higher, and then
we make a higher amount of profit." That was the untoward side effect of the government policy
on this, which, by the way, happens with many policies that are top-down. You can't predict
what happens and then it happens. "
I would like to think doctors, hospitals, and healthcare insurance companies are not prone
to this. Yet we have record of numerous surprise billing instances by hospitals, this one is an
example of one by a doctor. Medicare Advantage plans are over billing CMS for treatments
running totals up to $10 billion per year. And what about Commercial Healthcare Insurance? I
have not heard of insurance pushing back on over charges. Usually, they reject a bill or a
portion of it and the patient pays the balance.
And what Happens as a Result?
Again Dr. ZDogg: "Guess what's going to happen to her insurance premiums next year? They're
going to go up by 10%, 15%, 20 percent. And what will happen at employers around the country
who are paying most of the bill? They're going to drop or keep wages flat (happening today).
Healthcare becomes a financial albatross with collusion between healthcare providers charging a
bunch of money and insurance companies paying it, hospitals overbuilding, overcharging, and
doing stuff we don't even need. The results of these money games are a minority of people
getting rich and everybody else's wages staying stagnant. 1 in 5 Americans have collection
agencies coming after them for medical bills that are inflated and unnecessary.
Dr. ZDogg recommended exposure to sunlight might cure the problem.
The patient; "I made it very clear [to the doctor's office] that I was unhappy about it."
And told them I would report the doctor to New York state's Office of Professional Medical
Conduct. She also reached out to "Bill of the Month," a joint project of NPR and Kaiser Health
News. After a reporter started asking questions about the bill, Blue Cross and Blue Shield of
Minnesota stopped payment on the check it issued and is now investigating.
The bottom line to this is, it should have never got this far or even happen.
Recently it was disclosed Michigan No Fault Accident Coverage was paying an ~289% of
Medicare rates to hospitals and clinics to care for patient injuries suffered from automobile
accidents. No Fault coverage will die in a few years as the new legislation sponsored by
Quicken Loans Dan Gilbert and Michigan Repubs have allowed people to opt out or take lesser
coverage which will now pay hospitals and clinics 220% of Medicare rates. No Fault would not
disclose what it was paying caregivers. Another surprise which should have never happened . .
.
This story is from December 2019 and was in NPR
For Her Head Cold , Insurer Coughed Up $25,865, NPR, Richard Harris.
The solution is to have one network and a single payer. Simple.
run75441 , February 14, 2020 7:49 pm
Chris:
You remind of someone else who insists it is that simple. It is not unless you have
60% of Congress inline. And if you do make the change, look forward to much of the
Senate and the House being replaced as the population likes their Employer sponsored
commercial healthcare insurance in spite of being screwed over by commercial
healthcare, healthcare, and the pols who kiss the industries butt. What you and others
are insisting on as being so simple is not so simple to enact.
davebarnes , February 14, 2020 1:39 pm
I have Kaiser Medicare Advantage and am happy. Colon cancer fix cost me $2500 for surgery + chemo. Perianal abscess cost me $300. Three surgeries.
EMichael , February 14, 2020 2:49 pm
Chris,
The solution is indeed simple. Getting to the solution is a huge task.
Meanwhile, It would be very simple legislation to stop this criminal treatment by providers.
Person has insurance and is treated by someone out of network without giving specific orders to
go out of network, is only liable for the in network charges.
Hard to vote against that, but we all know how many will, and who they are.
The only surprise medical bills I have received is for claims that were denied by my
insurance company. Then the provider does not just demand what they would have received if the
claim had been approved, but the full billed amount, which is generally 2 to 10 times the
insurance amount. Providers should have to charge everyone the same price for the same thing.
Now they have an incentive to order dubious tests or procedures, because if a claim is denied,
they can bill for more money. I assume people without insurance are also billed for the full
amount, and they can least afford it.
I also think that if I call 911 and need emergency assistance, it should be provided by
the city or county, not a private company. That's true if police or fire engines are needed,
and likewise it should be for EMTs or ambulances.
"... If you are on Medicare, do not stay for observation unless you have a Plan G or Plan F. If you are on Plan N Supplemental to Medicare or lower, the plan will NOT pay 100% for Observation. You have to be admitted. You can go anywhere with Medicare for treatment. ..."
"... Medicare Advantage? You had better be in network or have some type of alternative program within your plan. ..."
The idea I have is not to be surprised. I am a careful patient who asks a lot of questions
and also advocate for myself. I have refused treatment when they use drugs which may threaten
my health further (Heparin). I am also not well liked by the bloodsuckers who come in to draw
blood and stab me through the vein for two weeks and destroyed my left arm in the process. Ask
them questions and do not be so willing to accept treatment (if cognizant) until they answer
your questions and then get their name. Take names and dates. It is ok to be a forceful
advocate for yourself. When all is said and done, the bill will come to you alone.
If you are on Medicare, do not stay for observation unless you have a Plan G or Plan F. If
you are on Plan N Supplemental to Medicare or lower, the plan will NOT pay 100% for
Observation. You have to be admitted. You can go anywhere with Medicare for treatment.
Medicare Advantage? You had better be in network or have some type of alternative program
within your plan.
There are good points to this article which is why I C and P-ed it here per their
request.
The cost of healthcare has become a hot topic in American politics in recent years, and with
good reason. A recent survey found that 22 percent
of Americans are losing sleep over healthcare or insurance costs, up from 13 percent just one
year ago.
One aspect in particular has even gained attention from both Congress and the President within
the past two months: surprise medical bills.
Congress has proposed bi-partisan legislation that sets up consumer protections against
surprise billing in certain situations. President Trump also issued an executive order in June
that calls for hospitals to be more transparent upfront about prices for common tests and
procedures, a measure that should go into effect later this year. ( While the House took out
the 10 year exclusivities for Biologic drugs, it ended up in the Budget bill giving exclusivity
for 12 years on new biologics. As I have pointed out repeatedly, risk adjusted R & D costs
are recouped in a median period of 3- 5 years. It is another
give-away to pharma. )
Past the leap, causes and prevention of Surprise Billing.
The cause of surprise
billing
Unexpected medical bills, often outrageously expensive, can catch patients by surprise if
they see a doctor who is not within their insurance network. It's a common issue, with the
Wall Street
Journal reporting that an estimated 51 percent of ambulance rides, 22 percent of ER visits
and 9 percent of elective cases lead to surprise medical costs.
What often happens is that while the hospital or clinic might be considered in-network, a
specific doctor might not be in-network (or vise versa). The legislation proposed by the Senate
includes cost protections for situations such as these, plus scenarios where patients receive
emergency care or follow-up care at an out-of-network facility due to travel restrictions.
While the new legislation and executive action may help patients and their families,
surprise billing will persist in situations outside the purview of these new protections. (
The proposed prevention of surprise billing did not make it through the Senate this time for
reasons I am not aware of today. More later .)
Preventing surprise healthcare
bills
The best way to combat surprise billing is to prevent it whenever possible. This requires
staying up-to-date on your insurance policies and looking at your options when scheduling
appointments.
Know the details of your insurance policy
The first step is understanding your specific insurance policy. Check with your provider for
a list of in-network hospitals, specialists and primary care physicians in your area so you can
know ahead of time where you'll have coverage. If you have an upcoming appointment, it's worth
calling your provider to double-check whether the facility and doctor you're seeing are
in-network and covered.
Your provider may also require prior authorization before an appointment in order to cover
some healthcare services or prescriptions, especially when visiting specialists.
Ask about costs upfront
Whether you're visiting a new primary care physician, seeing a specialist or have a planned
procedure coming up, call ahead to see what out-of-pocket costs you will be responsible for
paying. If you find that the facility or physician is out-of-network, you can request a
referral to a facility or physician that is in-network.
For planned visits, you can also ask about the billing codes for the tests or procedures
you'll be having so that you can confirm that your insurer will cover them. While many standard
preventative procedures like a basic cardiac stress test or mammogram are covered by insurance
policies, more advanced screenings such as a 3D mammogram may be billed under a different code
that is not covered by your insurance.
Make an emergency plan
While it's impossible to predict when emergencies will happen, you can make a plan to help
you prepare. If you know which emergency care providers are covered by your insurance plan, you
can have an idea of where to go. While it requires some research on the front-end, you can save
some stress and a lot of money in the long-run.
Understand your rights
In addition to new federal protections, many states have additional regulations regarding
"balance billing," when patients are billed for out-of-network providers at an in-network
facility. Don't be afraid to negotiate with hospital billing managers or doctors who billed you
when you are balance billed, and keep your insurance company in the loop on the situation.
Knowing your state's specific protections can help you get fees waived or lowered in these
cases.
Combating debt from surprise medical bills
Unfortunately, it's impossible to entirely prevent surprise medical bills -- especially in
the case of emergency services. In an emergency room, you have little to no control over which
physicians you see and what tests are run. You also don't always have time to call ahead to
check prices or request transfers to in-network facilities.
While it might not be possible to prevent some surprise healthcare costs, there are still
steps you can take to combat debt in these cases.
1. Double check itemized medical bills.
Mistakes happen. Sometimes patients are billed for tests, procedures or medications that
they didn't actually receive. Ask for an itemized bill, and ensure that you are only being
charged for services received. If you find a mistake in your bill, talk to the hospital's
billing department and the service provider.
In the case that a procedure or service on your bill should have been covered by your
insurance provider, ask about the specific billing code the hospital used. It's possible that
while the insurance provider covers a basic or general service, the billing code used may not
fall under the billing code your insurance company lists as covered. Talk with both the
hospital billing department and your insurance provider to see what can be done.
2. Avoid using credit cards whenever possible
Credit cards average around a 17 percent interest rate, meaning they are less-than-ideal for
covering high
medical costs . There are medical credit cards out there that offer short and long term
financing plans to cover medical expenses with minimal interest, which is an option for those
who can realistically pay off the debt within the specified time period.
When using a credit card is unavoidable, consider a credit card that offers a long intro
period to help you save on interest charges, such as well known Platinum
Visa Card might offer. If you end up with bills spread across multiple credit cards, a
balance transfer credit
card can also help you eliminate debt and save money on interest charges.
Just keep in mind that for all of these credit options, it's imperative that you can pay off
the debt within the 0% interest offer period. Otherwise, you'll be subject to high interest
rates that can cause even more financial stress.
For larger medical bills or debts, consider a personal loan (which offer lower, fixed
interest rates) to help cover the cost.
3. Protect your credit score
If for any reason you are unable to pay your medical bills on time, it's important to take
steps to protect your credit score. When you go more than 90-180 days without paying a medical
debt, it could become an unpaid collection account, which can show up on your credit report and
negatively affect your score. Luckily, newer credit score models such as the VantageScore 4.0
and FICO Score 9 often reduce the impact of these types of collection accounts.
If you know you'll be unable to pay medical bills, be open and honest with the hospital or
provider. You might be able to set up a plan that better fits your budget. At the very least,
you can explain the situation, pay as much as you can at the moment and potentially prevent
them from writing off your debt as a loss and selling it to a collection agency.
4. Open a savings account for unplanned medical costs
While you can't predict unplanned medical costs, you can prepare for them by saving money
for a rainy day. One option is contributing to a Healthcare Savings Account (HSA), which allows
you to add pre-tax/tax-deductible money into a savings account that you can use for approved
healthcare costs.
You can also set up a savings account with any bank to be used for healthcare costs. While
these accounts may not be tax-exempt, you can often get a better interest rate and avoid
regulations on what medical expenses you can and can't cover with the account.
Even if you only contribute $20 a month, it will add up over time and can help offset costs
to make medical expenses more affordable.
The Bottom Line
While it's promising that both Congress and the President are making strides towards
eliminating surprise medical bills and helping lower overall healthcare costs, sometimes
surprise billing is unavoidable. These tips can help you prevent these charges or combat
excessive debt that can often result from unplanned medical expenses.
davebarnes , January 11, 2020 9:28 pm
Kaiser Medicare Advantage.
Have NEVER has a strange nor bogus charge.
My colon cancer surgery + chemo was $2500 which I consider reasonable.
My 3 surgeries for a perianal abscess (trust me, you don't want one) was a few hundred
bucks.
4.5 miles to the hospital/medical center/pharmacy.
run75441 , January 11, 2020 11:42 pm
That is nice. Your time will come when they will charge more for those operations. You are
there forever and can not come back to Medicare. What do you think is happening with
commercial healthcare today for a majority of the people who have commercial healthcare?
likbez , January 12, 2020 12:09 am
Great post on a very important in the USA topic. Thank you run75441!
I would add the danger of calling ambulance from home in non-critical cases. Taxi to the
hospital is approx. 100 times cheaper and most cases is as effective :-).
In case the case is critical (like a real heart attack) be ready to pay out of network
changes ($5K-$15K) for the ride in states that do not provide protection against surprise
billing. Less then a half of the USA states some minimal (really minimal) protection against
those sharks.
Ambulances in the USA are overtaken by private equity and venture capital firms.criminals.
They are real Mafiosi. Or even worse because they profit of human sufferings. Private equity
sharks circle around and if they smell blood they will devour the victim without any merci. I
sometimes wonder why among around 40K of gun violence victims (39,773 in 2018) in the USA per
year this category is so underrepresented .
The core of the problem is that ambulances and private insurance companies do not agree on
a fair price, so the ambulance service doesn't join the insurance network. That leaves
patients stuck in the middle with out-of-network charges..
One patient got a $3,660 bill for a 4-mile ride. Another was charged $8,460 for a trip
from one hospital that could not handle his case to another that could.
Still another found herself marooned at an out-of-network hospital, where she'd been
taken by ambulance without her consent.
These patients all took ambulances in emergencies and got slammed with unexpected bills.
Public outrage has erupted over surprise medical bills -- generally out-of-network charges
that a patient did not expect or could not control -- prompting 21 states to pass laws
protecting consumers in some situations.
But these laws largely ignore ground ambulance rides, which can leave patients stuck
with hundreds or even thousands of dollars in bills, with few options for recourse, finds a
Kaiser Health News review of 350 consumer complaints in 32 states.
Patients usually choose to go to the doctor, but they are vulnerable when they call 911
-- or get into an ambulance. The dispatcher picks the ambulance crew, which, in turn, often
picks the hospital. Moreover, many ambulances are not summoned by patients. Instead, the
crew arrives at the scene having heard about an accident on a scanner, or because police or
a bystander called 911.
Betsy Imholz, special projects director at the Consumers Union, which has collected over
700 patient stories about surprise medical bills, said at least a quarter concern
ambulances.
As the days go by I become more convinced that the impeachment drama was used to cover up
the passing of the usmca and axing of the venture capital in health care bill and containing
surprise medical billing https://khn.org/news/investors-deep-pocket-push-to-defend-surprise-medical-bills/
FTA "We've started to realize it's not us versus the hospitals or the doctors, it's us versus
the hedge funds," said James Gelfand, senior vice president of health policy at ERIC, a group
that represents large employers.
From the KHN article on surprise billing
"surprise medical bills, which generally arise when an insured individual inadvertently
receives care from an out-of-network provider."
How did "inadvertently" get in there when it is a revenue generation model? Asymmetry of
information is always how profits are made.
I like to invert the model and estimate the outcomes for a lot of these fictions: if
working class people controlled the upward distribution of wealth, how would society be
different?
"... Where is AOC in all this? She was th e prime mover on impeachment, specifically impeachment over a phone call rather than concentration camps and genocide. And now with impeachment she gave Pelosi cover to sell the country out again. I was wondering why many libreral centrists were expreasing admiration for her, a socialist. Maybe they recognized something? ..."
Interesting, to me at least, that the rocket docket timetable of the House impeachment
coincided with the deadline to pass a budget to avoid a(nother) govt shutdown. While all msm
eyes were transfixed by the hyperventilating spectacle, behind the scenes the budget passed
through the Dem House was filled with more tax breaks for the corporations and the .001%,
more money than the admin asked for the MIC, and killed a bill that would end medical
'surprise billing' (another gift to medical PE investors and giant hospital corporations),
basically a whole neolib wish list.
Interesting the two events coincided, and, that Nancy decided not to sent on the articles
to the Senate at this time. What gives? Is she hold on to them for a future time when she'll
need to use them as another distraction for the msm to report on? (no, that could not be the
reason. ;) )
Pointed this out a couple of days ago (Slate and Buzzfeed). Happy that it is not just the
online press pointing out it was Democrats killing this measure, Democrats in leadership
positions. I also like that few, if any, of our media is falling for the kabuki used by Neal
to stick the shiv in. Everyone gets that the 'competing plan' was there strictly to derail a
law that end the hugely profitable but fraudulent price gauging of healthcare by private
equity.
If he keeps this up, walking POS Schumer might make me miss Al D'Amato nah Al and Chuck
are just two different colors of tulle, adding illusion to the political process.
..and they could have just passed it for the good PR and then de-fanged it
administratively, but it looks like they wanted to press the point:
"No, Proles, we're not gonna let you breathe, not a bit."
Where is AOC in all this? She was th e prime mover on impeachment, specifically
impeachment over a phone call rather than concentration camps and genocide. And now with
impeachment she gave Pelosi cover to sell the country out again. I was wondering why many
libreral centrists were expreasing admiration for her, a socialist. Maybe they recognized
something?
"... By 2013, physician staffing firms owned by Blackstone Group and Kohlberg, Kravis Roberts & Co. (KKR) – among the largest PE firms in the country – cornered 30 percent of this market. Since then, private equity ownership of these services has continued to grow. ..."
"... The Stanford study found that the likelihood that a patient admitted to an in-network hospital would face a surprise medical bill because at least one out-of-network doctor cared for them increased from 26.3 percent 2010 to 42.0 percent in 2016. A particularly egregious instance occurred when an assistant surgeon sent a bill for $117,000 to a patient who had surgery for herniated discs in his neck. ..."
"... Commenting on EmCare's relations with hospitals, Benedic Ippolito, a research fellow in public finance and health economics at the American Enterprise Institute, noted, "Right now, EmCare surprise bills patients and hospitals effectively turn a blind eye. ..."
"... A team of Yale University health economists examined the billing practices of EmCare, Envision's physician staffing arm. [xx] They found that when EmCare took over the management of emergency departments, it nearly doubled its charges for caring for patients compared to the charges billed by previous physician groups. These egregious practices have resulted in a Congressional investigation headed by Missouri Senator Claire McCaskill, lawsuits from shareholders, and court actions involving Envision and UnitedHealth Group, the largest U.S. insurer. [xxi] ..."
Surprise medical billing has become a critical issue facing Americans across the country because of purposeful corporate practices
designed to increase profits. As hospitals have outsourced emergency rooms and other specialty care to reduce costs, private investors
have bought up specialty physician practices, rolled them into powerful national corporations, and taken over hospital emergency
services. The result: large out-of-network surprise bills. The hidden actors: Leading private equity firms looking for 'outsized'
returns.
Surprise medical billing made headlines in 2019 as patients with health insurance found themselves liable for hundreds or even thousands
of dollars in unforeseen medical bills. When patients with urgent medical problems go to an emergency room (ER) or are treated by
specialty doctors at a hospital that is in their insurance network, they expect that the services they receive will be 'in-network'
and covered by their insurance. But often a doctor not in their insurance network is under contract with the hospital and
actually provides the care. When this happens, patients are stuck with unexpected and sometimes unreasonably high medical bills charged
by these 'out-of-network' doctors. This typically occurs when the hospital has outsourced the ER or other specialized services to
a professional staffing firm or a specialty doctors' practice. This problem has exploded in recent years because hospitals are increasingly
outsourcing these services to cut costs.
And more and more patients are faced with surprise medical bills -- adding substantially
to the already impossible medical debt that working people face. Hospital outsourcing of emergency, radiology, anesthesiology, and
other departments has provided an opening for physician practices to operate these services as independent organizations. Initially,
hospitals outsourced these services to small, local doctors' groups
But over the past decade, private equity firms have become major players -- buying out doctors' practices and rolling them up
into large corporate physician staffing firms that provide services to outsourced emergency rooms, anesthesiology and radiology departments,
and other specialty units. By 2013, physician staffing firms owned by Blackstone Group and Kohlberg, Kravis Roberts & Co. (KKR)
– among the largest PE firms in the country – cornered 30 percent of this market. Since then, private equity ownership of these services
has continued to grow.
Private equity firms also own two of the three largest emergency ambulance and air transport services – another major source of
surprise medical billing. Private equity ownership matters because the business model of private equity firms is to use a lot of
debt in a leveraged buyout of companies they acquire and then extract as much cash as possible out of them in order to pay down the
debt and reward their investors with 'outsized returns' that exceed stock market gains. They can be thought of as for-profit corporations
on steroids. Buying up specialty practices is financially attractive because there is a large and growing demand for outsourced doctors,
and out-of-network doctors can command a substantial premium for their services.
Emergency rooms and certain medical services provided in hospitals are not really part of a competitive 'marketplace' because
patients in emergency medical situations rarely have a choice: they need immediate medical care and cannot 'shop around' for an in-network
trauma doctor or radiologist.
Thus, surprise bills are difficult to avoid if patients face a medical emergency and must go to the ER or if they are hospitalized
and require access to specialty medical services. How Widespread is Surprise Billing and Why Has It Grown?
Surprise medical billing is exacerbating the already serious problem of medical debt in this country, which is a leading cause
of bankruptcy for American families.
[i]
And surprise billing is growing rapidly. Forty percent of Americans surveyed by the Kaufman Family Foundation in April, 2019,
reported receiving an unexpected medical bill; and 20 percent of those surveyed said it was due to out-of-network charges – or surprise
billing.
[ii]
A study by health researchers at Stanford University, for example, examined fees charged to patients with private insurance who
were treated by the emergency department of a hospital. They reviewed 13.6 million trips to the ER that occurred over the period
2010 to 2016. About a third (32.3 percent) of these trips in 2010 resulted in a surprise medical bill. But by 2016, that figure had
increased to 42.8 percent. That is, more than 4 in 10 trips to the ER ended with patients getting a surprise medical bill.
[iii]
For in-patient stays, surprise billing rose from 26 percent to 42 percent, and the average costs per patient also jumped from
$804 to $2,040. At this rate of increase, the estimated percent of hospital visits resulting in a surprise bill would be 48 percent
in 2019 – or almost one half.
The study also found that in 2016, 86% of ER visits and nearly 82% of hospital admissions incurred surprise ambulance service
bills. Similarly, another 2019 study found that patients who are admitted to a hospital from the ER are much more likely to receive
an out-of-network charge -- as many as 26% of admissions from the emergency room were found to include a surprise bill. The study
also found that 38 percent of Americans are 'very worried' and another 29 percent are 'somewhat worried' about being able to afford
surprise medical bills.
People particularly vulnerable to these charges are those with coverage from large employers that are self-insured. And vulnerability
also varied by region, with Texas, New York, Florida, New Jersey, and Kansas having higher rates of surprise billing; and Minnesota,
South Dakota, Nebraska, Maine, and Mississippi having lower rates.
[iv]
While large surprise medical bills are typically associated with doctors in the ER or in specialties such as radiology, anesthesiology,
or critical care units such as neo-natal, burn, or trauma centers, other out-of-network physicians may also issue surprise bills.
For example, those who assist a patient's doctor in a procedure or hospitalists who check on patients during hospital stays can also
charge separately for their services.
The Stanford study found that the likelihood that a patient admitted to an in-network hospital would face a surprise medical
bill because at least one out-of-network doctor cared for them increased from 26.3 percent 2010 to 42.0 percent in 2016. A particularly
egregious instance occurred when an assistant surgeon sent a bill for $117,000 to a patient who had surgery for herniated discs in
his neck.
The patient's own in-network surgeon sent a bill for $133,000, but accepted a fee of $6,200 negotiated with the insurance company.
The out-of-network assistant surgeon is seeking full payment of his charges. This is a particularly egregious example, but surprise
bills for a few thousand dollars are not uncommon.
[v]
The problem of surprise billing has grown substantially in recent years because hospitals have been under financial pressure to
reduce overall costs and have turned to outsourcing expensive and critical services to third-party providers as a cost-reduction
strategy. Outsourcing is not new, as hospitals began outsourcing non-medical ancillary services such as facilities management and
food services in the 1980s, in response to a round of structural changes in government financing.
By the 1990s, hospitals were experimenting with the use of independent 'hospitalists' to care for patients between rounds by the
local admitting doctors who had a hospital affiliation. Hospitalists' numbers increased over the next two decades as hospital staffing
firms grew and provided a range of temporary or short-term professionals to fill shortages in nursing, technical, or clinical positions.
[vi]
Recent outsourcing, however, has expanded to critical care areas – emergency rooms, radiology, anesthesiology, surgical care,
and specialized units for burn, trauma, or neo-natal care. Now hospitals contract with specialty physician practices or professional
physician staffing firms to provide these services – even if the patient receives treatment at a hospital or at an outpatient center
that is in the patients' insurance network. According to one study, surprise billing is concentrated in those hospitals that have
outsourced their emergency rooms.
[vii]
A recent report found that almost 65 percent of U.S. hospitals now have emergency rooms that are staffed by outside companies.
[viii]
Hospitals and healthcare systems have accelerated their outsourcing of critical care areas since 2010 in part due to declines
in Medicaid and Medicare reimbursements and to incentives under the Affordable Care Act to reduce costs and improve care quality.
[ix]
At the same time, on the supply side, hospitalist companies were merging and buying up practices of specialists employed mainly
in hospitals. Hospitalist companies evolved into physician staffing firms and expanded to include staffing for emergency rooms (ERs),
anesthesiology and radiology departments, and burn and neonatal intensive care units in hospitals across the country. The business
case for hospitals to outsource was straightforward. Emergency rooms are a major point of entry for patients who are admitted to
hospitals, and thus, a major conduit for the in-patient hospital stays that are critical for hospital revenue generation. But they
are costly and difficult to manage as they must be adequately staffed on a 24/7 basis regardless of patient flow, which is unpredictable.
Outsourcing the management, staffing, and billing of ER services shifts these management problems and the risk of underpayment for
these services to the staffing firm or a specialty doctors' practice. Hospital emergency rooms cannot turn patients away if they
lack adequate insurance coverage or any insurance at all; they must treat all patients. Emergency departments make money on ER visits
of patients with commercial insurance, but lose money on those with Medicare or Medicaid, and see very high losses when patients
have no insurance.
[x]
Private Equity's Business Model: Its Role in Outsourcing and Consolidating Specialty Services Private equity firms have played
a critical role in consolidating physicians' practices into large national staffing firms with substantial bargaining power vis-à-vis
hospitals and insurance companies. They have also bought up other emergency providers, such as ambulance and medical transport services.
They grow by buying up many small specialty practices and 'rolling them up' into umbrella organizations that serve healthcare systems
across the United States. Mergers of large physician staffing firms to create national powerhouses have also occurred. As these companies
grow in scale and scope and become the major providers of outsourced services, they have gained greater market power in their negotiations
with both hospitals and insurance companies: hospitals with whom they contract to provide services and insurance companies who are
responsible for paying the doctors' bills. Hospitals have consolidated in order to gain market share and negotiate higher insurance
payments for procedures.
Healthcare costs have been driven up further by the dynamics associated with payments for out-of-network services. As physicians'
practices merge or are bought out and rolled up by private equity firms, their ability to raise prices that patients or their insurance
companies pay for these doctors' services increases. The larger the share of the market these physician staffing firms control, the
greater their ability to charge high out-of-network fees. The likelihood of surprise medical bills goes up, and this is especially
true when Insurance companies find few doctors with these specialties in a given region with whom they can negotiate reasonable charges
for their services. The design of the private equity business model is geared to driving up the costs of patient care. Private equity
funds rely on the classic leveraged buyout model (LBO) in which they use substantial debt to buyout companies (in this case specialty
physician practices as well as ambulance services) because debt multiplies returns if the investment is successful. They target companies
that have a steady and high cash flow so they can manage the cash in order to service the debt and make high enough returns to pay
their investors 'outsized returns' that exceed the stock market.
[xi]
Emergency medical practices are a perfect buyout target because demand is inelastic, that is, it does not decline when prices
go up. Moreover, demand for these services is large – almost 50 percent of medical care comes from emergency room visits, according
to a 2017 national study by the University of Maryland School of Medicine, and demand has steadily increased.
[xii]
PE firms believe they face little or no downside market risk in these buyouts. Private-equity owned companies differ from publicly
traded for-profit chains not only in their greater use of debt, but also because the private equity firm, via the general partner
of the investment fund it sponsors, makes all investment decisions on behalf of the investor shareholders. Investors commit capital
to a PE-sponsored fund, typically for 10 years, and have no say in investment decisions. Thus, the PE general partner's power is
concentrated and largely unaccountable, as investors cannot 'exit' or sell their shares if they are dissatisfied – unlike shareholders
in publicly traded corporations.
[xiii]
In addition, PE firms charge their portfolio companies additional 'advisory fees' and 'transactions fees' that can amount to millions
of dollars over time. And because PE owned companies are not publicly traded on the stock exchange, they are not required to file
a detailed report to the Securities and Exchange Commission (SEC) the way that publicly traded companies must do. Their activities
and their financial transactions are largely hidden from the public eye, despite the fact that they receive substantial taxpayer
funding from Medicare and Medicaid for their services, though not for surprise charges. Two private-equity owned physician-staffing
firms dominate the market for outsourced doctors' practices -- Envision Healthcare, owned by KKR with 69,300 employees, and TeamHealth
owned by Blackstone Group with 20,000 employees. KKR also is a major owner (along with other private equity firms) of AirMedicalGroup
Holdings -- one of the nation's three largest ambulance and air transport companies.
We also showcase private equity owned Air Methods medical transport company. These examples help illuminate how and why private
equity firms have become national powerhouses in the provision of professional healthcare services and why their activities and those
of other private equity firms in this sector are leading to higher healthcare costs for patients and the industry as a whole.
Envision Healthcare
Envision Healthcare today is the result of fifteen years of private equity transactions in buying up and consolidating emergency
ambulance and specialty physicians' practices. It was formed in 2005 when private equity firm Onex took over two companies -- American
Medical Response (AMR) and EmCare -- and merged them. In and out of private equity ownership since 2005, Envision most recently was
acquired by KKR in October, 2018 in a public to private leveraged buyout worth $9.9 billion. Its sprawling organization employs tens
of thousands of healthcare professionals; and it supplies doctors in 774 physician practices to hospitals and ambulatory surgical
centers throughout the United States. It provides ER doctors, anesthesiologists, radiologists, hospitalists, and other specialists
covering intensive care, medical, neo-natal, pediatrics, psychiatric, skilled nursing, rehabilitation, and other inpatient units.
Its outpatient ambulatory surgical arm (AMSURG) provides trauma and acute care general surgery in 260 facilities in 35 states.
[xiv]
Between 2005 and 2018, Envision provided two types of emergency medical services: an ambulance and medical transport business
through American Medical Response (AMR) and emergency physician staffing through EmCare Holdings.
Today, Envision focuses on physician staffing services as it sold the ambulance and transport business in a $2.4 billion leveraged
buyout in 2018 to another private equity consortium that still includes KKR (as we detail below). The prior ownership patterns of
AMR and EmCare were similar. American Medical Response was listed as a publicly traded company as of August 1992; and in February,
1997, it was acquired by ambulance company MedTrans, a subsidiary of Laidlaw International. At an undisclosed date between 1997 and
2005, PE firm Peak Capital invested an undisclosed amount in the company. Like AMR, EmCare Holdings was acquired by Laidlaw International
in the summer of 1997 and subsequently received an undisclosed amount of investment from PE firm Peak Capital.
Emergency physician practices figured prominently among EmCare's 10 acquisitions and 17 sister physician staffing and management
firms.
[xv]
In December 2005, just months after acquiring and merging AMR and EmCare, Onex brought Envision Healthcare to the public market
via an IPO in which it retained a majority of the shares. Subsequent sales of shares left Onex with 31 percent of the company's equity
at the time it was again taken private, this time by Clayton Dubilier & Rice with participation of PE firm Ardian through a $3.2
billion LBO in May 2011. An IPO in 2013 returned Envision Healthcare to the public market. The PE owners retained about two-thirds
of the shares of the now-publicly traded company. The PE companies subsequently sold some of the stock. And in September 2017, two
hedge funds – Starboard Value and Comex Management – took minority stakes in Envision Healthcare.
Between July 2006 and October 2018, Envision Healthcare acquired 39 companies.
[xvi]
Envision Healthcare bought out AMSURG in December 2016 after AMSURG failed in an attempt to acquire TeamHealth (described below).
The deal brought together two seemingly complementary healthcare companies to form a single organization with pro forma market capitalization
of $10 billion and an enterprise value including debt of approximately $15 billion. A little over $8 billion of this was new debt.
However, KKR contributed $5.57 billion to the deal, using $4.43 billion to retire Envision's prior liabilities and the remainder
mainly as equity in the LBO.
Adding AMSURG's large chain of ambulatory surgical centers was supposed to make Envision Healthcare a dominant player across the
outsourced medical services landscape – emergency room doctors, hospitalists, outpatient surgery, and ground and air ambulance. But
integrating the two health care companies – with a combined 69,300 employees as of December 2017 – proved difficult for publicly
traded Envision Healthcare.
[xvii]
Envision Healthcare appears to be extremely profitable, but its financials are murky, with no publicly available accounting of
its transactions with each round of private equity buyouts. And under private equity ownership, when companies are taken private
or pass from one private equity fund to another, there is no transparency.
Each private equity buyout, however, is typically accompanied by levering substantial debt on the target company, which must be
serviced by managing for cash. Emergency medical services are attractive to private equity firms and are very lucrative because they
throw off a lot of cash, and as noted earlier, demand is inelastic and the fees are not subject to competitive market pricing. The
contracts negotiated between these physician staffing companies and hospitals also are not publicly available. Depending on how they
are crafted, they may provide incentives to outsource even more ER departments, and in turn increase out-of-network billing. One
Wall Street investor analysis, for example, highlights Envision's 'joint venture' model that raises serious questions.
A 2013 analysis by Deutsche Bank Securities described a 2012 joint venture between EmCare and the HCA Healthcare chain – with
a history of private equity ownership between 2006 and 2011 and substantial PE ownership of shares following its 2011 IPO. HCA apparently
agreed to give up directly charging for physicians' services and outsourced these services to EmCare in exchange for a 50-50 profit
split once EmCare achieved a 13% margin threshold, according to the Deutsche Bank calculation. This allowed EmCare to " penetrate
HCA's 160+ hospital portfolio more deeply with its physician offerings." As of 2014, EmCare valued its HCA joint venture at a net
revenue of $124 million, with assets of $155 million and liabilities of $31 million, according to the company's SEC filing. The filing
identified similar joint ventures with hospitals involving Evolution Health (also owned by Envision).
[xviii]
Commenting on EmCare's relations with hospitals, Benedic Ippolito, a research fellow in public finance and health economics
at the American Enterprise Institute, noted, "Right now, EmCare surprise bills patients and hospitals effectively turn a blind eye."
[xix]
Envision has come under heavy scrutiny for the huge out-of-network surprise medical bills it sends to ER patients.
A team of Yale University health economists examined the billing practices of EmCare, Envision's physician staffing arm.
[xx]
They found that when EmCare took over the management of emergency departments, it nearly doubled its charges for caring for patients
compared to the charges billed by previous physician groups. These egregious practices have resulted in a Congressional investigation
headed by Missouri Senator Claire McCaskill, lawsuits from shareholders, and court actions involving Envision and UnitedHealth Group,
the largest U.S. insurer.
[xxi]
TeamHealth
TeamHealth has also grown into a powerful national healthcare professional staffing company with 20,000 employees. It contracts
with hospitals to provide doctors and other healthcare professionals as ER staff, anesthesiologists, hospitalists, and hospital specialists
(OB/GYN, orthopedics, general surgery, pediatric services); and in post-acute care, ambulatory care, and behavioral health.
[xxii]
The company experienced successive rounds of private equity leveraged buyouts punctuated by IPOs that returned it to the public
markets – only to be taken private again through another LBO. In 1999, private equity firms Cornerstone Equity Investors and Madison
Dearborn Partners, with minority participation of Becken Petry O'Keefe and Company, acquired TeamHealth as a platform for a physician
staffing company. According to PitchBook (an industry research and data firm), TeamHealth acquired an anesthesiology practice, a
hospitalist company, and a health management business in its first two years. It made no further acquisitions until after it was
acquired by the Blackstone Group in 2005 in a leveraged secondary buyout (in which one PE fund sells a company to another PE fund).
TeamHealth made two more acquisitions between 2005 and 2009 – an emergency physician's group and a hospitalist company.
In 2009, Blackstone Group returned TeamHealth to the public market via an IPO, but retained possession of a majority of shares
in the newly public company. Passage of the Affordable Care Act in 2010, with its promise of cost containment via capitated and bundled
payments, spurred TeamHealth to go on a buying spree. Between 2010 and 2016, TeamHealth acquired 51 companies, mainly practices of
emergency doctors and anesthesiologists and a few hospital management companies. One very large exception to this pattern was TeamHealth's
2015 acquisition of IPC Healthcare.
[xxiii]
IPC Healthcare was a major hospitalist company. In its early years, it attracted four rounds of venture capital investments between
1998, when it was launched as IPC The Health Company, and 2002. In June 2002, IPC had an IPO and began its life as a publicly traded
company. Between 2002 and 2009, IPC acquired 20 physician practices. Between 2010 and 2015, following passage of the ACA, it acquired
78 more. The companies acquired by IPC were overwhelmingly hospitalist companies with a smattering of doctor's practices in specialties
such as geriatrics.
[xxiv]
TeamHealth's acquisition of IPC in 2015 raised questions. There was no evident fit between TeamHealth's specialty physician practices
and IPC's hospitalist companies. IPC was also in trouble with the Department of Justice, which in June 2014, had filed a civil lawsuit
against the company for "knowingly engaging in systematic overbilling" for services billed to Medicare and Medicaid and other government
health programs. Ultimately, TeamHealth paid $60 million plus interest to resolve these allegations.
[xxv]
This fueled speculation that TeamHealth, which had rebuffed AMSURG's attempt to acquire it, wanted this very large acquisition
in order to protect itself from being taken over. TeamHealth's explanation was that it wanted IPC's expertise in participating in
Medicare and Medicaid bundled payments programs.
[xxvi]
In February 2017, Blackstone Group once again took TeamHealth private in a $6.1 billion leveraged buyout. Similar to Envision
Healthcare, the financials of TeamHealth are murky. After many LBOs, its revenues, debt load, and financial stability remain unknown,
as do the contracts it negotiates with the phyisician groups it has acquired and the hospitals it contracts with for services.
And like Envision, its billing practices are being scrutinized. The Yale researchers who investigated EmCare and found excessive
use of surprise medical billing also examined TeamHealth's billing practices. They found that Blackstone owned TeamHealth has taken
a somewhat different tack. It uses the threat of sending high out-of-network surprise bills for ER doctors' services to an insurance
company's covered patients to gain high fees from the company as in-network doctors. In most cases, the researchers noted, TeamHealth
emergency physicians would go out-of-network for a few months, then rejoin the network after bargaining for in-network payment rates
that were 68 percent higher than in-network rates received by the previous ER doctors.
[xxvii]
While this avoids the situation of a patient getting a large, surprise medical bill for the services of ER doctors, it raises
healthcare costs and premiums for everyone.
Emergency Ambulance and Air Transport Services
Emergency ambulance and air transport is also a lucrative target for private equity investment, which has fueled consolidation
in this industry segment. Demand is inelastic – there is no competitive market pricing. And demand for air transport has grown considerably
because many rural hospitals have closed or consolidated, leading to far longer distances for access to emergency care. Two of the
three air transport companies that together control two-thirds of this US market are private equity owned – AirMedicalGroup Holdings
and Air Methods. The third, PHI Air Medical, is privately owned.
[xxviii]
Returning to the Envision story, recall that American Medical Response (AMR) was the ambulance service division that Envision
spun off in 2018. Before the divestiture, however, AMR grew to a national powerhouse in the decade from 2007 to2017 through 12 acquisitions
of ambulance and medical transport businesses and one air ambulance company7. In addition to these acquisitions, AMR has seven sister
companies – mainly ambulance companies, including several air ambulance businesses. It was acquired in 2017 by air ambulance company,
AirMedicalGroup Holdings (AMGH) -- owned by PE firms Ardian, Koch Equity Development, and KKR -- in a $2.4 billion leveraged buyout.
With this acquisition, AirMedicalGroup now holds a leading position in emergency and medical transport across a range of transport
modalities.
[xxix] The acquisition merged the largest provider of ground ambulance services in the U.S. with a leading operator
of medical helicopters, with over 320 locations in 38 states.
[xxx]
The combined entity creates the opportunity for KKR to substitute its more expensive medical helicopters for short trips previously
done by AMR's ambulances.
[xxxi]
Air Methods became private equity owned in 2017, when it was acquired by American Securities and Alpinvest Partners through a
$2.5 billion public-to-private LBO. The company's air medical transport services operate out of over 300 bases in 48 states.
[xxxii]
The buyout came in response to pressure from activist hedge fund investor, J. Daniel Plants, founder of Voce Capital Management.
Concerned about the bad publicity surrounding predatory charges by air ambulance companies, Plants wanted Air Methods to agree to
be taken private by a PE firm in order to keep information about its billing practices out of public view. According to the hedge
fund, Air Methods big price hikes created economic and political risks for the company. Going private would shield its financial
documents from patients and insurers. The hedge fund was right to be concerned about Air Methods predatory billing practices. The
average bill for being transported in one of its medical helicopters was $17,262 in 2009 and had risen to $40,766 in 2014. Air Methods
calculates that it accounts for nearly 30 percent of total air ambulance revenue in the U.S. Its profit increased sevenfold from
2004 to 2014.
[xxxiii]
In general, charges for out-of-network ambulance services are likely to be high. In the case of air ambulances, they are exceedingly
high – not only due to the high costs of air travel, but especially because an estimated 69 percent of charges are out-of-network
-- according to a 2017 US General Accountability Office (GAO) study of private insurance records for 2012-2017. That is, insured
patients in these cases ended up being billed for most of the charge. The GAO study also found that the median price for helicopter
service doubled between 2010 and 2014 – from roughly $15,000 to $30,000 per tri;p it also found that the average cost of an air ambulance
trip is over $36,000. .
[xxxiv]
Another study by researchers at Johns Hopkins University found charges were likely to be – as they put it – sky high. The study
found that air ambulance charges had risen substantially from 2012 to 2016, and in 2016 these charges ranged from 4 to 9 times higher
than what Medicare paid for this service. Some of the largest providers had among the highest charges. Between 2012 and 2016, the
median charge ratios (the charge divided by the Medicare rate) for the services increased by 46-61 percent.
[xxxv]
Legislative Solutions
Some hospitals have attempted to solve the problem of surprise billing on their own by simply requiring all attending physicians
in their hospitals to remain in-network – receiving payment from the insurance companies with whom the hospital has contracted. This
has been the traditional approach used by hospitals in managed care networks. According to John Cascell, Senior Vice President of
Managed Care at MemorialCare Health System in Fountain Valley, California, "Such stipulations were commonplace decades ago, but some
experts say the practice slipped out of favor around 2000 as major physician staffing companies -- which tend to make more money
when they're out of network -- gained market power."
[xxxvi]
MemorialCare, however, has retained this long-standing policy, which Cascell supports. The downside of this approach, however,
is that it may shift bargaining power to insurance companies who will seek to set lower in-network payments for specialty services.
In these cases, according to Cascell, MemorialCare takes a strong role in negotiating with insurance companies to maintain reasonable
payments.
[xxxvii]
More generally, the public, healthcare providers, insurers, and state and federal legislators recognize that individual solutions
are only stop-gap measures and that no individual hospital can solve the pervasive problem of surprise medical billing on its own.
Twenty-five states have passed legislation that aims to protect patients from surprise billing, but these laws do not fully cover
all types of situations. Over seventy-five percent of Americans believe that the federal government should step in and protect
them from surprise bills, according to a Kaufman Family Foundation April, 2019 national survey. The same survey found that 90 percent
of Democrats, three-quarters of Independents, and 60 percent of Republicans favored federal legislation to protect patients.
[xxxviii]
Americans differ, however, in who they think should bear the costs of care. According to the Kaufman survey, about half say insurance
companies alone should cover the costs of care (43 percent) while about half favor joint responsibility between providers and insurance
companies (47 percent).
[xxxix]
Two approaches to 'fixing' surprise medical bills have been put forward. One would benchmark the fees paid to out-of-network doctors
to the negotiated fees received by in-network doctors in that region for the procedure performed or the service provided. This would
have the effect of holding down health care costs by setting limits to what out-of-network physicians can charge. In the second approach,
out-of-network doctors would immediately be paid a given amount by the patient's insurance company – possibly 125 percent of the
Medicare payment or, alternatively, the median payment for that procedure or service in the geographic region – and could then take
the insurance company to arbitration in an effort to collect the balance of the patient's bill.
The second approach has the potential to raise health care costs if arbitration panels award out-of-network doctors all or a major
part of the fees they charge. This approach, which is favored by investor-owned physician staffing firms and by large physician practice
groups, would further raise health care costs for consumers. Even if many of these physician practices became in-network doctors,
as Envision now claims to be doing
[xl]
, the threat of going out-of-network remains. As the TeamHealth example illustrates, this allows physician staffing firms to
negotiate high in-network rates that drive up premium costs for consumers.
In sum, there is growing concern over the pricing practices of companies like Envision, TeamHealth, AirMedicalGroup, and Air Methods
-- leading emergency healthcare companies owned and operated by private equity firms. There is little oversight of the prices they
charge, and evidence suggests that these companies are among those responsible for driving up health costs by taking advantage of
the possibilities for surprise medical billing. But they are not alone, as private equity firms buy out medical services in specialties
other than trauma and radiology and as large physician practices take a page from the PE playbook when setting fees. Reining in these
charges is critical to efforts to slow the growth or even reduce health care costs.
[ii]
Ashley Kirzinger, Bryan Wu, and Mollyann Brodie. 2019. "KFF Health Tracking Poll – April 2019: Surprise Medical Bills and Public's
View of the Supreme Court and Continuing Protections for People with Pre-Existing Conditions." Figure 13. Kaufman Family Foundation.
April 24. https://www.kff.org/health-costs/poll-finding/kff-health-tracking-poll-april-2019/
(last accessed August 20, 2019)
[x]
Zack Cooper, Fiona Scott Morton and Nathan Shekita. 2018.
[xi]
For a detailed explanation of the PE business model, see Chapter 2, Eileen Appelbaum and Rosemary Batt. 2014. Private Equity
at Work: When Wall Street Manages Main Street , NY: Russell Sage Foundation Press.
[xii]
Jeff Lagasse. 2017. "Nearly Half of Medical Care Comes from Emergency Rooms, Study Shows."
[xiii]
Rosemary Batt and Eileen Appelbaum. 2019. "The Agency Costs of Private Equity: Why do Limited Partners Funds Still Invest?"
Academy of Management Perspectives. Forthcoming.
[xxvii]
Zack Cooper, Fiona Scott Morton, and Nathan Shekita. 2018.
[xxviii]
United States Government Accountability Office. 2019. "Air Ambulance: Available Data Show Privately-Insured Patients Are at Financial
Risk," GAO, March. https://www.gao.gov/assets/700 (last accessed
August 25, 2019)
[xxix]
PitchBook. 2019. American_Medical_Response_2019_8_10_13_21_18, American Medical Response Company Profile dated July 27, 2019.
[xxxiv]
United States Government Accountability Office. 2019.
[xxxv]
Ga Bai, Arjun Chanmugam, Valerie Y. Suslow, and Gerard F. Anderson. 2019. "Air Ambulances with Sky-High Charges," Health Affairs
, July: 38(7):1195-1200. https://www.ncbi.nlm.nih.gov/pubmed/31260345
(last accessed August 19, 2019)
[xl]
Envision's website states that it is committed to negotiating contracts for 'in-network status whenever possible.'
https://www.evhc.net/endsurprisecoverage (last accessed August
20, 2019)
Posted on
August 1, 2019 by Yves Smith I have to confess to having
missed how private equity is a central bad actor in the "surprise billing" scam that is being
targeted by Federal and state legislation. This abuse takes place when hospital patients, even
when using a hospital that is in their insurer's network, are hit with charges for "out of
network" services that are billed at inflated rack rates. Even patients who have done
everything they can to avoid being snared, like insisting their hospital use only in-network
doctors for a surgery and even getting their identities in advance to assure compliance, get
caught. The hospital is in charge of scheduling and can and will swap in out-of-network
practitioners at the last minute.
Private equity maven and co-director of the Center for Economic and Policy Research Eileen
Appelbaum explained in an editorial in The Hill in May how private equity firms have bought
specialist physicians' practices to exploit the opportunity to hit vulnerable patients with
egregious charges:
Physicians' groups, it turns out, can opt out of a contract with insurers even if the
hospital has such a contract. The doctors are then free to charge patients, who desperately
need care, however much they want.
This has made physicians' practices in specialties such as emergency care, neonatal
intensive care and anesthesiology attractive takeover targets for private equity firms .
Emergency rooms, neonatal intensive care units and anesthesiologists' practices do not
operate like an ordinary marketplace. Physicians' practices in these specialties do not need
to worry that they will lose patients because their prices are too high.
Patients can go to a hospital in their network, but if they have an emergency, have a baby
in the neonatal intensive care unit or have surgery scheduled with an in-network surgeon,
they are stuck with the out-of-network doctors the hospital has outsourced these services to
.
It's not only patients that are victimized by unscrupulous physicians' groups. These
doctors' groups are able to coerce health insurance companies into agreeing to pay them very
high fees in order to have them in their networks.
They do this by threatening to charge high out-of-network bills to the insurers' covered
patients if they don't go along with these demands. High payments to these unethical doctors
raise hospitals' costs and everyone's insurance premiums.
As an example, Appelbaum cites the work of Yale economists who examined what happened when
hospitals outsourced their emergency room staffing to the two biggest players, EmCare, which
has been traded among several private equity firms and is now owned by KKR and TeamHealth, held
by Blackstone:
.after EmCare took over the management of emergency services at hospitals with previously
low out-of-network rates, they raised out-of-network rates by over 81 percentage points. In
addition, the firm raised its charges by 96 percent relative to the charges billed by the
physician groups they succeeded.
The study also described how TeamHealth extorted insurers by threatening them with high
out-of-network charges for "must have" services:
in most instances, several months after going out-of-network, TeamHealth physicians
rejoined the network and received in-network payment rates that were 68 percent higher than
previous in-network rates.
A push on Capitol Hill to stop US patients from being caught unaware by medical bills is
weighing on the debt of KKR-backed Envision Healthcare, the target of one of the biggest
leveraged buyouts last year
Investors are concerned that a new so-called "surprise billing" law could crimp revenues
at companies such as Envision, which employs emergency-room doctors and anaesthetists through
its subsidiary EmCare .
"It is like a ransom negotiation: 'I'll hit your enrollees with giant bills unless you pay
me enough money not to do that'," said Loren Adler, associate director at USC-Brookings
Schaeffer Initiative for Health Policy.
The debt that has gone wobbly. Recall that so-called credit funds, also managed by private
equity firms, are big buyers of the leveraged loans that private equity firms use to finance
their acquisitions. And public pension funds like CalPERS invest in these credit funds:
Envision's $5.4bn loan due in 2025, sold in September when investor demand for leveraged
loans was very strong, slid from almost 97 cents on the dollar at the start of May to just
87.8 cents on the dollar on Thursday, as more detail surrounding possible legislation has
been released.
Leveraged loans for Blackstone's TeamHealth and private-equity-owned air ambulance companies
Air Methods and Air Medical have also taken hits.
The normally cool-headed, pro-business Financial Times readers were almost without exception
appalled: "..highway robbers .smacks of fraud sheer criminality .ambushing patients
.criminals." Welcome to health care, USA style.
Sadly, the article says that while both parties are eager to be seen to be Doing Something
about health care costs, neither wants to give the other side a win, making new Federal
legislation unlikely in the current session. But exposing private equity as the hidden hand
behind this extortion may lead to more inquisitiveness about the degree to which private equity
finding and exploiting economic choke-points has contributed to the suffering.
The Hospital that both my Primary Care Physician and my Cardiologist are affiliated with
has outsourced their Emergency Room.
If you show up needing care RIGHT NOW, your choice is to scrawl an assent on their little I
Pad or die.
I landed there twice this year, and the bills are just starting to show up from the first
trip.
Fuck'em.
If I live long enough to bother I'll fight them on the basis that I signed under duress and
if that doesn't fly there's Bankruptcy.
One of the peculiarities of our wildly inefficient medical care industry is that there are
so many 'pens' in the ink bottle that overhead costs eat up money that should be used to
improve services.
I describe our medical care system as a '100 silos' system. The jumble is enormously
expensive. We generously fund this industry, but we do not get anywhere near the benefit.
"Consent is for in-network services only and excludes out-of-network services"
Elisabeth Rosenthal in "An American Sickness" suggested that one add this statement to the
consent forms one is required to sign as a strategy to inoculate oneself against this
practice. I've not had an opportunity to try it and was wondering if anyone has done it and
if there was a reaction or objection from the provider.
For years, I have written words to the effect of "All charges not covered by insurance
will be paid at a rate to be negotiated" on health care providers' financial responsibility
forms, and initialed the addition. I've never had a doctor's office or hospital challenge it.
I think most don't even notice that I've done it.
I've also never had to invoke it, so I don't know how effective it is, but thinking I am
at least somewhat protected from surprise bills gives me some comfort in the face of our
crazy health care system.
By the way, I routinely cite "An American Sickness" when making the point to people that
it's not just the pharmaceutical companies and the insurance companies. It's pretty much
every part of the health care industry.
Which brings up what I was thinking about during last night's debate: Insurance companies
are only SOME of the profit seeking pigs chowing down at the healthcare trough. Even if we
eliminate them in a "medicare for all" plan the rest of of them will gladly eat their share.
It would take something more like a VA for all plan with hospitals run by the government to
deal with some of the others.
What a surprise the medical OFFAL will #### you to the max when you need help;
YAHOO, up ###, Medicare for ALL,RIGHT NOW!!! SCREAM it to your congress-critter!
If this does not change in 2020 I'm moving to a civilized nation like Canada even if I
have to walk there. Grrrrrr this is SO WRONG. How do retirees apply to move to Canada? Are
they letting us in anymore???
I'm just gonna avoid the medical system forever and die at home of natural causes or go to
New Jersey for assisted suicide if necessary. Thanks USA medical crapification you filthy
greedy (family blog)
My plumber showed me a type of client rights form that he is required to present during
various repairs. That form is essentially a mitigant against being extorted, given the
potential for such behaviors during exigent circumstances. Drip, drip, drip turns into
flooding, or no hot water turns into challenges with dishes and washing clothes. Now envision
your elderly relative in that situation.
An unscrupulous repairman could make some extra money by exploiting such circumstances,
turning a seemingly innocent service call into triple golden time toward that new
Mercedes. Disclosure: phrase inspiration from an old Frasier episode.
I once worked for such a dishonest plumbing service company, for a very short time. I was
fired after I refused to do unnecessary work at a customers house so as to jack up the bill.
That outfit, and another I briefly worked for later were both cases where investor syndicates
had 'bought' the companies, with predictable implementation of maladaptive behaviours.
"For the love of money is the root of all evil." 1 Timothy 6:10
Thank you. This is astonishing info. Because medicine is changing quicker than lumbering,
conniving private equity can kludge together new extortion rackets. It almost feels like PE
is running in place. And everybody is on to them thanks to info like this. Just FYI, our new
hospital that claims it is a non-profit health care corporation has just built a new wing for
"specialty clinics" housed on site. And of course it has been their billing practice from day
one to inform you that you might receive additional bills from any of these physicians. So
far this seems to be under control. We've had 4 same-day surgeries there and no big
surprises. But there is obviously a reason to establish this loophole. The takeover of
emergency rooms by KKR/EM Care and Blackstone Team Health is pure extortion. Extortion
lurking in the wings. I hope PE rots in hell sooner than later.
The intro to the post could have been an instant replay of my hospital experience. Reading
the many comments about medical billing shenanigans is somewhat "comforting" in that my
experience wasn't singular. However, it is important that more people recognize the hospital
billing scam and that some doctors have never memorized the Hippocratic Oath. If today's
modern medicine saves you, the medical billing will likely "kill" you.
Speak of the devil. Right now, I'm sitting in a clinic waiting room while my wife has
minor surgery for a basal cell carcinoma. She went to a medicare advantage plan awhile back
due to the high premiums of her medicare supplemental plan. She was assured everything was in
her network. We'll see, I guess.
"... By Rachel Bluth, Kaiser Health News reporter. Originally published at Kaiser Health News . ..."
"... On average, 16% of inpatient stays and 18% of emergency visits left a patient with at least one out-of-network charge. Most of those came from doctors offering treatment at the hospital, even when the patients chose an in-network hospital, according to researchers from the Kaiser Family Foundation. Its study was based on large employer insurance claims. (Kaiser Health News is an editorially independent program of the foundation.) ..."
"... The research also found that when a patient is admitted to the hospital from the emergency room, there's a higher likelihood of an out-of-network charge. As many as 26% of admissions from the emergency room resulted in a surprise medical bill. ..."
"... Each time ..."
"... "but most people don't: an ER encounter is an "outpatient visit" for billing purposes. For Medicare benes, that makes it a "Part-B" claim subject to different (i.e. higher) deductibles and co-pays." ..."
Posted on
June 22, 2019 by Lambert Strether Lambert here:
But it doesn't matter. People love their health insurance companies! (And do note the role,
entirely accidental I am sure, played by body shops outside staffing firms.)
About 1 in 6 Americans were surprised by a medical bill after treatment in a hospital in
2017 despite having insurance,
according to a study published Thursday.
On average, 16% of inpatient stays and 18% of emergency visits left a patient with at
least one out-of-network charge. Most of those came from doctors offering treatment at the
hospital, even when the patients chose an in-network hospital, according to researchers from
the Kaiser Family Foundation. Its study was based on large employer insurance claims. (Kaiser
Health News is an editorially independent program of the foundation.)
The research also found that when a patient is admitted to the hospital from the
emergency room, there's a higher likelihood of an out-of-network charge. As many as 26% of
admissions from the emergency room resulted in a surprise medical bill.
"Millions of emergency visits and hospital stays left people with large employer coverage at
risk of a surprise bill in 2017," the authors wrote.
The researchers got their data by analyzing large-employer claims from IBM's MarketScan
Research Databases, which include claims for almost 19 million individuals.
Surprise bills don't just come from the emergency room. Often, patients will pick an
in-network facility and see a provider who works there but isn't employed by the hospital.
These doctors, from outside staffing firms, can charge out-of-network prices.
"It's kind of a built-in problem," said Karen Pollitz, a senior fellow at the Kaiser Family
Foundation and an author of the study. She said most private health insurance plans are built
on networks, where patients get the highest value for choosing a doctor in the network. But
patients often don't know whether they are being treated by an out-of-network doctor while in a
hospital.
"By definition, there are these circumstances where they cannot choose their provider,
whether it's an emergency or it's [a doctor] who gets brought in and they don't even meet them
face-to-face."
The issue is ripe for a federal solution. Some states have surprise-bill protections in
place, but those laws don't apply to most large-employer plans because the federal government
regulates them.
"New York and California have very high rates of surprise bills even though they have some
of the strongest state statutes," Pollitz said. "These data show why federal legislation would
matter."
Consumers in Texas, New York, Florida, New Jersey and Kansas were the most likely to see a
surprise bill, while people in Minnesota, South Dakota, Nebraska, Maine and Mississippi saw
fewer, according to the study.
Legislative solutions are being discussed in the White House and Congress. The leaders of
the Senate Health, Education, Labor and Pensions Committee introduced a package Wednesday that
included a
provision to address it. The legislation from HELP sets a benchmark for what out-of-network
physicians will be paid, which would be an amount comparable to what the plan is paying other
doctors for that service.
That bill is set for a committee markup next week.
Other
remedies are also being offered by different groups of lawmakers.
At this point, I am pretty sure with few exceptions the people who love their insurance
are top management and or the companies that negotiate these profiteering contracts with
those same insurance companies. Only the bubble beltway hasn't gotten the message. Witness
all those people at the Fox Town Hall with Sanders that shocked the moderators when they
asked the gotcha question about their employer health insurance.
""It's kind of a built-in problem," said Karen Pollitz, a senior fellow at the Kaiser
Family Foundation and an author of the study. She said most private health insurance plans
are built on networks, where patients get the highest value for choosing a doctor in the
network. But patients often don't know whether they are being treated by an out-of-network
doctor while in a hospital."
again no menu, no price tags, no team shirts .
it ain't a "market".
(""rational actors with perfect information" lol)
we've got around 10k in debt for the first month or so of our long emergency with cancer
the period before medicaid kicked in.
some of it will get paid.
most of it will likely not(something about blood and turnips )
interestingly and apparently largely unknown is that one can get a "debt consolidation
loan" for credit card, mortgage, and other "consumer" debt .but not for medical debt.
you must, instead, deal with fifty bill collectors representing many medical outfits you may
have never heard of -- -imaging, labs, that guy in a white coat who walked by and looked in
the door --
one of the articles of faith with the neoliberal order, is that since transactions are
inherently Good, it makes sense to maximise them.
so instead of the floor doctor being employed by the hospital, itself she is employed by an
LLC with an anodyne, hard to remember, name.
The problem here is not the health insurer. It is corruption in the provision of medical
services by the in network hospital that permits out of network doctor staffing agencies and
doctors to perform expected medical services on its premises.
I live in the Capital district area of NY. I discovered recently that almost all the
hospitals here have entered into contracts with emergency care staffing corporations for the
provision of medical care. In addition, Urgent care facilities staffed by only Physician's
Assistants are proliferating here. This area is apparently regarded as a good target for
medical profiteers.
In a rational society, you know one where the recognizes the captive or powerless entity
and provides them the protection they are denied, the hospital/medical group etc would be
responsible to make sure all parities working there are in network. And by law all additional
out of network charges would be theirs.
Of course in a truly enlightened and rational society we would have single payer and the
government would use all its power making sure that society at all levels were healthy and
well cared for when they weren't. And massive profits would be on things that were truly
discretionary like private jets and yachts not on emergency care.
In 2015 I came down with sepsis after a prostate biopsy (which turned out positive for
cancer). Was admitted to John Muir hospital in Walnut Creek via the ER (I was a Muir system
patient at the time). Subsequently got a bill advising that the Emergency Dept at Muir was
"out of your Network" (an "independent contractor"). Eye roll.
'Nuther thing I already knew, but most people don't: an ER encounter is an "outpatient
visit" for billing purposes. For Medicare benes, that makes it a "Part-B" claim subject to
different (i.e. higher ) deductibles and co-pays.
Ah. Now that's news I can use. As I mentioned below, I spoke to a claims adjuster
yesterday concerning my bus accident. One of the questions she asked was about my eligibility
for Medicare. So, the question wasn't just informational in nature. Real money is
involved.
Thanks for the enlightenment.
My late daughter was a Kaiser-Permanente member. She was admitted to a KP hospital several
times during her recent Stage IV pancreatic cancer ordeal (she died 15 months ago). Each
time , she had to go through the ER for admission. Even Kaiser , who owns their
own hospitals, subs out their ERs to "independent contractors," which, of course, raised
Danielle's co-pays and "co-insurance." The only route to admission was an 8-12 hr
"triage" stint in the ER.
There's hardly any such thing as a through-the-front-door "elective admission" any
more.
That's the definition of fraud, right there.
When I was on a jury hearing a "pill mill" case from Biloxi Mississippi, we were told that
one definition of a "pill mill" was when the 'patient' was required to go through, and pay
for, a full doctors appointment for what was essentially a renewal of a pre-existing
prescription. The mandatory "triage" endurance each time a "regular" patient was admitted for
an already diagnosed condition fits this definition. Perhaps a resort to the RICO provision
would be salutary.
Sorry about your daughter. I hope she 'passed' peacefully.
Thanks. Danielle
died peacefully (6 weeks into home hospice care), but her illness was anything but.
Talk about "surprise bills," the night at the ER she decided to go into hospice care
rather than do another futile admit, they insisted she come home via ambulance (subbed out to
the city fire & rescue dept) -- all 1.9 miles to our house. After she died, I kept
getting bills for her, one of which was about $2,500 for the ambulance ride (
"Seriously?" ). Needless to say, that did not get paid. Wish in one hand, [bleep] in
the other, see which one fills up faster. She died way beyond broke, there was no "estate" to
be probated or attached. Not that a host of claimants didn't repeatedly try. They all came to
know Bad Bobby, who, while not a lawyer, was way ready for all of them (It wasn't my
first rodeo, and I didn't want anyone BS'ing my grandson into assuming any bogus
liabilities).
Good to know, many of my friends are getting Medicare Part B insurance solicitations from
Kaiser. Will inform them to look elsewhere. My condolences to you Sir.
Everyone needs to use things like Yelp and other rating services to make such things known
to the curious public.
"but most people don't: an ER encounter is an "outpatient visit" for billing purposes.
For Medicare benes, that makes it a "Part-B" claim subject to different (i.e. higher)
deductibles and co-pays."
I don't get it. You want ER services to fall under Part B ("out patient"), because it has
a relatively small deductible. And once it's satisfied, you're clear for the year.
Part A, for hospital admissions, has a much larger deductible, and it's applied per
admission, not per year.
Well, legally, because you're not yet admitted "to the floor," it's necessarily an
outpatient encounter. People just don't know that generally. You're right about the
"deductible." The co-insurance is quite another matter ( apropos of both A and B).
Which is why one needs a "Medi-Gap" supp. Humana Medi-gap lost their butts on me last year.
In June after Danielle died I had hernia surgery, followed by open heart aortic valve
replacement ("SAVR px") in late August. My OoP for the year was nil. Thank you Humana.
In a bit of irony, I'm now Kaiser, "Medicare Advantage." My OoP caps for the year at
$6,700. Though, I don't expect anything major, got all my heavy lifting done in 2015 and last
year.
They prey on the weak and helpless, especially the ones that go for emergency care. This
is another example of hospitals not really caring for the well being of the sick. Once they
capture a victim, their aim is to suck him dry.
The insurance companies are to blame too because they allow the out of network charges to
occur. The insured doesn't know what service or provider is "in network". He makes a good
faith attempt to go to "in network" hospitals but then the gougers take over.
The 'attending physician' I saw during my ER sojourn after last month's bus accident was a
"Body Shop Droid." The bill I received, which was the one I described earlier, the
semi-threatening one, was from an "Emergency Room Physicians Management Company LLC." I have
nothing to compare it to, but it came to just over $700 dollars US, for two or three 'look
see's' at my battered carcass.
The ambulance "service," a properly neo-liberalized separate commercial entity, (anyone
remember when ambulances were a part of the hospital apparat?,) billed me just over $1000
dollars US. I finally reached a claims adjuster for the bus companies insurance company
yesterday. One of the questions she asked me, after I had established that I had been
'ambulanced' to the hospital was, how many people were transported in that one ambulance?
When I quipped about 'double dipping' on the part of the ambulance "services," she laughed
and said, "If you only knew."
I have still not heard from the hospital itself.
In Elisabeth Rosenthal's excellent book "An
American Sickness" she recommends adding the following statement to any consent form you sign
in the hospital "Consent is limited to in-network services only and excludes out-of-network
services". My wife and I carry copies of this in our wallets just in case. Haven't had
occasion to try this yet and see their reaction.
The corollary of "Someone has to pay!" is "Someone gets it for free."
What happens locally at San Franciscan General Hospital:
Undocumented person or homeless guy;
1.Get ride to hospital in ambulance.
2. Get free translator, if needed
3. Claim no I.D.
4. Get treatment.
5. Pick up free meds at pharmacy.
6. "No hope of recovery"= "Free"
American citizen with insurance
1. Walk in hospital.
2. Spend half an hour proving I have insurance.
3. Get treatment.
4. Get bill for hundreds of thousands because they "are out of network ."
A state bill is in the works to ban this. However, taxpayers will still provide free care
for indigents and now, per a new state law, not only illegals in emergency rooms, but all
illegals, until age 26, get full medical inpatient insurance coverage, paid by taxpayers.
Being first gen Italian I applied for Italian citizenship back before Eurolandia was
consummated just in case the rules were changed. Main reason was worries over my on and off
health insurance, so just to be safe. Sure enough found myself in my fifties w/o insurance,
which is a seriously unwise situation, and hesitently moved to Italy. It's been rough to say
the least, the country is deep in the dumps, but the health system is WONDERFUL. Yeh,
everyone moans and complains about a long list of valid problems with health care here, but
they have no idea the alternative. I tell everyone here to mark my words and protect what
they got from the devious, erosive neo-liberal threat.
Preaching to the choir on NC but just in case anyone has doubts the positives; no
financial stress to compound health stress, no corporate bureaucracy, state system is quite
well streamlined, no copays if you're unemployed or poor, outweighs ALL the negatives.
I think the title is a little inaccurate, it's not 1-in-6 patients, it's 1-in-6 visits (or
stays). Two visits in a year bring an individual's odds to 1-in-3, etc.
On average, 16% of inpatient stays and 18% of emergency visits left a
patient with at least one out-of-network charge.
Even when patients were admitted to in-network facilities, though, 16% of these
stays resulted in at least one out-of-network charge for a professional
service.
And out-of-network charges can occur for simple services like a blood test, this recently
happened to a friend. She visited a service office listed by her insurer, but the office had
contracted with an out-of-network analysis lab, resulting in a non-covered $1100+ charge.
Which is a bit amazing in itself, during a recent checkup (my first in 12 years) which was
covered by a Medicaid plan, I inquired about the costs for my various tests, to understand
affordability; how much would this or that cost if I walked in without any coverage plan? My
comprehensive blood test would have cost $183, my echo-cardiogram $118. What about the
hormone-level test my friend got? Under $500. All these prices are for cash up front of
course, avoiding the 25%+ in interest and finance fees that a payment plan would incur.
Tangentially, I just saw an anti-Medicare for All ad on TV in my market yesterday (the DC
metro area), the first such I have seen. The focus of the ad was that M4A would result in
long wait times for procedures; 4 weeks for a cancer consultation, 8 weeks for a kidney
replacement consultation, and so on. The ad was so patently misleading it was kind of
astonishing: people already wait many many weeks for medical consultations under our
gloriously inefficient "excellent" healthcare system–a fact I'm sure most Americans are
familiar with. I know of people with cancer diagnoses who have had to wait months to get an
appointment with a specialist. So, I'm surprised that's the tack that the lobbyists would
take in their "M4A will ruin everything" scary ad. That was the whole focus of the ad: wait
times. Seemed like a weak tea argument to me.
May
30, 2019 by Yves Smith Yves here. This article is a
bit fuzzier than I'd like on the details of how the proposed California legislation to bar
balanced billing would work, and past failures to halt this practice says that details
matter.
However, as I read this piece, the intent is make health insurance work like old-fashioned
indemnity plans, at least as far as emergency room coverage is concerned. Indemnity plans were
once the norm, and the insured could go to any doctor. No network, no GP gatekeeping.
The sticky part here is the patient is supposed to be on the hook for only what he'd have to
pay if he went to an emergency room that was in network. That would seem to give the upper hand
to the insurance companies, since the hospital has no recourse to the patient beyond his
obligation for an in-network visit. The insurer sends the same reimbursement to the
out-of-network hospital as it would to an in-network hospital, and washes its hands of the
matter.
One downside for the insurer is that they will now be on the hook for ER bills from any
hospital. So they will wind up increasing premiums as a result. But routine care, managing
chronic conditions like diabetes, and scheduled surgeries still constitute the substantial
majority of what those premiums are intended to cover.
By Ana B. Ibarra, Reporter for California Healthline, based in Sacramento. Previously,
she covered health in California's Central Valley for the Merced Sun-Star. She is a 2015 Center
for Health Journalism fellow and a Cal Poly Pomona graduate. Originally published at Kaiser Health
News
California has some of the nation's strongest protections against surprise medical bills.
But many Californians still get slammed with huge out-of-network charges.
State lawmakers are now trying to close gaps in the law with a bill that would limit how
much hospitals outside of a patient's insurance network can charge for emergency care.
"We thought the practice of balance billing had been addressed," said state Assemblyman
David Chiu (D-San Francisco), author
of the bill . "Turns out there are major holes in the law potentially impacting millions of
Californians with different types of insurance."
"Balance billing," better known as surprise billing, occurs when a patient receives care
from a doctor or hospital -- or another provider -- outside of her insurance plan's network,
and then the doctor or hospital bills the patient for the amount insurance didn't cover. These
bills can soar into the
tens of thousands of dollars .
Chiu's proposal would prohibit out-of-network hospitals from sending surprise bills to
privately insured emergency patients. Instead, hospitals would have to work directly with
health plans on billing, leaving the patients responsible only for their in-network copayments,
coinsurance and deductibles. Hospitals are fighting the proposal, calling it a form of
rate-setting.
"If we are able to move this forward in California, it could be a model and standard for
what happens around the country," Chiu said of his measure, which the state Assembly is
expected to consider this week.
Surprise billing is a scourge for patients around the country.
Last year , a Kaiser Family Foundation poll found that two-thirds of Americans are "very
worried" or "somewhat worried" about being able to afford a surprise bill for themselves or a
family member. (Kaiser Health News, which produces California Healthline, is an editorially
independent program of the foundation.)
Health policy experts say the problem demands federal action rather than an inconsistent
patchwork of state laws. And President
Donald Trump has called on Congress to pass legislation this year to put a stop to surprise
medical bills.
"In one swipe, the federal government can offer a universal approach in protecting
consumers," said Kevin Lucia, a research professor with Georgetown University's Health Policy
Institute.
Lawmakers in both the U.S. Senate and House
have introduced bills to end surprise billing. But passing federal legislation promises to
be an uphill
battle because two influential lobbying groups -- health insurers and health providers --
have been unable to agree on a solution.
Frustrated by waiting for federal lawmakers to act, states have been trying to solve this
issue. As of December 2018, 25 states offered some protection against surprise billing, and the
protections in nine of those states were considered "comprehensive," according to the
Commonwealth Fund . California, New York, Florida, Illinois and Connecticut are among the
nine.
New state laws also have been adopted since,
including in Nevada , which will limit how much out-of-network providers, including
hospitals, can charge patients for emergency care, starting next year.
In California, a 2009 state Supreme Court ruling
protects some patients against surprise billing for emergency care, and a
state law that took effect in 2017 protects some who receive non-emergency care.
But millions remain vulnerable, largely because California's protections don't cover all
insurance plans. The California Supreme Court ruling applies to people with plans regulated by
the state Department of Managed Health Care. That leaves out the roughly 1 million Californians
with plans regulated by the state Department of Insurance and the nearly
6 million people with federally regulated plans, most of whom have employer-sponsored
insurance.
The state law governing non-emergency care also doesn't apply to the millions of residents
with health
plans regulated by the federal government.
Chiu's bill attempts to close those loopholes by targeting hospitals and their billing
practices. With this strategy, a patient's health plan -- and the agency that regulates it --
would not matter, explained Anthony Wright, executive director of Health Access California, a
Sacramento-based advocacy group that is sponsoring the legislation.
The proposal "extends protections to a broader set of Californians," Wright said.
The California Hospital Association opposes the measure, which would limit the amount
hospitals could charge insurance plans to a certain rate for each service, varying
by region .
The association believes that would equate to the state setting prices, which could
discourage health plans from entering contracts with hospitals, said Jan Emerson-Shea, a
spokeswoman for the association.
"We fully support the provision of the bill that protects patients. It is the rate-setting
piece that is our concern," she said.
Chiu said his bill was prompted by the peculiar billing practices at Zuckerberg San
Francisco General Hospital
spotlighted by Vox in January.
Unlike most large hospitals, San Francisco General does not contract with private insurers.
Vox found that the hospital considered patients with private insurance out-of-network, and was
slapping many of them with whopping bills.
Stefania Kappes-Rocha was one of them.
On April 30, 2018, Kappes-Rocha, 23, landed in San Francisco General's emergency room with a
fever and intense pain in her lower right back caused by a kidney infection. A student at Hult
International Business School at the time, she had a private plan through the college.
"I didn't know it at the time, but that was the problem -- that I did have insurance,"
Kappes-Rocha said.
She was sent home a day later with ibuprofen. About two months later, she was billed
$27,767.70.
"I couldn't move because of the pain," she said. The last thing on her mind was that she'd
be on the hook for the entire cost of her hospital visit.
Her insurance eventually agreed to pay about $24,000 of her bill.
"I fought back, I pressured them every week," she said. "But some people don't know they
should do that."
Skewered by media reports, the hospital announced in April
that it would no longer balance-bill privately insured patients.
There's a reason that this state bill originated in the civic disaster that is San
Francisco.
San Francisco General, now named for the billionaire, used to be an excellent public
teaching hospital affiliated with the University of California. It has one of the better
trauma units in California, thanks to the proximity of nearby gang turf wars and housing
projects that keep it replenished with fresh gunshot wounds.
Someone has to pick up the tab for San Francisco being a magnet for the uninsured homeless
and undocumented from all over the western hemisphere. All this is very expensive.
The word among some locals, third generation Americans, who grew up in the city, even
those who have insurance , if they go to the emergency room, is to claim to not be insured,
give a false name and social security number for emergency treatment. That idea came from
refugees flushing their passport down the toilet on the plane.
OK, I actually followed the link to the SF Chronicle you posted to support the claim that
in SF, one city, "billions have been spent on free health care for 'homeless' (scare quotes??
why??) people."
In fact, that article does not even use the word "healthcare" and implies the exact
opposite of what you claim, stating that 2.2% of a $250 million annual budget dedicating to
homelessness issues was spent on "health services" for the homeless. The vast bulk of the
budget went to fight evictions and keep housed people from becoming homeless. It does not
discuss emergency departments at all.
You're making stuff up, not just little things, but enormous things.
Might I add, IMHO, this kind of thing is typical of conservatives, and dovetails nicely
with today's post about conservative ideology dying out.
You corrected my pre-coffee error. Thank you.
People that make things up don't post a contradictory URL.
"Billions have been spent on the homeless in San Francisco", is what I meant to say.
Healthcare is part of that, which includes ambulance rides, fire department calls. BTW,
there's lots of debate about numbers. "Billions includes housing, subsidies etc.
Why "homeless" quotes? There are actual Homeless people who have been kicked out of public
housing or who simply cannot afford rents. The majority of the "homeless" in San Francisco
are recently arrived who have never had a home here, move from place to place and are mostly
just junkies and drug users, who would continue to be, even if given "a home."
I'm a Bernie, Medicare for All, Peace in The Middle East, free transit, tax the wealthy
"conservative", glad they are coming around.
You should actually read that article you linked to.
Where is your figure for the billions that were supposedly spent on the homeless in San
Francisco coming from? As that article makes clear, most of the money is being spent on
people who live in apartments in San Francisco, to keep them from becoming homeless. Another
huge chunk is spent on people who are homeless and in precarious temporary arrangements
rather than on the street. Very little is being spent on the "visible homeless" as the
article calls them.
Your general impression that SF is a net economic contributor in any way to American
society is absurd. It is sucking wealth out with scam companies like Uber while it is casting
out lower income people to every other corner of the state and country.
If SF did take in some homeless people and provide them a few thousand dollars a year of
services, that would be a drop in the bucket compared to the damage its citizens have done.
But you have not provided one word of evidence that the homeless in SF have primarily come
from out of town, much less out of state. Given the Bay Area's efforts to gentrify over the
decades, it seems quite likely that they were formerly housed inhabitants of the city.
"Your general impression that SF is a net economic contributor in any way to American
society is absurd."
You must be confusing me with someone else?
I think San Francisco is a giant black hole of exorbitant social services for "homeless",
illegals, and profit sucking billionaires that often pay zero local taxes. i.e. Twitter, in
it's special Mid Market Resurrection Zone. All those stock options think of the savings.
Add up the money spent over the last 25 years or so on homeless and preventing homelessness
and it's in the billions.
$40,000 per "homeless" person per year. With the passage of Proposition C, to go to $70,000
per year.
I grew up in San Francisco and have been involved in local politics for half a century. So
where are you from? Where are you getting your numbers? Please share. We can all learn from
each other.
As long as the people making the rules are monetarily above worrying about health care
costs, the rest of us will continue to get squeezed out of existence. Put some people in
charge who cannot afford today's medical costs and you will see them go down. Pretty simple
actually ( at least in my head)
I have direct experience with this sort of 'balance billing'. It's not just the hospitals
that do it. Doctors are a big part of the problem, too.
My doctor recommended major surgery and so we scheduled a specific time and date with the
hospital. My medical insurance required the use of in network doctors. So I explained to the
chief nurse (in a long discussion prior to admittance) at the in-network hospital I needed to
vet ALL doctors for their network status. Actually put it in writing. (I gave them a list of
the known in-network doctors affiliated with the hospital.)
Survived the surgery (as you can tell). But to my surprise a 'balance bill' appeared in
the mail. Then another. What?! I don't recognize any of these people (doctors). In California
the Legislature has given the State Medical Board authority over hospital operating room
procedure. The medical board 'requires' three doctors to be 'present' in the operating room
for certain major surgeries; they are selected by the primary surgeon. These other two
doctors, whom I was never introduced to (before or after surgery) had sent me the unexpected
billing (with no discussion of the medical work they performed– or not) in the mail. Of
course, they were not in-network and my insurance initially refused to pay them.
Long story shortened, I was able to convince my insurance provider to pay them in-network
fees. The doctors refused it, we went to court, they got nothing (zero, nada, zilch). Written
record carried the day.
Hospital care in America is a wild ride. You literally need a personal advocate every
minute you are in one.
Canadian specialist doctors who are REALLY greedy may stay around and join those trying to
privatize our system, or they may move to the US where greed is king. We made the mistake
back in the 1970s of engaging an obstetrician at a maternity hospital in Vancouver for the
birth of our first two children. For our oldest he showed up seconds before the birth,
leaving a me and a resident who had not done a birth before. Of course, the nurses knew
exactly what to do. His fee from medicare was, I guess, being there to catch. With our second
two years later, he knew exactly what might happen–my wife would race through the
transition phase of labour and almost immediately into delivery. That did not matter to him,
he still arrived within seconds of delivery completion.
Our third was with a GP in a different city. He was a REAL doctor, present and supportive. It
didn't matter, though, because the obstetrician had moved to Texas where he could schedule
caesareans around his golf game.
I have a Medicare PPO from Humana. The hospital selected by them for emergencies is
Northern Nevada. I happened to fall off my porch and hurt my arm. I went to the emergency
room and was told I had a fractured elbow. Some time later Humana denied the payment for the
attending doctor because he was in the group of emergency physicians that man the emergency
room and were not in Humana's network. Catch-22 – The emergency room bill is in network
but the doctors are not.
Calling all lawyers: Please answer.
Is this not Agency of Estoppel on Humana's part?
The Emergency Room of Northern Nevada Hospital is writ large by a large neon sign. The
doctors there are contracted with Northern Nevada and practice in their facility. I contend
that the doctors are agents of the hospital and Humana is denying that agency by not paying
the bill. Agency of Estoppel is illegal, I was taught in my limited business law course.
What you have just described is pretty common in Texas. These doctors do not have a
contract with the hospital and are usually 3rd party. Is your PPO supplemental or are you in
an Advantage (BS) Plan? If you are truly in Medicare and using a Supplemental for the 20% of
Part B not covered, you are safe.
If you are in an Advantage Plan I would go back to Humana and ask them to negotiate a
price. Not an attorney; but, doctors are agents of the hospital whether 3rd party and
contracted or employed.
The hospital is in network, they ask for your insurance,
and then supply out of network doctors, who don't contact you to enter into a contract to
provide out of network services. i don't see how a contract has been
made with these out of network doctors.
You probably signed an ABN ("I'm responsible for what
insurance does not pay."} So, that is an "I gotcha" in favor of their right to bill you. I've
been crossing out their ABNs and writing I will only be responsible for what insurance
pays.
When you go to the ER, you get whoever comes through the door which baldski got. Again
what I will say, this is happening with greater frequency and especially in Texas where a
hospital contracts the ER doctors out to a 3rd party and does not negotiate the ER rates. It
is like having a vendor in your hospital who is contracted to the hospital and charges
whatever price. There is a term for this and it is little more than entrapment.
Every one of us should be concerned about this. We are vulnerable, even in our homes.
Ambulances take you to the nearest hospital where there is space in Emergency, not
necessarily to one in your network. You may be unconscious or incoherent.
Next issue:. Ongoing care. A friend had a pancreatitis attack while on vacation. After ER,
he was admitted and told he needed immediate surgery. His insurance company refused to pay
for the surgery, saying he could have returned home safely. As you can imagine, the bill was
a big one. Insurance never came through, and he settled with the hospital for a large
amount.
I think the issue with balance billing is not whether the ER is in your network. Here in
Massachusetts, for instance, health plans cover every ER visit to every ER on earth. The
issue is that some of the doctors provide services which are for whatever reason not
considered "emergency" for the purposes of your health plan and if that doctor is out of
network, you get charged for the "balance" beyond whatever small amount the plan will pay.
Oftentimes the doctors are greedy sharks and pile on the charges which understandably the
insurer is unwilling to pay.
The ER admission itself is only a manageable amount, about $500 when I went. It was the
fees and medications that added up.
In Yves's fine piece, a spokesman for hospitals complained that the new legislation was a
form of 'rate setting."
Well heck yes. When consumers are helpless and a legitimate contract is impossible, it is
accepted that courts and legislatures can regulate the fees.
For that matter, Maryland has had regulated hospital charges for several decades, and I
know of no crisis that has occurred nor of a hospital that went broke.
The very idea that every hospital bill for emergencies should involve attorneys and the
media is grotesque. Seeiing the hospital as a greedy, grabbing institution that sets fees at
$100,000 and accepts $10,000 would be considered idiotic in most nations. In Germany, a
bargaining unit for all hospitals meets annually with a bargaining unit for all insurers and
they set all the fees. In America, hospitals
"bargain" esssentially by financial terrorism.
The other 49 states do not regulate pricing and set market rates. Places like University
of Michigan hospital charge more than other generic hospitals, As hospitals consolidate,
there is less competition as the most recent Commonwealth Fund funded Health Affairs study
determined in their findings. Indeed from 2007 to 2014, hospital-prices for inpatient care
grew 42% compared to 18 percent for physician-prices for inpatient hospital care. For
hospital-based outpatient care, hospital-prices rose 25 percent compared to 6 percent for
physician-prices.
If you go to a hospital with 3rd party doctors, they can balance bill you. We are not in
Germany and it varies state by state what can be done.
You being an insurance guy like ME should already know this as you expound about it over
at Charles Gaba's site.
Regarding a candidate addressing a really important domestic issue in USA, Pres. Trump has
drawn the teeth (to an extent) on that one, and put the Democratic party in the position of
either supporting the Republican initiative, or throwing sand in the wheels of a measure
which will be very popular with the American public:
May 9 - surprise medical bills will be outlawed
"...Today I'm announcing principles that should guide Congress in developing bipartisan
legislation to end surprise medical billing...we have bipartisan support, which is rather
shocking..."
May 20, 2019
Private Equity is a Driving Force Behind Devious Surprise Billings by Eileen Appelbaum Surprise medical bills are in the news almost daily. Last Thursday, the
White House called for legislation to protect patients from getting surprise doctor bills
when they are rushed to the emergency room and receive care from doctors not covered by
insurance at an in-network hospital.
The financial burden on patients can be substantial -- these doctor charges can amount to
hundreds or even thousands of dollars.
What's behind this explosion of outrageous charges and surprise medical bills? Physicians'
groups, it turns out, can opt out of a contract with insurers even if the hospital has such a
contract. The doctors are then free to charge patients, who desperately need care, however much
they want.
This has made physicians' practices in specialties such as emergency care, neonatal
intensive care and anesthesiology attractive takeover targets for private equity firms.
As health reporter Bob Herman observed , acquisition of these health services "exemplifies
private equity firms' appetite for buying health care providers that wield a lot of market
power."
Emergency rooms, neonatal intensive care units and anesthesiologists' practices do not
operate like an ordinary marketplace. Physicians' practices in these specialties do not need to
worry that they will lose patients because their prices are too high.
Patients can go to a hospital in their network, but if they have an emergency, have a baby
in the neonatal intensive care unit or have surgery scheduled with an in-network surgeon, they
are stuck with the out-of-network doctors the hospital has outsourced these services to.
This stands in stark contrast to other health-care providers, such as primary-care
physicians, who will lose patients if they are not in insurers' networks.
It's not only patients that are victimized by unscrupulous physicians' groups. These
doctors' groups are able to coerce health insurance companies into agreeing to pay them very
high fees in order to have them in their networks.
They do this by threatening to charge high out-of-network bills to the insurers' covered
patients if they don't go along with these demands. High payments to these unethical doctors
raise hospitals' costs and everyone's insurance premiums.
That's what happened when private equity-owned physician staffing firms took over hospital
emergency rooms.
A 2018
study by Yale health economists looked at what happened when the two largest emergency room
outsourcing companies -- EmCare and TeamHealth -- took over hospital ERs. They found:
" that after EmCare took over the management of emergency services at hospitals with
previously low out-of-network rates, they raised out-of-network rates by over 81 percentage
points. In addition, the firm raised its charges by 96 percent relative to the charges billed
by the physician groups they succeeded."
TeamHealth used the threat of sending high out-of-network bills to the insurance company's
covered patients to gain high fees as in-network doctors. The researchers found:
" in most instances, several months after going out-of-network, TeamHealth physicians
rejoined the network and received in-network payment rates that were 68 percent higher than
previous in-network rates."
What the Yale study failed to note, however, is that EmCare has been in and out of PE hands
since 2005 and is currently owned by KKR. Blackstone is the once and current owner of
TeamHealth, having held it from 2005 to 2009 before buying it again in 2016.
Private equity has shaped how these companies do business. In the health-care settings where
they operate, market forces do not constrain the raw pursuit of profit. People desperate for
care are in no position to reject over-priced medical services or shop for in-network
doctors.
Private equity firms are attracted by this opportunity to reap above-market returns for
themselves and their investors.
Patients hate surprise medical bills, but they are very profitable for the private equity
owners of companies like EmCare (now called Envision) and TeamHealth. Fixing this problem may
be more difficult than the White House imagines.
"On April 3, Nina Dang, 24, found herself in a position like so many San Francisco bike riders -- on the pavement with a
broken arm.
A bystander saw her fall and called an ambulance. She was semi-lucid for that ride, awake but unable to answer basic
questions about where she lived. Paramedics took her to the emergency room at Zuckerberg San Francisco General Hospital,
where doctors X-rayed her arm and took a CT scan of her brain and spine. She left with her arm in a splint, on pain
medication, and with a recommendation to follow up with an orthopedist.
A few months later, Dang got a bill for $24,074.50. Premera Blue Cross, her health insurer, would only cover $3,830.79
of that -- an amount that it thought was fair for the services provided. That left Dang with $20,243.71 to pay, which the
hospital threatened to send to collections in mid-December..."
"Monopolies hurt the public and the republic alike; the job of policing that power must be taken seriously."
Elizabeth Warren
Within so many of the corporate dominant monopolies like Healthcare, Banking, Pharmaceuticals, some companies seem to be
free to do just about whatever they wish in billing consumers.
Healthcare in the US is bordering on insane when it comes to billing practises and lack of practical recourse or common
sense, with Big Pharma running a close second. But the Banks are not all that far behind.
I have met many, many dedicated professionals in the healthcare industry, but like most participants they are just being
swept along because they have little practical recourse or power. To speak up is to be punished, and severely.
A simple law that states that when a patient is brought into a hospital emergency room for treatment, their private
insurance and the treatments must be provided at the network rates in their insurance policy, or at the prevailing rate for
a Medicare patient, whichever is lower. And any uncollectible services to be written off or compensated by government will
be done at the Medicare rate and not at some ficitonal billing statement.
I believe that New York State has a law requiring ER and Hospital doctors to accept private insurance for patients as if
they are in-network. This includes those 'consultations' which happen during a hospital stay by doctors who accept no
insurance and who charge whatever they feel like charging for some service, of which provider or price the patient is never
informed beforehand.
The real solution is of course universal healthcare, which has been implemented for years by every major developed nation
but the US. This will not happen for the same reason that we are seeing no movement towards meaningful reform in Pharma
or Banking. And you know exactly why, unless you have been living in a bubble or are willfully blind.
Stocks managed to extend their rally today despite some setbacks.
We will see what Trumpolini has to say about our 'crisis' at the southern border this evening, and the trade war, and
probably whatever else crosses his mind. My only certainly is that it will not involve any meaningful reform in healthcare,
finance, insurance, or pharmaceuticals.
That's a fantasy: "It is important to lock this agreement in, quickly, before my account is sold to a third-party collection
agency, which is nowhere near as likely to accept such a deep discount" Many hospitals sells you to collection immediately.
Mostly this is a cheap self-promotion of a yet another snake oil salesmen... Some more tidbit still might be useful You
are warned.
If you try to fight medical-industrial complex alone most of the time you will be crushed. As a minimum you need a legal help.
Often you need insurance too: at the end it is cheaper to have insurance then to fight astronomic bills. But those bottom feeders
still can get to you via balance billing. and in most case, when you stay in hospital they do get back to you with the
additional biils. That's why you will need a lawyers to fight this.
The usual trick of this scammers is to get "out of the network" ambulance and bill you $5K or more. Even the transfer from
one hospital to another via ambulance can cost you tons of money.
Unnecessary procedures is another important danger. Stents is one such danger, in case of suspicion for the heart attack.
You can get several several of them even if do not need them as a courtesy of those greedy jerks ;-)
And they will never agree for Medicare rates. Forget about it.
Notable quotes:
"... As we have already learned, all healthcare services have been assigned a code by the AMA, a five digit CPT code. So, if you trip and fall off your patio, you might get a doctor's bill like the following table located in your handouts: ..."
"... You may receive other bills from several doctors such as anesthesiologists and radiologists, as well as laboratory services, therapists, and the ambulance company. The bills all look similar, and the strategy and tactics I am presenting, today, should work for each of them as well. ..."
"... The purpose of this overpricing by the medical providers is to force the insurance companies to the negotiating table. The insurance company is bringing a large volume of patients to the medical providers, the members in their network, so they are able to negotiate a lower discounted allowable fee from the medical providers. However, if the insurance carrier is not able to negotiate a contractual allowable fee schedule, then they will end up paying the higher billed charges of the out-of-network provider for the members that still end up being treated by that medical provider in emergencies when precertification is not required. ..."
"... Now, on to where you can find these prices. Well, if you have insurance, then after you receive medical care and the healthcare providers send their claims to the insurance carrier, you should receive from the payer an Explanation of Benefits (EOB), or you probably can go online and view an Electronic Remittance Advice (ERA). For every CPT code that the providers billed , you will see both a billed charge and allowable. ..."
"... Fortunately, as you will now learn, there is a much more simple and better way to be 100% certain of your diagnosis, diagnosis code, procedure, procedure code, and even the medications the physician will offer you, at least for elective conditions. Here it is. If it isn't an emergency, then make a doctor's appointment! ..."
"... Does this sound unlikely? Too good to be true? Then consider this: Medical providers are highly incentivized to give the patients they treated huge discounts. Why? Because they know that collecting money from patients foments malpractice litigation. They would rather have you pay them pennies, than have you sue them for millions. ..."
"... I recently had breakfast with a pharmacist friend of mine that has worked as a manager for Walgreens for more than a decade. mrs_horseman is probably smiling when she hears that I have a pharmacist friend, because she knows how I feel about most of the people in that industry. Nonetheless, I told him about this presentation I am making, and asked if he had any advice for negotiating directly with the pharmacies for medications. It turns out, he does, and I would have never guessed the tactic he described. ..."
Approximately 63% of Americans have no emergency savings for things such as a $1,000
emergency room visit or a $500 car repair, according to a survey released Wednesday of 1,000
adults by personal finance website Bankrate.com, up slightly from 62% last year. Faced with an
emergency, they say they would raise the money by reducing spending elsewhere (23%), borrowing
from family and/or friends (15%) or using credit cards to bridge the gap (15%).
You are going to need five things, which I am going to give to you, today, free of
charge!
Some absolutely critical industry vocabulary
A clear understanding of how healthcare is priced in the USA
Insight into to actual pricing
A proven negotiation strategy, including:
a. The point of contact
b. Foreknowledge of what prices medical providers will usually agree to
c. A sample offer and agreement
The confidence to successfully negotiate
Unfortunately, I couldn't come up with a better way to impart to you an understanding of the
industry lingo, other than these simple handouts. However, this information is so important for
you to be able to understand any negotiation strategy that I simply must slog through each term
with you now. Please, I ask that you hold your questions and comments until I get through the
vocabulary. Many of the terms are cross-referenced, and will become more clear after we here
them all.
Premium: The monthly amount enrollees pay the insurance company to be covered.
Deductible: The amount paid by the member before insurance will begin to reimburse services.
It is reset annually, and based on the level of benefits or amount of premium paid. For
example, with a $1,000 deductible the patient must pay medical providers for the first $1,000
of allowable expenses incurred by the patient each year, after which costs may be split
according to a coinsurance arrangement, and/or may be limited to the patient's out of pocket
expenses.
Coinsurance: A cost-sharing requirement of some insurance plans where the patient assumes a
percentage of the costs for covered services after the amount of the deductible has been met.
Coinsurance is described as a ratio, for example 30/70, meaning the patient is responsible for
paying 30% and the insurance will pay 70% of the allowable.
Copayment (co-pay): The amount to be paid to a physician by or on behalf of the patient in
connection with the services rendered by the physician. It is due at the time of service, is a
fixed dollar amount determined by the insurance company based on the level of benefit, and is
usually found printed on the patient's insurance card.
Out of Pocket Expense: The total of covered health care expenses that are paid for by the
member or patient, not including any premium. This is typically the total of the deductible and
any coinsurance paid during a year. It may be a maximum amount where after 100% of allowable
expenses are paid by the insurance company.
Explanation of Benefits (EOB or ERA: Electronic Remittance Advice): The insurance company's
explanation of the benefits they have, or have not, paid to a medical provider, along with any
remaining amounts for which the patient is responsible, if any.
CPT code: Current Procedural Terminology codes maintained by the American Medical
Association. These five digit codes describe most medical, surgical, and diagnostic services
and are used for administrative, financial, and analytical purposes such as on fee schedules
and bills. These CPT codes are also known as Level 1 HCPCS codes, with Level 2 HCPCS codes
being for non-provider medical services like ambulances and prosthetic devices. The CPT code is
equivalent to a part number, SKU Stock Keeping Unit, or UPC Universal Product Code.
Inpatient Prospective Payment System (IPPS): A system of payment for the operating costs of
acute care hospital inpatient stays under Medicare Part A (Hospital Insurance). Under IPPS,
each case is categorized into a diagnosis-related group (DRG). Each DRG has a payment weight
assigned to it, based on the average resources used to treat Medicare patients in that DRG.
Diagnosis-Related Group (DRG): a system to classify hospital visits into similar groups. Its
intent is to identify the products that a hospital provides, such as an appendectomy. DRGs are
assigned by group based on diagnosis (ICD code). DRGs may be further grouped into Major
Diagnostic Categories (MDCs). DRGs are used to determine how much Medicare and some insurance
plans pay hospitals and other services like home health.
ICD code: The International Statistical Classification of Diseases and Related Health
Problems provides codes to classify diseases and a wide variety of signs, symptoms, abnormal
findings, complaints, social circumstances and external causes of injury or disease.
Supposedly, every health condition can be assigned to a unique category and given a code.
Billed charges (usual and customary fees): The undiscounted fees a healthcare provider lists
on the bill (list price, or retail). These fees are usually set well above the highest
allowable of all the provider's contracts, sometime as much as 800% or even 1,000%. The purpose
of this overpricing is to force the insurance companies to the negotiating table.
Allowable: The discounted fee for service a healthcare provider has contractually agreed to
accept from an insurance company. It is listed by CPT code on the EOB or in a fee schedule
available from your insurance company, Medicare, or Medicaid. UNDERSTANDING THIS TERM IS THE
KEY TO UNDERSTANDING HEALTH INSURANCE AND TO NEGOTIATING DIRECTLY WITH MEDICAL PROVIDERS.
Global Period: The number of days after a medical procedure when the fee for office visits
is included, contractually, in the allowable for the procedure. It is typically 30, 60, or 90
days.
Elective: For our purposes, care for any medical condition that is not an emergency.
Emergency: A medical condition manifesting itself by acute symptoms of sufficient severity,
which may include severe pain, such that the absence of immediate medical attention could
reasonably be expected to result in serious jeopardy to patient health, and/or serious
impairment to bodily functions, and/or serious dysfunction of any bodily organ or part.
EMTALA: The Emergency Medical Treatment and Labor Act (EMTALA) is a federal law that
requires anyone coming to an emergency department of a hospital with an emergency condition to
be stabilized and treated, regardless of their insurance status or ability to pay.
Insurance Verification: the process where a healthcare provider contacts the financially
responsible party (usually an insurance company, Medicare, or an employer) and verifies that
coverage is in effect and the information current. This generally includes the amount of the
deductible met by the patient, copayment amounts, and coinsurance terms.
Precertification: The process of obtaining approval from insurance, in advance, for a
proposed treatment or diagnostic test, and is NEVER required for emergency care.
Medicaid: The United States health program for eligible individuals and families with low
incomes. It is a means-tested program that is jointly funded by the states and federal
government, and is managed by the states. Generally is the lowest allowable fee for medical
care.
Medicare: a social insurance program funded by taxes and administered by vendors hired by
the United States government. Medicare provides health insurance coverage to people who are
aged 65 and over, or who meet other special criteria such as a disability. Generally it
reimburses close to the average allowable fee for medical care. It is the easiest fee schedule
to access at: www.CMS.gov
Tricare: Health insurance for military personnel and their dependents.
Workers Compensation: Insurance that provides medical care for employees who are injured in
the course of employment. It is usually has the highest allowable fees for medical care.
... ... ..
To begin to understand how healthcare is priced, we are going to look at
the doctor's
bill given to a patient,
the claim forms the doctor and hospital send to the insurance
carrier, and
ERAs that the insurance carrier then send back to the patient and the
providers.
As we have already learned, all healthcare services have been assigned a code by the AMA, a
five digit CPT code. So, if you trip and fall off your patio, you might get a doctor's bill
like the following table located in your handouts:
On the hospital's bill you might see something like this:
It is important to understand that the amounts shown on both of these bills are
un-discounted Billed Charges (Usual and Customary Fees). They are the highest price the
provider might ever hope to receive for the service, also known as full retail, or MSRP. Don't
panic when you get these bills, because as everyone knows, "Never pay retail."
You may receive other bills from several doctors such as anesthesiologists and radiologists,
as well as laboratory services, therapists, and the ambulance company. The bills all look
similar, and the strategy and tactics I am presenting, today, should work for each of them as
well.
If you have insurance, the providers will send your carrier a claim with essentially the
same data as is on the bill they will provide to you if you are not insured, or if you simply
request a copy.
An important fact is that Federal Law, as a requirement for the medical provider's
participation in Medicare, requires that a medical provider charge every patient the same
amount for a given CPT item. What it does not require, however, is that a medical provider
accept the same payment amount from every patient for a given CPT item. This allows insurance
companies, government payers, and you to negotiate a discounted fee, known as a contracted
allowable, and not be in violation of the law.
The purpose of this overpricing by the medical providers is to force the insurance companies
to the negotiating table. The insurance company is bringing a large volume of patients to the
medical providers, the members in their network, so they are able to negotiate a lower
discounted allowable fee from the medical providers. However, if the insurance carrier is not
able to negotiate a contractual allowable fee schedule, then they will end up paying the higher
billed charges of the out-of-network provider for the members that still end up being treated
by that medical provider in emergencies when precertification is not required.
This creates a tiered-pricing structure for medical services that looks very much like this
table in your handouts:
At this point, if you are paying close attention, then it should start to dawn on you where
I am leading you with this talk, which, after all, is titled: How to negotiate directly with
physicians and hospitals.
Spoiler Alert: You are learning how to negotiate for Medicare rates, at worst, and Medicaid
rates, at best. In our example, a bilateral elbow fracture patient in Texas received surgeon
and hospital bills totaling $179,219. Medicare allows $30,542 and Medicaid $22,600, which means
the government negotiated an 83% or 87.4% discount, respectively. You can too!
Before we move on to providing you with access to these fee schedules, and then a
negotiation strategy, do you have any questions about how healthcare is priced in the USA?
Now, on to where you can find these prices. Well, if you have insurance, then after you
receive medical care and the healthcare providers send their claims to the insurance carrier,
you should receive from the payer an Explanation of Benefits (EOB), or you probably can go
online and view an Electronic Remittance Advice (ERA). For every CPT code that the providers
billed , you will see both a billed charge and allowable.
Quick show of hands: how many of you have received a medical bill, or an EOB, and threw it
away because you could not understand it? That is intentional! They want you to be confused.
However, after today, I doubt that you will ever do that again.
What if we do not have insurance, or we want to know the allowable, because we think this is
important information to know so that we can negotiate before receiving healthcare? Think
having a baby or elective surgery. Do not worry! The federal government provides us with the
Medicare rates online, and I believe that each state provides its Medicaid fee schedules
online.
You would soon discover, however, that it is much easier to determine the allowable for a
physician service than a hospital service, for which you will likely need to look up the DRGs
for the ICD codes and then try to cross-reference them with the IPPS Fee Schedule, at a
minimum, or you may even need to look up and calculate conversion factors. It is not easy,
again, intentionally so!
Regardless, we would first need the CPT codes for the services you are seeking from the
physician, and probably the ICD codes, too, in order to price hospital services. You could try
to guess at the diagnosis and the services you think the doctor is going to provide to you, and
then try to use a search engine to determine the ICD codes and CPT codes, or buy a coding
book.
"I know I need a hip replacement. My trainer at the gym told me so. I'll just Google,
hip replacement ICD and CPT code."
Good luck with that! The odds of you guessing the correct diagnosis and appropriate
procedures (without going to medical school) are incredibly slim, especially with the new
ICD-10 diagnosis codes. Also, chances are good that your athletic trainer doesn't know what the
hell she is talking about when it come to medicine, and in reality, you probably just need a
new athletic trainer, and not a new hip.
Is your head spinning, yet? Good! Now, stop it, because you will see that we don't need to
do any of that! It's all just a red herring designed to keep us confused and the health
insurers in business and profitable. Sounds a lot like our banking system, no?
Fortunately, as you will now learn, there is a much more simple and better way to be 100%
certain of your diagnosis, diagnosis code, procedure, procedure code, and even the medications
the physician will offer you, at least for elective conditions. Here it is. If it isn't an emergency, then make a doctor's appointment!
You may be thinking, "Isn't that putting the cart before the horse? Don't we want to know
the costs in order to negotiate the fees before the services are provided?" The surprising answer is, no! Why? Well, because we only need to negotiate the fee schedule, specifically, Medicare or
Medicaid, and not the exact fee. This is very important. Think back to the tiered-pricing
structure.
Eventually, we may want to know the actual (or sometimes estimated) allowable amounts in
order to budget for elective procedures, but this occurs after, or at the time of the
physician's office visit, when they can provide us with the ICD codes, CPT codes, and usually
the allowable amount, too! Later, we may choose to audit the allowable amount they give us, to
make sure it is correct, and we were not over charged, but this is seldom done, as most people
still trust their doctor, and the discounts you will be receiving are so HUGE you may feel a
little guilty. Also, I will tell you, the auditing process is very tedious, not to mention the
appeal process.
Therefore, we are now going to start talking about a negotiating strategy before we even
attempt to access any pricing data. Again, we first need to know the diagnoses and proposed
treatments. So, the solution is to start with a simple negotiation with the physician's office,
probably just for the cost for the initial office visit, at the very least, and maybe some
expected diagnostic tests. This is best done over the telephone, is easier and more successful
than you might think, and is analogous to finding a mechanic to, "just take a look," at your
car and tell you what is wrong with it, and then getting an estimate to repair it. Just like we
expect to pay a little bit for the mechanic to diagnose our car, we should expect to pay a
little bit for the doctor to diagnose us. The funny thing is that my mechanic and Medicare both
charge or allow about $100 for a diagnosis. This is not so funny if you are the surgeon that
spent 13 more years in school than the auto mechanic with a high school diploma.
Here we go, step by step:
1) I usually prefer to skip the added expense of going to a GP or family practice
intermediary just to get a referral to a specialist that can actually help, especially when I
can determine what medical specialty is likely to be most helpful for by medical condition by
visiting the website of the American Board of Medical Specialties. (Is your ignition system
acting up, your suspension riding a little rough, need new tires, brakes squeaking,
transmission grinding?)
2) Use the links on abms.org to visit the appropriate specialty board's website, and then
use their "find a physician" with the sub-specialty likely to be most helpful for the
condition
3) Start calling the sub-specialty physician offices listed, tell them you are a prospective
new patient, and ask to speak to the Business Office Manager. Ask him or her the following
questions:
a) "Do you accept Medicare and/or Medicaid insurance?" If yes, then...
b) "Super! Do you accept cash payment at the time of service?" If yes, then...
c) "Great! Then, of course, you will accept as payment in full, the Medicaid allowable, but
paid in cash by me to you, directly, at the time of service? Correct?" If yes, then (e). If no
then (d).
d) "I guess I understand. Well, then surely you will at least accept as payment the
Medicare allowable, paid in cash by me to you, directly, at the time of service? If yes,
then (e). If no then conclude the call, because you cannot fix stupid.
e) "Thank you! Can you please tell me what the estimated amount is for an office visit,
using this fee schedule, so I can know how much money to bring, and please make a note on my
account that we have negotiated a Single Case Agreement for me to pay these rates to you, in
cash, at the time of service?
f) Tell him or her your specific reason for the visit (I am leaking red fluid on the floor
of my garage) and that you want to be fully prepared for the visit. Ask what diagnostic tests,
if any, are usually required for this type of problem, lab, X-ray, CT, MRI, ultrasound, etc.,
and which ones would probably need to be done outside the physician's clinic?
g) Make sure to get the BOM's name and contact information, and the appointment time and
date.
After your office visit, if it turns out that you need a procedure such as day surgery at an
Ambulatory Surgery Center (ASC), an inpatient admission at a hospital, a diagnostic test like
an MRI or CT, or a series of treatments such as physical therapy, then you simply repeat the
above negotiation, starting with the facility your physician recommends, and in the case of a
hospital or ASC, always where he or she has privileges. ASC's allowable rates are always much
lower than a hospital, so act accordingly. When telling the BOM that you are a prospective new
patient, make sure to give the name of your physician. Instead of just making a note of any
negotiated agreement in your account, the BOM and you should execute a written Single Case
Agreement. It is usually a one-page agreement that looks something like this sample found in
your handouts:
It should be obvious to you why, when possible, these negotiations should occur before
treatment, which is more often than you might imagine. In general, elective conditions are
negotiated in advance in this manner. Next, we are going to look at emergency conditions, which
are more than likely negotiated after examination and treatment.
Before we do, are there any questions?
Ok, so I experience some kind of true medical emergency, where my life or limb is in
jeopardy, like a heart attack. mrs_horseman puts me in an ambulance that rushes me to the
Emergency Room at the hospital, and they run all kinds of tests, and give me some very
expensive medications. Fortunately for me, a long enough timeline has not yet passed, my
survival rate has not dropped to zero, and I don't even get to go to the cath lab or have
emergency heart surgery. However, we do get several large medical bills from the hospital, ER
doctor, ambulance, laboratory, and cardiologist. I either have no insurance, am self-insured,
or I have a catastrophic insurance plan with a very high deductible that I am not likely to
meet with this event, or this year. What do I do?
When I receive each bill, I immediately call each provider and get the name and address of
the BOM. I then draft a Single Case Agreement Offer and Acceptance, and I offer to pay the
estimated Medicaid allowable clearly labeled as such (by using the tiered-pricing structure I
covered earlier) and expiring 10 days after it is received. I may also include some horseshit
narrative about how I just received a small windfall, and was advised by my attorney to settle
my hospital bill before I piss it away on fast women and slow horses, or worse, squander it. I
send this to the BOM, Certified Mail-Return Receipt Requested , with my attorney copied on the
bottom of the offer. The BOM may argue the accuracy of my Medicaid estimate, and make a counter
offer with a more accurate Medicaid allowable, but the odds are very, very, high that he or she
either agrees to the Medicaid allowable, or counters with something like a Medicare allowable.
Either way, at this point I have successfully negotiated somewhere around an 83% - 87% discount
on average, less for doctors, more for hospitals.
It is important to lock this agreement in, quickly, before my account is sold to a
third-party collection agency, which is nowhere near as likely to accept such a deep discount,
and far better than a healthcare provider at actually getting blood from a turnip. Medical
providers are now turning their accounts over to collections as soon as 90 days from the date
of service, which can mean that you are still being treated for this condition when this
happens! Do not let this happen to you! Open the bills! Mail the offer! Maybe they say no, but
that is not likely. On the other hand, the collections agencies are working very hard to get
you on a payment plan for Billed Charges, with interest, for the rest of your life!
Does this sound unlikely? Too good to be true? Then consider this: Medical providers are
highly incentivized to give the patients they treated huge discounts. Why? Because they know
that collecting money from patients foments malpractice litigation. They would rather have you
pay them pennies, than have you sue them for millions.
There it is. I said it. Think about that for a moment.
Now, considering the minimal risk of negotiating, and the large potential reward, do you now
have the confidence to successfully negotiate directly with physicians and hospitals?
Before I spend just a few more minutes talking about pharmacies, and then finally some
self-insurance goals, are there any questions or comments?
I recently had breakfast with a pharmacist friend of mine that has worked as a manager for
Walgreens for more than a decade. mrs_horseman is probably smiling when she hears that I have a
pharmacist friend, because she knows how I feel about most of the people in that industry.
Nonetheless, I told him about this presentation I am making, and asked if he had any advice for
negotiating directly with the pharmacies for medications. It turns out, he does, and I would
have never guessed the tactic he described.
Are you ready? Coupons and free discount cards. He explained that if one simply goes online and searches for Walgreens coupons, it is
usually possible to save between 5% and 60%. He specifically recommends Good Neighbor Pharmacy
Prescription Savings Club.
He says that when you purchase medications, then you have 5 days to return to the same
location Walgreens and bring a coupon for reimbursement of any savings. He says that if you are paying cash, then you must be sure to request a generic, if
available. For long term meds, he explains that the drug manufacturer's web sites will often offer a
free co-pay assistance card. If you have insurance, then you can present the free card from the
manufacturer to the Walgreens pharmacy, and it will cover your co-pays. In closing, I want to talk just a bit about insurance and one of the situations where we
would want to be able to negotiate directly with physicians, hospitals, and pharmacies.
As we have discussed, today, one of the primary benefits of having health insurance is to
take advantage of the discounts negotiated by the insurance company or government. However, we
just learned that providers are usually willing to accept similar discounted rates from cash
pay patients.
The other big benefit of health insurance is to share with other people the risk of having
to pay large bills that are the result of serious and unexpected injuries or illnesses. This is
the traditional role of insurance. However, the costs and benefits of sharing risk are directly
related to the health and healthcare consumption habits of all the members of the risk pool. As
the post-vasectomy head of a healthy household, do I really want to be swimming in the
Obamacare risk pool with millions of morbidly obese, perpetually pregnant, HIV infected drug
abusers? No. It is too expensive!
What to do? Well, what do many smart employers in Texas do to save money with Worker's Compensation
Insurance? They self-insure! They have money put away in case of an emergency. If they have an employee
that is injured, then they negotiate directly with the healthcare providers, and pay deep
discounts well below the statutory Worker's Compensation allowable, which we learned earlier is
usually the highest allowable. They pay themselves a premium each month, which is effectively a
forced savings plan. Sometimes, these companies may also purchase a relatively inexpensive
health insurance plan called catastrophic, just in case a really big and expensive event
occurs, like the whole oil refinery blows up and puts a few hundred employees in the hospital.
However, if nothing happens, and the employees don't have any accidents, the company gets to
keep most of the money, instead of giving it all to the insurance companies!
Hmmm. I wonder. Could I do that for my health insurance? Yes, and in fact mrs_horseman and I
do exactly this. We have a high-deductible catastrophic health insurance plan and a $600
savings line item in our budget that we pay ourselves every month. We bet on ourselves to be
healthy, unlike an HSA, where you bet on yourself to be unhealthy. This is true, and why we
simply refuse to take the pre-tax bait of an HSA.
"... our intelligent algorithm using state of the art innovative techniques of automation innovation disruption innovation disruption automatically sends orders to police and judges to prepare and serve pay or stay warrants, making sure your debtor goes to jail for their crime! ..."
"All 51 startups that debuted at Y Combinator W17 Demo Day 2" [
TechCrunch
]
(
day
one
). This is a good one:
Collectly helps doctors collect 2x's more debt than they have before. It's a business with
$280 billion sent to debt but the debt collectors only collect on average up to 20%. The founder
is a former CEO of a debt collection agency and collected over $100 million before
The acerbic Pinboard comments:
D Pinboard * Follow
@Pinboard
YC so far: surreptitious recording of phone calls, bus tickets for
the starving, debt collection, go live in a box, cow collars,
chatbots
Collectly
is some really depressing stuff. Wow. More from their website.
3. Transparent collection
Our intelligent software automatically reaches out to customers that didn't pay in
time, so you will never need to manually chase them again. And you can see every
action on every case.
Totaly fair.
Totaly fair? I had to read it twice. Is that a typo? Or does it mean something?
Next up:
our intelligent algorithm using state of the art innovative
techniques of automation innovation disruption innovation disruption automatically
sends orders to police and judges to prepare and serve pay or stay warrants, making
sure your debtor goes to jail for their crime!
Edit: Weird, this went in the wrong place. Oh well.
"... Probably the most telling example on neoliberal transformation is transformation of healthcare. ..."
"... Mulligan's research shows how "market values come to displace competing notions of what is "good" or "right" in health care" (Mulligan 2010:308–309). She argues that quality in health care is not only a technical matter for evaluating the performance of systems, but, more importantly, it is a particular epistemology, a specific way of knowing. ..."
"... Managing for-profit health care systems successfully requires innovative mechanisms of population control (Abadía-Barrero et al. 2011), including people's acceptance of market principles. ..."
"... In this historical context, what is crucial is the understanding of the relationship between techniques of governance and the production of social inequality (i.e., an ideological domination reflected in people's support for political practices that are antithetical to their interests). ..."
"... James began his career as a broker on Wall Street. In 1984 he left the financial world and founded MultiCare, which grew to be a largest private EMS operation in the Northeast operating 140 ambulances in the New Jersey, New York, and Philadelphia region. ..."
Several anthropologists have written about how "market ideology and corporate structures
are shaping medicine and health care delivery" (Horton et al. 2014; Lamphere 2005; Rylko-Bauer
and Farmer 2002:476).
Mulligan's research shows how "market values come to displace competing notions of what
is "good" or "right" in health care" (Mulligan 2010:308–309). She argues that quality in health
care is not only a technical matter for evaluating the performance of systems, but, more importantly,
it is a particular epistemology, a specific way of knowing.
The information that is produced in technical public health policy terms, and, I would add,
in technical legal terms, is "a knowledge-making practice that creates information about the
health care system and for managing the system in new ways" (Mulligan 2010:309).
Managing for-profit health care systems successfully requires innovative mechanisms
of population control (Abadía-Barrero et al. 2011), including people's acceptance of market
principles.
In this historical context, what is crucial is the understanding of the relationship
between techniques of governance and the production of social inequality (i.e., an ideological
domination reflected in people's support for political practices that are antithetical to their
interests).
According to Fassin (2009), Foucault's undeveloped concept of a Politics of Life can illuminate
how in regulating populations and normalizing societies, moral ideas about the meaning of life
and about how life is valued are enforced.
An understanding of moral definitions of human life must take into account how history becomes
embodied, which then illuminates the political tensions that support differential values by
which life is organized, represented, and responded to, for example through public policy (Fassin
2007).
An interesting example of how pervert the healthcare system became in the USA under neoliberalism
is proliferation of private ambulance services which are technically always "out of network" and
after providing services (often non-essential) bill outrageous amount to lemmings who do not know
how to fight the system. Average private ambulance bill is probably around $5K in the USA. If
you have insurance your bill will be around ~$3.5K
This so called differential billing in now outlawed in a couple of states, but still is legal
in most states.
This industry also creates specialized collector agencies that deal almost exclusively with
collecting ambulance bills like Revenue Guard - Ambulance Billing & Financial Management (
https://www.revenue-guard.com/)
== quote ==
Revenue Guard Executive Team
James J. Loures, President & CEO James began his career as a broker on Wall Street. In 1984 he left the financial world and
founded MultiCare, which grew to be a largest private EMS operation in the Northeast operating
140 ambulances in the New Jersey, New York, and Philadelphia region. After merging MultiCare
with the publicly traded Rural-Metro in 2001, James then founded Revenue-Guard in 2004. The company
has grown to be a premier provider of EMS revenue cycle and management services in the hospital
marketplace, and currently bills over 120 million in revenue annually for their clients. James
studied economics at Rutgers University .
Steven J. Loures, Co-Founder and Chief Operations Officer
Steven Loures has 30 years of experience in the Emergency Medical Services / Mobile Health Services
field and is considered an expert in revenue cycle, compliance and improving ambulance service
operating margins. His real-world revenue cycle knowledge combined with 20 years of managing ambulance
operations uniquely differentiates himself with a comprehensive industry perspective. His leadership
has provided client confidence to initiate targeted change knowing his proven track record. He
is the point of contact for all new and existing clients.
Prior to his current role Steven was the New Jersey Division General Manager of Rural Metro
Ambulance. Rural Metro is a large nationwide provider of Emergency Medical Services. He was responsible
for oversight of 350 employees, 6 operating locations in three states including New Jersey, Pennsylvania
and New York City. Additionally, Steven's responsibilities included all budgets, revenue cycle
management, billing compliance, and Sarbanes Oxley financial controls.
Prior to Rural Metro Steven was a Commercial Lear Jet Pilot. The operation provided nationwide
long distance critical care air ambulance services. Steven graduated from Embry-Riddle Aeronautical
University, Daytona Beach Florida with his Federal Aviation Administration Commercial, Multi-Engine,
and Instrument ratings. Early in his career path Steven was a certified NJ paramedic at age 21
and one of the youngest certified paramedics in New Jersey.
Stephanie Dall, Vice President of Finance
Stephanie joined Revenue-Guard in 2005 and is responsible for Finance, Administration, Compliance
and client reporting. She has 20 years experience in finance and administration with Rural-Metro
Inc. the leading EMS provider in the nation. Stephanie develops budgets and establish performance
metrics for Revenue-Guard. Stephanie has a bachelors degree in accounting from Rutgers University.
Jennifer Aldana, Vice President of Revenue Cycle
Jennifer joined Revenue-Guard in 2007 to manage and run the billing services division. She manages
a staff of 60 billing specialist processing over $120M in ambulance claims annually. Jennifer
is a former revenue cycle manager at Rural-Metro The country's largest EMS service based in Scottsdale,
Arizona. She handles all system customizations, ePCR integration and client support services.
Jen studied at Pace University in New York City.
"... Successful medical coders learn and follow coding guidelines and use them to their benefit. Often if a claim is denied incorrectly, medical coders and billers use coding guidelines as a way to appeal the denial and get the claim paid. ..."
"... Each diagnosis code has to be coded to the highest level of specificity , so the insurance company knows exactly what the patient's diagnosis was. ..."
"... I've helpfully underlined places where an "unusual opportunity for profit" might be spotted and amplified; after all, it's not the coder's job to set policy in borderline cases; that's for management. ..."
"... A pair of transposed digits in a medical identification number was the difference between insurance coverage for Mike Dziedzic and the seemingly never-ending hounding for payment by the hospitals that cared for his dying wife. The astute eye of a medical billing advocate who Dziedzic hired for help caught the innocuous mistake - the sole reason his insurance company had refused to pay more than $100,000 in claims that had piled up and why collectors were now at his doorstep. ..."
"... Had it remained unnoticed - as often happens to patients faced with daunting medical debt - Dziedzic said, he most surely would have lost his Rifle home, his way of life and had little choice but to live in bankruptcy. ..."
"... thousands of providers turned to more expensive Medicare billing codes, while spurning use of cheaper ones. They did so despite little evidence that Medicare patients as a whole are older or sicker than in past years, or that the amount of time doctors spent treating them on average was rising. ..."
"... More than 7,500 physicians billed the two top paying codes for three out of four office visits in 2008, a sharp rise from the numbers of doctors who did so at the start of the decade. Officials said such changes in billing can signal overcharges occurring on a broad scale. Medical groups deny that. ..."
"... The most lucrative codes are billed two to three times more often in some cities than in others, costly variations government officials said they could not explain or justify. In some instances, higher billing rates appear to be associated with the burgeoning use of electronic medical records and billing software. ..."
"... eight of 10 bills its members have audited from hospitals and health care providers contain errors. ..."
"... It's estimated that at least 3 percent of all health care spending – roughly $68 billion – is lost to fraud and billing errors annually. ..."
"... Accounts of medical billing errors vary widely. While the American Medical Association estimated that 7.1 percent of paid claims in 2013 contained an error, a 2014 NerdWallet study found mistakes in 49 percent of Medicare claims. Groups that review bills on patients' behalf, including Medical Billing Advocates of America and CoPatient, put the error rate closer to 75 or 80 percent. ..."
"... Most services don't get paid based on ICD, they get paid based on HCPCs/CPTs (healthcare procedure codes) which is what is shown in the nerdwallet image. Also revenue codes will be used for facility services (such as the room charge in image). ..."
"... ICD-Diaganosis codes just tell you what conditions the provider diagnosed you with. ICD-Procedure codes are sometimes used for payments but usually only on inpatient claims. ..."
From my review of Akerlof and Shiller's Phishing for Phools ,
November 25, 2015 :
As businesspeople choose what line of business to undertake - as well as where they expand,
or contract, their existing business - they (like customers approaching checkout) pick off the
best opportunities. This too creates an equilibrium. Any opportunities for unusual profits are
quickly taken off the table, leading to a situation where such opportunities are hard to find.
This principle, with the concept of equilibrium it entails, lies at the heart of economics.
The principle also applies to phishing for phools. That means that if we have some weakness
or other - some way in which we can be phished for fools for more than the usual profit - in the
phishing equilibrium someone will take advantage of it . Among all those business persons
figuratively arriving at the checkout counter, looking around, and deciding where to spend their
investment dollars, some will look to see if there are unusual profits from phishing us for phools.
And if they see such an opportunity for profit, that will (again figuratively) be the "checkout
lane" they choose.
And economies will have a "phishing equilibrium," in which every chance for profit more than
the ordinary will be taken up.
We might summarize Akerlof and Shiller as "If a system enables fraud, fraud will happen," or,
in stronger form, "If a system enables fraud, fraud will already have happened."[1] And as we shall
see, plenty of "opportunities for unusual profits" exist in medical coding.
Successful medical coders learn and follow coding guidelines and use them to their benefit.
Often if a claim is denied incorrectly, medical coders and billers use coding guidelines as a
way to appeal the denial and get the claim paid.
Hmm. "Their" benefit. Here are the guidelines:
The specificity of the diagnosis code: Each diagnosis code has to be coded to
the highest level of specificity , so the insurance company knows exactly what the
patient's diagnosis was.
The correct reporting of procedure codes: There are too many rules and regulations
to go into here. There are specific ways to code each visit , which help identify
the service that was provided to the patient.
Reasonable and customary charges: Regulating bodies also suggest that providers
charge only "reasonable and customary" rates for their services. This prevents over-inflation
of medical fees.
Procedure code modifiers: When certain procedure codes are sent on the same claim
form, they sometimes require medical billing modifiers , which help differentiate
between the codes that were charged on the date of service.
I've helpfully underlined places where an "unusual opportunity for profit" might be spotted
and amplified; after all, it's not the coder's job to set policy in borderline cases; that's for
management. The
Denver Post gives a horrific example:
Miscoding Fictions, frauds found to abound in medical bills
A pair of transposed digits in a medical identification number was the difference between
insurance coverage for Mike Dziedzic and the seemingly never-ending hounding for payment by the
hospitals that cared for his dying wife. The astute eye of a medical billing advocate who Dziedzic
hired for help caught the innocuous mistake - the sole reason his insurance company had refused
to pay more than $100,000 in claims that had piled up and why collectors were now at his doorstep.
Had it remained unnoticed - as often happens to patients faced with daunting medical debt
- Dziedzic said, he most surely would have lost his Rifle home, his way of life and had little
choice but to live in bankruptcy.
But the Center's analysis of Medicare claims from 2001 through 2010 shows that over time,
thousands of providers turned to more expensive Medicare billing codes, while spurning use of
cheaper ones. They did so despite little evidence that Medicare patients as a whole are older
or sicker than in past years, or that the amount of time doctors spent treating them on average
was rising.
More than 7,500 physicians billed the two top paying codes for three out of four office
visits in 2008, a sharp rise from the numbers of doctors who did so at the start of the decade.
Officials said such changes in billing can signal overcharges occurring on a broad scale. Medical
groups deny that.
The most lucrative codes are billed two to three times more often in some cities than in
others, costly variations government officials said they could not explain or justify. In some
instances, higher billing rates appear to be associated with the burgeoning use of electronic
medical records and billing software.
Now, I'll be the first to admit that I can't quantify the impedance mismatches, the miscoding,
and the upcoding. Regardless, medical coding is
the key dataflow in the healthcare system :
"Roughly $250 billion is moving through those codes," [says Steve Parente, professor of finance
at the Carlson School of Management at the University of Minnesota]. On top of that, about 80%
of medical bills contain errors, according to Christie Hudson, vice president of Medical Billing
Advocates of America, making already-expensive bills higher. Today's complex medical-billing system,
guided by hundreds of pages of procedure codes, allows fraud, abuse and human error to go undetected,
Hudson says. "Until the fraud is detected in these bills the cost of health care is just going
to increase. It's not accidental. We've been fighting these overcharges they continue to happen
and we continue to get them removed from bills." These errors, which are hard to detect because
medical bills are written in a mysterious code, can result in overcharges that run from a few
dollars to tens of thousands.
Experts say there are tens of thousands more like Dziedzic across the country with strangling
medical debts.
Medical Billing Advocates of America, a trade group in Salem, Va., says that eight of 10
bills its members have audited from hospitals and health care providers contain errors.
It's estimated that at least 3 percent of all health care spending – roughly $68 billion
– is lost to fraud and billing errors annually. Some say new reform laws will only make things
worse." Others say that errors occur largely because of "the complexity of deciphering bills and
claims weighted down by complex codes."
Accounts of medical billing errors vary widely. While the American Medical Association
estimated that 7.1 percent of paid claims in 2013 contained an error, a 2014 NerdWallet study
found mistakes in 49 percent of Medicare claims. Groups that review bills on patients' behalf,
including Medical Billing Advocates of America and CoPatient, put the error rate closer to 75
or 80 percent.
Gee, I wonder if the errors are randomly distributed?
Neoliberal "Consumer"-Driven Solutions
My guts have started to gripe, so I won't go into detail about how you too, the citizen
, can learn medical billing codes if you want to dispute your bill. See this cheery post from
NerdWallet
on "How to Read Your Medical Bill :
Once you have the itemized medical bill for your care, you're ready to analyze it for mistakes
and overcharges.
Your medical bill is going to be chock-full of codes and words you may not understand, so the
first step is gathering resources that will translate them into plain English.
One useful adjunct to the coding discussion concerns other billing details such as meds. There
is wide variability in prices charged, and when you see $160 for a single pill (e.g., Hexabrix)
or $26 for a single Tylenol, then something is not right. Of course, that does not include any
allocation for nurses, pharmacy or other potential costs, since those are rolled into other line
items to decipher. When hospital billing reps are asked about the reasonability and basis of their
charges, they spout the canned line about being in line with their local competitors.
Why not have some program with mutual insurance companies, removing in theory some of the profit
that is driving the typical health care insurers?
Most services don't get paid based on ICD, they get paid based on HCPCs/CPTs (healthcare
procedure codes) which is what is shown in the nerdwallet image. Also revenue codes will be used
for facility services (such as the room charge in image).
ICD-Diaganosis codes just tell you what conditions the provider diagnosed you with. ICD-Procedure
codes are sometimes used for payments but usually only on inpatient claims.
_________________________________
Additionaly, coding also affects "risk adjustment" in Medicare Advantage and ACA payments and
this form of payment does use ICD codes. They use the codes on the claims to determine how "sick"(has
conditions that will cost more) each member is and give insurers more or less money based on the
average risk scores of their members. Since it relies on coding this system is also subject to
gaming.
In Medicare Advantage this is done relative to non-Medicare Advantage population, so if the
MA plans are upcoding they get more money from Federal government. In 2010 CMS was given the ability
to use some adjustment factors to MA payments to address the issue but I don't really know how
effective it is.
In ACA this is done relative to all the other insurers in the individual/small group market(so
all the money is changing hands between the insurers). More established plans generally do better
since they have more data on members from before ACA to make sure they get coded in addition to
resources they probably built from Medicare Advantage. This ends up disadvantaging smaller and
newer plans like co-ops.
_____________
"... That is not the bill you want. To know what you're actually being charged for, you'll want to call the clinic or hospital and ask for the complete, itemized bill for all services you received, with codes. It is your right to know what you're being charged for, but you will probably have to call and request the detailed charges. The body of that bill should look more like this: ..."
Clerical errors are more likely than you might think, says Gross, who has seen small mistakes in
names and addresses result in huge billing complications. Before you move on, make sure your name,
address, insurance information and dates of care are correct on the top of the bill.
When you receive inpatient or outpatient care, the first statement you'll receive is most likely
a summary bill. Often, but not always, health care providers will send only a summary of charges
with a final charge at the end. The body of the bill has a few generic categories and no codes, looking
something like this:
That is not the bill you want. To know what you're actually being charged for, you'll want
to call the clinic or hospital and ask for the complete, itemized bill for all services you received,
with codes. It is your right to know what you're being charged for, but you will probably have to
call and request the detailed charges. The body of that bill should look more like this:
Once you have the itemized medical bill for your care, you're ready to analyze it for mistakes
and overcharges.
Next, know what the codes are for
Before we get into the nuts and bolts of reading your medical bill, it's worth noting that there's
more than one type of code that may be listed on your bill.
HCPCS Level I, or CPT Codes, are universal, used by all providers
in the U.S. and consist of five digits that identify procedures or tests. Often, they are listed
as service codes.
HCPCS Level II Codes identify supplies or products used during your visit. These
codes often start with a letter, rather than a number, but are also referred to as service codes.
"... Record the names and phone numbers of the people you are dealing with. ..."
"... Document the date, time, and results of your phone calls. ..."
"... Pay something - even a small amount - on each bill each month as a gesture of good faith. ..."
"... Be aware, though, that some services charge high fees and do nothing to really help reduce your debt. ..."
"... Don't ignore bills. Though tempting, this is not a good strategy. Hospitals and providers are more likely to negotiate with you if you contact them immediately. ..."
"... Don't transfer debt to a credit card. Most experts warn that this is a poor choice for paying off medical debt ..."
Unless you have successfully challenged your bill, you are responsible for paying all of your medical
bills. If you cannot pay, here are some things to consider.
Try to negotiate a payment plan. Your hospital or provider may be willing to accept smaller
monthly payments. Keep in mind that your payments generally need to be reasonable and you must
keep up with your payments. In its
advice to parents of chronically ill children (link is external) , the American Academy of
Family Physicians recommends the following:
Notify the appropriate offices quickly.
Keep in touch with your creditors.
Record the names and phone numbers of the people you are dealing with.
Document the date, time, and results of your phone calls.
Pay something - even a small amount - on each bill each month as a gesture of good faith.
Apply for Wisconsin
Medicaid or
BadgerCare Plus
. If you are eligible, Medicaid may pay for some of your existing medical bills. Wisconsin
Medicaid coverage can begin as early as the first day of the month, three months before the month
you apply, if you would have been eligible in those months, so apply as soon as possible.
Go for credit counseling. Be aware, though, that some services charge high fees and do
nothing to really help reduce your debt. Make sure you are working with a credit counseling
service (also known as an adjustment service agency) that is licensed by the Wisconsin Department
of Financial Institutions.
A
list of licensed credit counselors (link is external) can be found at the Department of
Financial Institution's website. If you have questions or complaints about a particular agency,
call their Licensed Financial Services Section at (608)-261-7578.
Be creative about finding help from outside sources. Charitable foundations, civic organizations
and churches and community groups might be able to help. The
Patient Pal
(link is external) (PDF, 197 KB) from the
Patient Advocate Foundation (link is
external) includes some fundraising ideas for those with high medical bills.
Don't ignore bills. Though tempting, this is not a good strategy. Hospitals and providers
are more likely to negotiate with you if you contact them immediately.
Don't transfer debt to a credit card. Most experts warn that this is a poor choice for paying
off medical debt for two reasons:
The interest rates on your credit card will add significantly to your total payment.
Transferring medical debt to a credit card may affect your eligibility for Medicaid. Some
medical costs can be deducted from gross income to determine your Medicaid eligibility. Medical
debt on a credit card may no longer qualify as medical debt.
Dealing with collection agencies
If your hospital or other health care provider has turned your bill over to a collection agency,
you are protected against harassment by the Fair Debt Collection Practices Act (FDCPA).
Disputing a Debt (link is external) , from the Wisconsin Department of Financial Institutions,
provides information on how to deal with collection agencies.
If you have questions about your rights or the conduct of a collection agency, contact the Department
of Financial Institutions at (608) 264-7969, or 1-800-452-3328 (in Wisconsin only).
Medical debt collectors must abide by specific regulations, as set forth by the
Fair Debt Collection Practices Act . Collectors cannot harass or lie to debtors, or perform any
other practices deemed unfair.
You can get a free Kindle version of "Debt Collection Answers" ebook on Amazon
here .
Notable quotes:
"... We have heard from consumers who first hear about a medical bill from a collection agency. There is no federal law that protects you from this type of situation. ..."
Having even a small medical debt reported as past due or in collections can seriously damage your
credit history, you may be tempted to pay just to protect your credit.
Some medical providers may even try to pressure you into paying your debt owe by refusing to provide
you (or one of your family members) with additional medical care until you do. Some of them may even
refuse you future care while you are paying off your debt through an installment plan! Others may
have a policy that as long as you owe them money, you must pay up-front for all future medical services
they provide to you.
Warning: Aggressive medical providers can be a special problem for seniors living on fixed
incomes when their spouses have been hospitalized or have accumulated a large outstanding bill with
one or more of their doctors.
When Can I Be Sent to Collections On a Medical Bill?
If at all possible, you want to keep a medical bill out of collections. Once it is turned over
to a collection agency, it will likely appear on your credit reports as a collection account and
damage your credit rating.
Your medical debt may be turned over to collections:
If you are making payments. Even if you are making payments, you may find your account
turned over to collections with no advance warning . In addition, if you are late with a payment
under a payment agreement - even by one day - you may find your account in collections. There
is no federal law that stops a medical provider from turning an unpaid account over to collections
just because you are making payments.
While you are disputing a bill. If you have not paid a bill because you are disputing it,
or if you are waiting for your insurance company to pay it, beware! Your bill may be turned over
to collections with no advance warning.
If a medical bill remains unpaid - even if you never received a billing statement! We
have heard from consumers who first hear about a medical bill from a collection agency. There
is no federal law that protects you from this type of situation.
How can you protect yourself from medical debt collection? Don't ignore medical bills. Talk to
the medical provider. Get everything in writing, or follow up in writing yourself
... ... ...
If You Have Insurance and Your Insurer Refuses to Pay All or a Portion of Your Medical Bills
It's not unusual for health insurers to deny coverage for medical care. If that happens to you
and you believe that the care should be covered, or if your insurer pays some but not all of your
medical bill and you believe it should cover the entire bill, here's what we recommend:
Review your health insurance policy for an explanation of why the insurance company made the
decision it did.
If you don't find a good explanation in your policy, call the company's customer service office.
If you are unhappy with its explanation, contact your insurance agent or your health plan administrator,
if you receive your health insurance through your employer.
If your agent or the plan administrator is unable to help you with your claim, appeal the
decision of your health insurance company. Your agent or plan administrator can tell you how to
do that. At the same time, you may want to file a complaint against your insurance company with
your state's insurance commission or department, which may have a complaint resolution process.
Sometimes, filing this kind of complaint will make an insurance company rethink its approach to
a claim in order to avoid a problem with the state commission or department that is regulating
it.
Contact a consumer law attorney with experience in medical debt collection issues for help
if none of the actions you've taken have gotten you the results you had hoped for. Simply receiving
a letter from an attorney may get your insurance company to reverse its decision. It's also possible
that you may have to file a lawsuit against the company in order to get action. However, an attorney
will not take your case unless he or she thinks that you have a strong basis for a lawsuit and
a good chance of winning. If the attorney does, he or she will probably take your case on a contingent
fee basis, which means that you won't have to pay the attorney an up-front fee but instead, the
attorney will be paid by taking a share of whatever money he may win for you.
"... The CFPB says debt collection is a multi-billion dollar industry affecting 70 million consumers. People are most often contacted about medical and credit card debt. And more consumers complain to the CFPB about debt collection than any other financial product or service. ..."
"... Debt collectors can contact you by phone, letter, email or text message, as long as they follow the rules and disclose that they are debt collectors. It's against the law for a debt collector to pretend to be someone else to harass, threaten or deceive you. ..."
"... Collectors cannot lie to collect a debt, by falsely representing themselves or the amount you owe. And other than trying to obtain information about you, such as a telephone number or whereabouts, a debt collector generally is not permitted to discuss your debt with anyone other than you, your spouse, or your attorney. ..."
"... Also when you pay them off keep the document marked paid in full or zero balance or whatever else the send you on file including your financial proof (canceled check, money order, credit card receipt) keep it until you die! ..."
"... Debt industry buys billions of dollars of dead debt. 90% does end up as default judgement because scared debtors do not have the money to hire a attorney or do not know what to do. The other 10% of debtors who hire attorneys are off the hook. ..."
"... Consumer debts are self inflicted foolishness, medical debts aren't, but just goes to show the Empire is ran by business interests who refuse to allow any type of universal medical and have installed a system that allows them profits for illness and death ..."
A new Consumer Financial Protection Bureau report found that more than one in four consumers felt
threatened when contacted by debt collectors. The first-ever national survey of consumer
experiences with debt collectors found consumers often faced calls that came too often, at odd
hours and contained warnings of jail time and other threats. Some were contacted for debts they
didn't owe. And many said when they asked the collector to stop contacting them, the request was
ignored.
CFPB Director Rich Cordray said the report casts a "troubling light" on the industry, and that
the bureau is working to stop abuses. But what are your rights when facing off with a debt
collector?
A few things to know:
YOU ARE NOT ALONE
The CFPB says debt collection is a multi-billion dollar industry affecting 70 million
consumers. People are most often contacted about medical and credit card debt. And more consumers
complain to the CFPB about debt collection than any other financial product or service.
The Federal Trade Commission, which enforces the Fair Debt Collection Practices Act, also said
debt collectors generate more complaints to its offices than any other industry. While many debt
collectors are careful to comply with consumer protection laws, some engage in illegal practices.
YOU ARE PROTECTED
The Fair Debt Collection Practices Act provides protection for those being pursued for personal
debts, such as money owed on a credit card account, an auto loan or a mortgage. It doesn't cover
debts incurred to run a business.
YOU HAVE RIGHTS
Debt collectors can contact you by phone, letter, email or text message, as long as they
follow the rules and disclose that they are debt collectors. It's against the law for a debt
collector to pretend to be someone else to harass, threaten or deceive you.
They may not contact you at inconvenient times or places, such as early in the morning or late at
night. And they may not contact you at work if they're told not to.
Debt collectors may not harass, oppress, or abuse you, according to the FTC. That includes
threats of violence or using obscene language. Federal law also limits the number of calls a debt
collector can place.
Collectors cannot lie to collect a debt, by falsely representing themselves or the amount you
owe. And other than trying to obtain information about you, such as a telephone number or
whereabouts, a debt collector generally is not permitted to discuss your debt with anyone other
than you, your spouse, or your attorney.
YOU CAN TAKE ACTION
Report any problems you have with a debt collector to your state Attorney General's office, the
Federal Trade Commission and the Consumer Financial Protection Bureau. Many states have their own
debt collection laws that vary from federal law, so contact your attorney general's office for
help.
Gary G
They are debt collectors the lowest form of bottom feeding #$%$ on the planet.step one,
NEVER tell them any personal information whatsoever.step two, get a phone number and case
number so you can call them back.step three call them from a phone that can record the
conversation (theres an app for that)step three, call them when you are really ready to talk
to them Inform them the call is being recorded. let them know clearly what forms of contact
are and are not acceptable.step four, get the pertinent information about the debt including
the debtor any account numbers and any settlement offers they have. Still NEVER give away any
personal information. once you have all the information you need end the call, if at any time
during the call you feel you are being harassed or intimidated inform them it is not
acceptable (remember you are recording the conversation) and terminate the call. call back
later.Now you are in control and can make informed decisions.If at some point you want/need to
work out a settlement NEVER finalize anything on the phone, GET IT IN WRITING. NEVER, agree to
give them your credit card or banking information under any circumstances!!!once you make an
arrangement keep the printed document with the arrangement on file for the rest of your life.
Also when you pay them off keep the document marked paid in full or zero balance
or whatever else the send you on file including your financial proof (canceled check, money
order, credit card receipt) keep it until you die!
steven
Based on personal experience, the worst debt collectors are of the medical variety. Two
years of a fatal ovarian cancer case overwhelmed not only my finances, but jeopardized my
mental health as well. The only thing that kept me going was the necessity of showing up for
work, and the support of coworkers and (may I say this?) my managers as well.
Mark
Consumer Financial Protection Bureau will be gutted under the GOP agenda. So the next time
some cable company, Wall Street bank, or some other huge corporation screws you over, you'll
have no recourse and you'll be on your own.
pfk
I find tgheses stories and the ads on TV (If you owe $1000 to IRS..., If you have more than
$5,00 credit card debt, Reduce $50,00 debt to $5000..., etc) to e morally contemptible. If you
cannot afford something do not buy it; if you have a job, pay your IRS taxes, etc. I'm tired
paying extra for everything I buy or do for these people who spend and expect someone else
(me) to pay.
a
hogwash! To scare off a junk debt buyer attorney all you need to do is make one call to
your attorney. Many of you collectors "start fake lawsuits" to coerce debtors to pay. With no
filing numbers, court stamps, etc... Once the debtor's attorney files a 'notice of appearance'
and asks for a real lawsuit/trial, what happens? The creditor never files the lawsuit. Why?
Because the junk debt buyer has to PROVE IT. The JDB creditor has no original contract signed
to prove the debt exists, no chain of assignment/invoice to show they have standing to sue
(own the debt) nor the account statements to verify what is owed. They are hoping at best for
default judgements.
Debt industry buys billions of dollars of dead debt. 90% does end up as default judgement
because scared debtors do not have the money to hire a attorney or do not know what to do. The
other 10% of debtors who hire attorneys are off the hook.
You see Junk Debt Buyers buy
debt with no contract signed by debtors, have no invoice they even own this particular debt in
detail and no account statements to verify correct amount owed.
So debtors, beware, pay the few hundred dollars to your attorney to ask for a lawsuit and
notice of appearance and see how fast that debt collector disappears. 99% of junk debt
buyers/creditors buy unwarranted debt and CAN NOT PROVE IT IN COURT. There is a disclaimer on
the debt stating there is no contract, invoice that it is sold nor account statements offered.
Just sue these junk debt buyers and they go away. If they sell the debt to another JDB again
sue again and they drop the debt again. Resold debt has even less chance of winning in court
because even less proof is available every time it is sold.
But DO NOT AVOID the fake lawsuit. If you do the creditor gets the default judgement and will
garnish wages, lien your house, and will win. Now if the original creditor files the lawsuit
you will most likely lose and owe (they have all the proof in their records). So in this case
make a settlement offer of lump sum repay or payments you can afford.
Call me scum or whatever but I have used this strategy and it works. After a few decades of
paying usurious interest rates I have some cash finally coming back; and no need to file
bankruptcy. After 7 years it drops off your credit report and credit score goes way up. Make
it anywhere to 4-7 years (depending on your state law timeframe) and the statute of
limitations kicks in and money not legally owed any longer. Just do not make any payments on
it to renew statute of limitations. No problems! Hell I gambled the money away anyway, how was
I suppose to get it back -Ha, Ha. Joke was on the JDB in my case!
Gregory
Very poor article. Take it from some one who was being threatened for some one else's debt.
A certified letter to the debt collector explaining you do not owe the debt means that once
they receive the letter they can no longer contact you.
Violation of that law carries a 10,000 dollar fine. If the amount is in dispute the same
tactic works, except they can contact you with the proof of what you owe. A lot times this
involves too much work and they do not pursue it. So if they do not pursue it once the Statute
of Limitations is over the debt can no longer be collected.
The limit varies by State Law and amount. Finally be aware that uncollected debts are often
sold and the new "owner" of the debt may try to collect on it. Again a certified letter stops
them as you have proof of notification that the debt is not owed. I hope this helps the
victims out there.
Chub
Buying debt has become a large industry that attracts a lot of crooks. Companies buy debt
for as little as a dime on the dollar! The original lender benefits because they are getting a
little something out of a debt that they have no hope of collecting. The buyer of the debt
benefits because the potential profit is very
Many of the people buying debt aren't your traditional debt collection agency. They are many
times just an individual with a cell phone who could bend the rules because they can change
their name and location as easy as you can report their activity. Many times you are just
dealing with thugs with cellphones. If you owe them, don't be afraid to offer a lesser amount
because they had bought the debt so cheap that they may still make a pretty good profit.
Chief_blamestormer
Realize that some debtors never borrowed a dime. It could be the result of a civil
judgement. If you think all civil judgements are fair, then have a look at the cases in your
local courthouse, or serve a couple rounds of jury duty.
W,
19 hours ago
Industry? There's nothing industrious about. Bill collectors are mostly thugs who can't get
real jobs so they have to leverage their values off other people's misery.
Consumer debts
are self inflicted foolishness, medical debts aren't, but just goes to show the Empire is ran
by business interests who refuse to allow any type of universal medical and have installed a
system that allows them profits for illness and death
, which is similar to a developing
country, not a developed superpower.
"In a report from Bankrate.com, the firm found that almost six in 10
Americans don't have enough savings to pay for a $500 car repair or a $1,000
emergency room bill" [
247
Wall Street
]. "While Millennials may be looked down on by older
demographics, they are the most equipped generation to pay for an unexpected
expense using their savings. It was found that 47% of those within the ages
of 18 to 29 responded that they would use their savings to cover such a
burden, up from 33% in 2014." I'd argue that's not virtue, but a rational
response to the neoliberal destruction of universal benefits and government
services generally.
Re: Bankrate story – is there such thing as a $1k ER bill anymore? We
paid nearly $3k for our unexpected trip, which involved 15 minutes with the
doc, no tests or scans, and only a single dose of Childrens' Tylenol for
consumables. (5 year old tried to poke his eye out with a stick and failed –
but only just).
And of course our crapified insurance hadn't hit the deductible so we had
to pay the whole bill out of pocket.
I'm lucky - I only have a $150 deductible, which is what I paid when I
needed five stitches in my hand last year. The total bill was "only"
about $1250, probably because I never saw an actual doctor. A nurse
practitioner sewed me up. The explanation of benefits from the insurance
company later showed that they only paid the hospital about one third of
the billed price. I'm sorry that you had to pay the whole thing; I guess
the insurance companies only enforce their standard payable fees when
it's their money on the line.
btw..Animal bites should be left open and bandaged and treated w/
antibiotic so they heal from the inside out..
I remember in my misspent college youth an idiot scuba diver in
Honduras (feeding a moray eel cheese wiz out of a can, guess what
happened when she ran out?) who came to my friend's dad (a surgeon)
insisting he sew her up.
He only bandaged her with butterfly bandages and gave her some
kick-ass antibiotics. She was sure she was being undeserved (w/ gratis
treatment) because he refused to sew her up, potentially trapping an
infection.
I had a similar experience: 3 stitches on my sons finger. Treated by
nurse (no doc), sutures and lidocaine was $1800. It got me wondering
about how anyone could hope to reform health care when the accounting is
so completely out of whack with reality.
"Hierarchies aren't natural phenomena
within the human race. Outside of parenting, human beings aren't born with
the inclination to be ruled, controlled, 'managed,' and 'supervised' by
other human beings" [
The
Hampton Institute
]. Hierarchies are artificial constructs designed to
serve a purpose. They are a necessity within any society that boasts high
degrees of wealth and power inequities. They are a necessity for maintaining
these inequities and ensuring they are not challenged from below."
"In a report from Bankrate.com, the firm found that almost six in 10
Americans don't have enough savings to pay for a $500 car repair or a $1,000
emergency room bill" [
247
Wall Street
]. "While Millennials may be looked down on by older
demographics, they are the most equipped generation to pay for an unexpected
expense using their savings. It was found that 47% of those within the ages
of 18 to 29 responded that they would use their savings to cover such a
burden, up from 33% in 2014." I'd argue that's not virtue, but a rational
response to the neoliberal destruction of universal benefits and government
services generally.
"[A] good deal of [Wallace] Stevens's poetic output conveyed a feeling of
sehnsucht
("inconsolable longing"). For example, in 'Sad Strains of
a Gay Waltz,' Stevens writes of American southerners (although the words
just as easily apply to their author) as 'voices crying without knowing for
what, / Except to be happy, without knowing how.' The object of Stevens's
inconsolable longing changed over time. In his early professional days, when
he first moved to New York City, it was his hometown of Reading, Pa. Writing
to his future wife, Elsie, Stevens lamented that he 'lost a world' when he
left there" [
The
American Conservative
].
Re: Bankrate story – is there such thing as a $1k ER bill anymore? We
paid nearly $3k for our unexpected trip, which involved 15 minutes with the
doc, no tests or scans, and only a single dose of Childrens' Tylenol for
consumables. (5 year old tried to poke his eye out with a stick and failed –
but only just).
And of course our crapified insurance hadn't hit the deductible so we had
to pay the whole bill out of pocket.
I'm lucky - I only have a $150 deductible, which is what I paid when I
needed five stitches in my hand last year. The total bill was "only"
about $1250, probably because I never saw an actual doctor. A nurse
practitioner sewed me up. The explanation of benefits from the insurance
company later showed that they only paid the hospital about one third of
the billed price. I'm sorry that you had to pay the whole thing; I guess
the insurance companies only enforce their standard payable fees when
it's their money on the line.
btw..Animal bites should be left open and bandaged and treated w/
antibiotic so they heal from the inside out..
I remember in my misspent college youth an idiot scuba diver in
Honduras (feeding a moray eel cheese wiz out of a can, guess what
happened when she ran out?) who came to my friend's dad (a surgeon)
insisting he sew her up.
He only bandaged her with butterfly bandages and gave her some
kick-ass antibiotics. She was sure she was being undeserved (w/ gratis
treatment) because he refused to sew her up, potentially trapping an
infection.
I had a similar experience: 3 stitches on my sons finger. Treated by
nurse (no doc), sutures and lidocaine was $1800. It got me wondering
about how anyone could hope to reform health care when the accounting is
so completely out of whack with reality.
1. Pursuant to the New York Insurance Law, may a medical provider, such as an ambulance company
issued a certificate to operate under N.Y. Pub. Health Law § 3005, bill a patient directly for prehospital
emergency ambulance services where a New York authorized insurer or health maintenance organization
("HMO") has made partial payment of a bill?
2. Pursuant to the New York Insurance Law, may a medical provider, such as an ambulance company
issued a certificate to operate under N.Y. Pub. Health Law § 3005, bill a patient directly for prehospital
emergency ambulance services where a New York authorized insurer or health maintenance organization
has denied payment entirely?
Conclusions:
1. Pursuant to N.Y. Ins. Law §§ 3216(h)(24), 3221(l)(15) and 4303(aa) (McKinney Supp. 2006), the
ambulance company may not bill a patient directly for prehospital emergency ambulance services where
a New York authorized insurer or HMO has made partial payment of a bill under an insurance contract
that provides major medical or similar comprehensive-type coverage. However, if such a contract is
not involved, these provisions do not apply and there is no prohibition in the Insurance Law against
the ambulance company billing the patient directly for the balance of the bill.
2. Yes. The ambulance company may bill a patient directly for prehospital emergency ambulance
services where a New York authorized insurer or HMO has denied payment entirely, subject to the remedies
available to the patient.
Facts:
This inquiry is general in nature.
Analysis:
N. Y. Ins. Law § 4303 (McKinney Supp. 2006) applies to non-profit health plans and HMO's. Although
HMO's are primarily regulated by the New York Health Department, their subscriber contracts are regulated
by the Insurance Department as if they were subscriber contracts of non-profit health insurers. See
N.Y. Public Health Law § 4406(1) (McKinney 2002).
N.Y. Ins. Law § 4303(aa) (McKinney Supp. 2006) provides, in relevant part, as follows:
(aa)(1) Every contract issued by a hospital service company or health service corporation which provides
major medical or similar comprehensive-type coverage shall include coverage for prehospital emergency
medical services for the treatment of an emergency condition when such services are provided by an
ambulance service issued a certificate to operate pursuant to section three thousand five of the
public health law.
(2) Payment by an insurer pursuant to this section shall be payment in full for the services provided.
An ambulance service reimbursed pursuant to this section shall not charge or seek any reimbursement
from, or have any recourse against an insured for the services provided pursuant to this subsection,
except for the collection of copayments, coinsurance or deductibles for which the insured is responsible
for under the terms of the policy.
(3) An insurer shall provide reimbursement for those services prescribed by this section at rates
negotiated between the insurer and the provider of such services. In the absence of agreed upon rates,
an insurer shall pay for such services at the usual and customary charge, which shall not be excessive
or unreasonable.
(4) The provisions of this subsection shall have no application to transfers of patients between
hospitals or health care facilities by an ambulance service as described in paragraph one of this
subsection. . . .
N.Y. Ins. Law § 3221(l)(15) (McKinney Supp. 2006), which applies to group or blanket accident
and health insurance policies issued by commercial insurers and N.Y. Ins. Law § 3216(h)(24) (McKinney
Supp. 2006), which applies to individual accident and health insurance policies issued by commercial
insurers contain identical provisions.
In accordance with the above, if the insurance contract provides major medical or similar comprehensive-type
coverage, it must include coverage for prehospital emergency medical services for the treatment of
an emergency condition when such services are provided by an ambulance service issued a certificate
to operate pursuant to section three thousand five of the public health law. The insurer must provide
coverage for emergency ambulance services based upon the rates negotiated between the insurer and
the provider of such services. If no participating provider contract exists, the insurer must pay
for the services at the usual and customary charge, which shall not be excessive or unreasonable.
Once the insurer makes payment at the usual and customary charge, the provider must accept such
payment as payment in full. The provider may not bill the patient directly for emergency ambulance
services for the balance of a bill, except for the collection of copayments, coinsurance or deductibles
that the insured is responsible for under the terms of the insurance contract.
Please note that N.Y. Ins. Law §§ 3216(h)(24), 3221(l)(15) and 4303(aa) (McKinney Supp. 2006)
are applicable only to insurance contracts that provide major medical or similar comprehensive-type
coverage. Thus, if such a contract is not involved, these provisions do not apply and there is no
prohibition in the Insurance Law against the ambulance company billing the insured directly. In addition,
these provisions do not address a situation in which a New York authorized insurer or HMO has denied
payment entirely for emergency ambulance services (i.e. where the insurer or HMO states that coverage
was not in effect or that treatment was not medically necessary). In such cases, the ambulance company
may bill the patient directly, subject to the remedies available to the patient.
If the ambulance company or patient disputes a payment made by the insurer or HMO as not constituting
the usual and customary charge or disputes the fact that no payment was made, the ambulance company
or patient may raise the issue with the insurer or HMO and/or file a complaint with the Department's
Consumer Services Bureau.
Lastly, the New York Attorney General's Office has conducted an investigation on balance billing
by ambulance companies. For further information, the inquirer was directed to contact the Attorney
General's Office at (518)474-7330 or access their web site which is located at http://www.oag.state.ny.us.
This opinion does not provide an analysis of the No-Fault Insurance Law, which would result in
a different analysis and conclusion, since the inquirer already had OGC Opinions on this subject.
1 Please note also that this opinion is limited to an interpretation of the New York Insurance
Law. No opinion is rendered on any other laws.
For further information you may contact Associate Attorney Pascale Jean-Baptiste at the New York
City Office.
1 See OGC Opinion No. 03-02-18, dated Feb. 18, 2003 and OGC Opinion No. 03-04-36,
dated April 30, 2003; see also OGC Opinion No. 05-05-29, dated May 28, 2005.
"... Balance billing is on the rise nationally. In 2011, around 8 percent of privately insured individuals used out-of-network care, 40 percent of which resulted in unanticipated medical costs due to balance billing, reports Health Services Research . ..."
"... Balance billing complaints are up 1,000 percent in Texas . ..."
"... The rise in balance billing is partially attributable to a lack of network transparency with patients. ..."
"... The New York Times ..."
"... Kaiser Health News ..."
"... In 2014 Aetna sued a physician at Monmouth Medical Center in Long Branch, N.J., a hospital within Aetna's network, who did not notify a patient he would not accept Aetna's discounted reimbursement rate, according to the lawsuit. The physician charged Aetna $31,939 to treat abdominal pain in the patient. After Aetna paid the amount it deemed reasonable - $2,811, based on Medicare rates - the physician balance billed the patient for an additional $10,635. ..."
Patients, caught in the financial crosshairs, often feel powerless to negotiate costs. Consumer
advocacy groups and federal and state legislators are turning their attention to balance billing
practices this year with renewed vigor, forcing payers and providers to find other ways to settle
financial disagreements.
Here are 20 things to know about balance billing.
1. Balance billing is on the rise nationally. In 2011, around 8 percent of privately insured individuals
used out-of-network care, 40 percent of which resulted in unanticipated medical costs due to balance
billing, reports
Health
Services Research . In 2015, a nationwide study from
Consumers Union found nearly one third of privately insured Americans received an unanticipated
bill when their health plan paid less than expected for medical services within the past two years.
2. Balance billing complaints are up 1,000 percent in Texas . According to the
Texas Department of Insurance , balance billing complaints rose from 112 in 2012 to 1,334 in
2015, an increase of 1,000 percent.
3. Lack of provider, network transparency. The rise in balance billing is partially attributable
to a lack of network transparency with patients. In many cases patients are unaware they have received
out-of-network care until they receive a balance bill in the mail. Nearly 70 percent of individuals
with unaffordable out-of-network medical bills did not know the healthcare provider was not in their
plan's network at the time of care, according to a survey conducted by
Kaiser Family Foundation and The New York Times .
4. Emergency room services to blame, in part. A
Health Services Research survey found in 2011, 68 percent of inpatient involuntary contact with
out-of-network physicians was related to emergency care. These kinds of unanticipated medical bills
may arise when a hospital participates in an insurer's network but its employed emergency physicians
do not. For example, more than half of the hospitals in some Texas insurers' networks did not have
a single physician on staff covered by the insurer, according to a 2015 study from the Centers for
Public Policy Priorities in Austin.
5. Balance billing and contracted physicians. Many hospitals use physician outsourcing firms for
anesthesiologists, emergency physicians, pathologists and radiologists, or will bring in an outside
assistant surgeon to help with procedures. In many cases, these physicians do not participate in
the same network as the hospital, unbeknownst to the patient. When physician groups and insurers
are unable to resolve reimbursement disputes, patients can be served with much higher out-of-network
charges. In Texas, for example, the specialty services most likely to submit balance bills are anesthesiologists,
lab services, surgery and radiology, reports the
Texas Department of Insurance .
6. Payers will fight out-of-network physicians with lower reimbursement rates. Last year, health
insurance giant UnitedHealthcare said it would scale back how much it pays out-of-network physicians
who practice at in-network hospitals, accusing physicians of demanding excessively high reimbursement
levels, according to
Kaiser Health News . During a
billing dispute with out-of-network Bayonne (N.J.) Medical Center, the insurer accused the hospital
of charging out-of-network rates 10 to 12 times higher for a medical service than area hospitals
participating in United'snetwork. If a payer refuses to match physician reimbursement rates, the
financial burden is passed on to the patient. In the aforementioned dispute between Bayonne and UnitedHealthcare,
the patient was balance billed $1,170 for a total of five stitches.
7. Insurers are narrowing networks in an effort to reduce costs. As insurance companies have narrowed
provider networks to keep premiums down, the number of patients who inadvertently received
out-of-network care has jumped at hospitals, particularly with regard to contracted physicians.
8. Payers have sued providers for 'excessive' out-of-network fees. Aetna
has sued a half dozen out-of-network physicians in recent years, alleging gross over charging
for medical services. In 2014 Aetna sued a physician at Monmouth Medical Center in Long Branch, N.J.,
a hospital within Aetna's network, who did not notify a patient he would not accept Aetna's discounted
reimbursement rate, according to the lawsuit. The physician charged Aetna $31,939 to treat abdominal
pain in the patient. After Aetna paid the amount it deemed reasonable - $2,811, based on Medicare
rates - the physician balance billed the patient for an additional $10,635.
9. Balance billing can occur even when a payer adjusts out-of-network emergency bills to in-network
rates for patients. A patient recently accused Duke University Medical Center in Durham, N.C., of
balance billing his account for an out-of-network rate after the patient submitted in-network payment
rates to Blue Cross Blue Shield. Owing to the medical emergency of his situation,
Matthew
Aitken said he received an in-network rate from Blue Cross Blue Shield of North Carolina. However,
Mr. Aitken alleged Duke proceeded to charge him for the remainder of the bill at the higher out-of-network
rate, resulting in a bill nearly double that of Mr. Aitken's out-of-pocket limit.
10. Air ambulance billing disputes, complaints on the rise. In rural areas of the U.S. the high
price for life-saving
air ambulance flights has grabbed media attention as rural residents, faced with excessive balance
billing, have turned to state and federal auditors for intervention. Those in rural areas often must
rely on air ambulance flights in life-or-death situations in lieu of feasible ground transportation.
Reimbursement rate disputes between payers and medical air transport companies have strapped patients
with devastating medical bills. When Amy Thomson's newborn daughter was in heart failure, Ms. Thomson
had to use an air ambulance service in rural Montana for transport to a more capable facility. At
the time her insurance company, PacificSource, did not have an in-network air ambulance company near
her family, reports
Montana Public Radio . Ms. Thomson received a $43,000 balance bill from Airlift Northwest
after PacificSource contributed a policy cap of $13,000.
11. Provider-based billing practices. Consumers have been increasingly vocal about surprise medical
bills derived from
provider-based billing practices. Provider-based billing allows a healthcare organization to
bill patients for physician care in addition to a service charge for the patient's use of hospital
facilities and equipment. In some cases, a patient may be responsible for the service bill if their
insurance declines to pay or if the patient has a high deductible health plan. Large hospitals like
Cleveland Clinic have faced increased scrutiny for provider-based billing practices. After paying
a $30 copayment for in-network care with a Cleveland Clinic chiropractor,
Julie Beinhardt reported receiving a balance bill of $3,000 for provider-based service fees her
insurance plan refused to cover.
12. President Barack Obama signed legislation against provider-based billing. Last year, President
Obama signed
legislation outlawing provider-based billing at off-campus outpatient facilities. The legislation
does not apply to existing outpatient centers that already engage in the practice, however.
13. The president's 2017 budget proposal includes a provision to eliminate surprise medical bills.
Although details are minimal, the president's 2017 budget proposal includes a provision to eliminate
balance billing privately insured patients. The administration would address the issue by requiring
physicians who regularly provide services in hospitals to accept in-network rates for service reimbursement,
even if they aren't in the insurer's network.
14. About a quarter of U.S. states have laws that protect consumers from out-of-network medical
bills incurred by emergency care. According to a study from
Kaiser Family Foundation , 24 states have implemented laws that restrict providers from balance
billing in emergency care situations, including California, Delaware, New Jersey, New York and Pennsylvania,
among others.
15. More states are proposing independent dispute resolution between payers and providers in balance
billing cases. Independent dispute resolution establishes a legal space in which providers and health
insurers can settle disagreements regarding balance billing without involving the patient. The states
of
Illinois
and New Yorkhave arbitration methods in place, and
Florida ,
Washington and
Pennsylvania are currently considering a similar resolution methods.
16. New York has some of the strongest consumer protection laws. Under
New York law , consumers are generally protected from owing more than their in-network copayment,
coinsurance or deductible on bills they receive for out-of-network emergency services. Patients can
complete an assignment of benefits form that absolves them of financial responsibility and allows
the provider to pursue payment from the health plan in balance billing disputes.
17. Florida state legislature is currently embroiled in a fight to pass balance billing laws.
Legislation to outlaw balance billing in Florida has continued to creep through the state legislature
since last fall. Introduced in both the house and senate, the bills have sparked conflicting and
outspoken opinions from patients, payers, hospitals and physicians. Hospitals have largely denounced
the bill, blaming balance billing disputes on payers that demand allegedly unsustainable reimbursement
rates, reports
Sunshine State News .
18. The "End Surprise Billing Act". Federal lawmakers are making moves to outlaw balance billing
nationally. Co-sponsored by 25 lawmakers, the End Surprise Billing Act would protect patients from
balance billing who went to in-network facilities for emergency services, reports
Consumerist . In non-emergency cases, it would require providers to notify patients
within 24 hours if an out-of-network specialist will be involved in an episode of care.
19. Consumers don't know how to navigate the legal waters. According to a
Consumer Union report, 57 percent of patients who encountered balance billing from contracted
physicians within the last two years paid in full because they didn't know their rights to fight
the bills. An overwhelming majority (87 percent) did not know which agency or department in their
state government is tasked with handling complaints about health insurance. "So many times, people
just give up [in surprise billing disputes]," Elisabeth Benjamin, vice president of health initiatives
with Community Service Society of New York, told
NPR .
20. The New York Times dedicated a series to consumer encounters with surprise healthcare
bills. Elisabeth Rosenthal's series in The New York Times entitled
Paying Til it Hurts examined the personal and financial implications of excessive, unexpected
medical costs on Americans, their families and their healthcare consumption. Ms. Rosenthal's installments
often feature individuals with unaffordable balance bills like
Peter Drier , who was served a $117,000 balance bill for an out-of-network physician's assistant
he never knew was present during surgery.
"... "One should know what the cost of the procedure is, and that is something that is just impossible to figure out before or after the procedure," Luthra says. "I had no way of knowing beforehand there were going to be these six different types of providers . . . sending me bills." ..."
Sanjiv Luthra of Los Altos, Calif., suffered from the pain and fatigue of rapid-onset
arthritis so severe that he couldn't walk 10 feet until he underwent double knee-replacement surgery
in 2006. Now, two years later, he can walk and run, but he still suffers the fallout from another
ailment:
medical bills.
Six hours in an operating room, two knee replacements, medications and a five-day
hospital stay added up to a bill of $80,000, Luthra estimates. That's not counting bills for an anesthesiologist,
physical therapy, additional medicines and special exercise equipment to help him recover.
"One should know what the cost of the procedure is, and that is something that
is just impossible to figure out before or after the procedure," Luthra says. "I had no way of knowing
beforehand there were going to be these six different types of providers . . . sending me bills."
Luthra's insurance company was able to negotiate with the hospital so that it
paid about $20,000, and he parted with about $5,000, including expenses outside the hospital.
But individual patients can haggle for lower medical bills, too. Here are tips
on how to go about it.
Work up the courage to ask. It's not just insurance companies that can negotiate.
"The typical insurer gets about a 60% discount," says Gerard Anderson, the director
of the Johns Hopkins Center for Hospital Finance and Management. "If you go into the hospital and
ask the
chief financial
officer
,
you may get a 30% discount, but you have to ask for it. It's totally up to the discretion of the
CFO how much they or the person in the billing office are willing to give you."
Although it's common to negotiate with a real-estate agent or car salesperson
you probably never will see again, it's much more difficult to negotiate with a doctor you trust
to make you well and to provide continuing care for your family. Only 31% of Americans have tried
to negotiate the price of medical bills, a survey by Consumer Reports National Research Center indicated.
But of those who tried, 93% have been successful at least once, and more than a third saved more
than $100.
Explore low-cost treatments. Many doctors incurred large loans to finance medical school and probably understand the need to get
a fair price as well as you do.
But even though almost 80% of physicians will prescribe a generic medication over
a brand-name drug to save patients money, far fewer consider patient costs when recommending diagnostic
tests (51%) or choosing between hospitalization and outpatient treatment (40%), according to a survey
of physicians by the Center for Health System Change and the
University of
Chicago
If money is an issue, you need to ask your doctor if cheaper, medically sound
options are available. The trick is to keep it friendly and ask nicely. For minor health ailments
such as ear infections and pinkeye, drugstore clinics list reasonable prices upfront, with no negotiating
required.
Find the correct person. Although they are heavily involved in treatment decisions, doctors may not be directly involved in
other billing issues, so you need to find a person with the ability to adjust your bill.
"I would suggest the consumer go to the office manager," says Timothy Cahill,
a health-care consultant in Louisville, Ky., who has negotiated hospital bills on behalf of patients.
The office manager should be able to direct you to the person in charge of billing.
Offer cash payments. This could be a mutually beneficial solution for you and the medical establishment.
"Paying cash is worth a lot to a doctor in terms of time and trouble, and it is
a lot less complex for the hospital to deal with," says Shankar Srinivasan. He is a co-founder and
the chief technology officer of Vimo.com, a company that uses public records to figure out what prices
insurers negotiate with hospitals. Cash, he says, saves hospitals the trouble of negotiating financing
terms, paying credit card transaction fees and sending collection agencies after patients who fail
to pay.
Scrutinize the bill and your insurance. If you don't have the cash to pay a large medical bill, you need to educate yourself about what your
insurance should cover and try to negotiate a discount off the sticker price.
"As a consumer, just like a detective, you have to really understand the specifics
of your insurance benefit plan, take the initiative of setting up conference calls (including yourself,
the hospital and your insurance company) proactively, and you have to document everything," says
Luthra, who is chief operating officer of the health-care-consulting company Benu. "You don't just
pay the bill as is."
This article was reported and written by Emily Brandon for
U.S. News & World Report.
"... The average balance billed to patients was $622.55 , though the study reported bills as high as $19,603.30. But, ERs are not the only source of surprise bills. ..."
"... Even when a patient goes to a hospital for routine surgery, and takes care to choose an in-network hospital and in-network surgeon, the anesthesiologist, radiologist or pathologist assigned to the case may be out of network, and follow up with a surprise bill. ..."
"... If you have a serious medical emergency, your nearest hospital may not be in-network and all your treatment may result in out-of-pocket expense for high surprise bills. But, even if you visit an in-network ER, you have little control over the choice of doctor: By definition, you are facing an emergency, and must take whoever is available. ..."
"... Check with your state insurance regulator to see if your state has any consumer protections against surprise bills. ..."
"... At present, California, Colorado, Connecticut, Florida and New York do have such protections against unexpected balance bills - either for out-of-network ER situations alone or for additional types of surprise bills. ..."
"... If your state does not offer protection against surprise bills, check first to make sure the provider is really not in your network. Back offices and billing companies deal with many plans and sometimes make mistakes. Providers who are in your network have to accept the insurer's contracted rate. ..."
"... If the provider is out of network, do some research on an independent website, such as fairhealthconsumer.org , to estimate what the procedure typically costs in your locality. ..."
"... If neither the insurer nor the provider is willing to budge, do not be afraid to seek help. If you get your insurance through your employer, your human resources department may be able to intervene. Call your state representative or your local consumer protection office. With the right assistance, you might be able to reduce the bill, if not make it go away entirely. ..."
Surprise bills are never a welcome surprise. Typically, they arrive after you arranged care from
a doctor and a hospital that were both in your health plan's network, but then you were unexpectedly
treated by one or more other providers who, unbeknownst to you, were outside that network.
When
these out-of-network providers send you a bill for their services, you may have to pay the full amount
out of pocket or, if your health plan covers out-of-network care, to pay the balance of the bill
that your insurance fails to cover. And the balance bill generally requires you to pay more than
the out-of-pocket amount you would have owed if you had been treated by an in-network provider.
Emergency rooms are one of the most common locations where healthcare results in surprise bills.
As detailed recently in
an article by two Yale
scholars in the New England Journal of Medicine, in more than one in five cases nationwide, ER
visits to an in-network facility involved out-of-network physicians. The average balance billed
to patients was
$622.55, though the study reported bills as high as
$19,603.30.
But, ERs are not the only source of surprise bills.
Even when a patient goes to a hospital for routine surgery, and takes care to choose an in-network
hospital and in-network surgeon, the anesthesiologist, radiologist or pathologist assigned to the
case may be out of network, and follow up with a surprise bill.
Several states have already
enacted laws to protect consumers against surprise bills, although some of the statutes protect
patients only in the case of balance bills for out-of-network ER services for a serious medical emergency.
Currently, the issue is being discussed in a number of statehouses. In the meantime, here are steps
you can take to protect yourself from such surprises.
Prevent surprise bills
The best defense against a surprise bill is prevention. If you have a serious medical emergency,
your nearest hospital may not be in-network and all your treatment may result in out-of-pocket expense
for high surprise bills. But, even if you visit an in-network ER, you have little control over the
choice of doctor: By definition, you are facing an emergency, and must take whoever is available.
However, for a planned surgery or other procedure, you probably have time to speak up. Make sure
that your doctor and hospital are in your plan's network. Check with them and with your plan. Ask
your physician and your hospital in advance if they can arrange to have only in-network providers
treat you.
Some hospitals may have no in-network specialist for care you might require. Find out if another
hospital in your area can provide all your necessary services on an in-network basis. In some areas,
there may be no in-network specialists available of the type you need. In that case, inform your
plan that its network lacks necessary services and find out if the terms of the plan or state law
provide you protection from large balance bills in such circumstances.
Always refer to your plan by its exact official name. Often insurers have multiple plans with
similar names but different networks. If you use the wrong plan name when inquiring about a plan's
network, you may get a wrong and costly answer. Make your inquiries and requests in writing so you
have documentation. Ask for the names of the providers who will be involved in your care, and check
with your insurer and with the providers themselves to see if they are all in your plan's network.
Check if your state protects consumers
If you do get a surprise bill, take action. Check with your state insurance regulator to see
if your state has any consumer protections against surprise bills. Many states have laws that
require HMOs to protect consumers from surprise bills, especially with respect to necessary ER services.
Fewer states have similar protections for other types of health plans, such as PPOs and EPOs.
At present, California, Colorado, Connecticut, Florida and New York do have such protections
against unexpected balance bills - either for out-of-network ER situations alone or for additional
types of surprise bills. Generally, these laws provide that the consumer is required to pay
only the amount he or she would owe for the services if provided in-network. States have different
mechanisms for settling the balance, but they generally involve the insurer and the provider, not
the patient.
If your state does not provide protection
If your state does not offer protection against surprise bills, check first to make sure the
provider is really not in your network. Back offices and billing companies deal with many plans and
sometimes make mistakes. Providers who are in your network have to accept the insurer's contracted
rate.
If the provider is out of network, do some research on an independent website, such as
fairhealthconsumer.org, to estimate
what the procedure typically costs in your locality. If your plan's reimbursement is based on
an amount that is less than the typical charge, you can use this information to ask the plan to pay
the provider on the basis of at least the typical rate. If the out-of-network provider's charge is
higher than the typical rate, you might be able to negotiate with the provider to reduce your costs.
You can try to persuade the provider to reduce the charge, or to discount an excessive balance bill,
by showing the provider that his or her charge is above the typical market rate.
If neither the insurer nor the provider is willing to budge, do not be afraid to seek help.
If you get your insurance through your employer, your human resources department may be able to intervene.
Call your state representative or your local consumer protection office. With the right assistance,
you might be able to reduce the bill, if not make it go away entirely.
Robin Gelburd, JD, is the president of
FAIR Health, a national, independent
nonprofit with the mission of bringing transparency to healthcare costs and insurance reimbursement.
FAIR Health oversees the nation's largest repository of private healthcare claims data, comprising
over 21 billion billed medical and dental charges that reflect the claims experience of over 150
million privately insured Americans. Follow on twitter
@FAIRHealth
Two excellent resources-Healthcare Blue Book and FAIR Health-can give you estimates of how much
health care services should cost in your area. Plus, your insurer's website may also provide a tool
that will allow you to compare costs.
Notable quotes:
"... But the bill did come-all $9,000 of it. The ambulance company charged $6,500, including a $300 fee for the linens and a $30 charge for aspirin. The E.R. billed the remaining $2,500. "My mouth literally dropped open when I saw the cost," she says. ..."
"... "I've always heard emergency room visits were costly, but $9,000 for nothing more than a conversation that lasted one minute? That's robbery," she says. ..."
"... "Employers often try to stay away from filing a claim under worker's compensation, so it does not impact their experience rating or trigger an [occupational safety and health administration] review, but it would save her money." ..."
It's no secret that hospital bills in the U.S.-especially ones from the E.R.-can often hit
astronomical proportions.
According to a recent cost study conducted by researchers at Stanford University, the
University of Minnesota, the University of California, San Francisco and the Ecologic Institute,
the median charge for an emergency room trip in the U.S. comes in at $1,233. But where it really
gets interesting is when you look at the specific reasons for those E.R. visits: The researchers
found that the treatment price for a headache could range from $15 to a whopping $17,797. As for
a sprained ankle, it could set someone back a paltry $4 or up to $24,110!
So what gives with these wildly fluctuating price points?
For starters, most emergency room prices are inflated based on the rates at which insurance
companies will reimburse the hospital on a patient's behalf. That's why a single aspirin can cost
$30 per pill in the E.R., which is more than six times the price for a bottle of them at the drug
store.
On the flip side, patients will often contact the hospital or surgeon's billing office to ask
for a cost reduction, further adding to the inconsistency in pricing. It's a practice that often
works in a patient's favor, says billing advocacy specialist Sharon Salters of Medical Cost
Advocatea professional medical bill negotiation service.
And then there's also the fact that most hospitals offer discounts to self-paying
individuals-especially if there's a risk that they might not pay at all.
So to help shed some light on the complexities of hospital medical billing for the average
consumer, we asked three people to share their craziest emergency room stories, the even crazier
bills that followed-and the steps they took to remedy them.
... ... ...
The Emergency: Head Injury
The Bill: $9,000
A few months ago, Amanda Harris, 27, of Morristown, N.J., fainted at work, hitting her head in
the process. Due to liability concerns, her production company required Harris to take an
ambulance to the emergency room, despite her refusal. "I didn't even have a cut on my head, just
a slight bump. No headache, no nausea, no confusion, nothing," she says.
Harris waited for over an hour in the E.R. before her husband told the nurse that they were
leaving. Minutes later, a doctor spoke to Harris for under a minute, confirming that she was fine
to go. "He didn't do any tests-no light in my eyes, no blood pressure," says Harris. "I left
thinking I wouldn't even get a bill."
But the bill did come-all $9,000 of it. The ambulance company charged $6,500, including a $300
fee for the linens and a $30 charge for aspirin. The E.R. billed the remaining $2,500. "My mouth
literally dropped open when I saw the cost," she says.
What This Patient Did: Harris called her insurer and fought the bill.
Luckily, her insurance covered all but a $3,000 deductible-but she was too exhausted to push for
more. "I've always heard emergency room visits were costly, but $9,000 for nothing more than a
conversation that lasted one minute? That's robbery," she says.
What the Expert Says: Even though Harris didn't want to take an ambulance,
Salters says that her company's suggestion was well-advised. "However, she should consider
working with her employer to file the claim with her company's worker's compensation carrier,"
says Salters. "Employers often try to stay away from filing a claim under worker's compensation,
so it does not impact their experience rating or trigger an [occupational safety and health
administration] review, but it would save her money."
How You Can Avoid Outrageous E.R. Bills (Really!)
When it comes to a trip to the E.R., the reality is that there's usually no time to shop
around and compare prices in advance. But if you do some research before an emergency happens,
you could potentially keep costs significantly down.
Consider Urgent Care for True Non-Emergencies. If your medical problem isn't life-threatening (think sprains, minor cuts and
fevers), you can visit an urgent care center instead. An Annals of Internal Medicine Study found
that the average urgent care visit from 2005 and 2006 cost $156-compared with $570 for the same
visit to an emergency room.
Double-Check Your Bill.
Hospital billing systems aren't perfect, so it's wise to keep track of any treatments that you
receive in the E.R.-including time spent in the operating room, which can cost up to $200 a
minute! To prevent billing mistakes, ask for an itemized statement before you're discharged, so
you can compare it with your own record-keeping.
Negotiate Your Health Care Costs.
Most importantly, don't be shy when it comes to bargaining. Two excellent resources-Healthcare
Blue Book and FAIR Health-can give you estimates of how much health care services should cost in
your area. Plus, your insurer's website may also provide a tool that will allow you to compare
costs.
The negotiation can seem like a lot of extra work, but the payoff can be tens of thousands of
dollars in savings shaved off a potentially outrageous E.R. bill.
Two excellent resources-Healthcare Blue Book and FAIR Health-can give you estimates of how much
health care services should cost in your area. Plus, your insurer's website may also provide a tool
that will allow you to compare costs.
Notable quotes:
"... The ambulance company charged $6,500, including a $300 fee for the linens and a $30 charge for aspirin ..."
It's no secret that hospital bills in the U.S.-especially ones from the E.R.-can often hit astronomical
proportions.
According to a recent cost study conducted by researchers at Stanford University, the University
of Minnesota, the University of California, San Francisco and the Ecologic Institute, the median
charge for an emergency room trip in the U.S. comes in at $1,233. But where it really gets interesting
is when you look at the specific reasons for those E.R. visits: The researchers found that the treatment
price for a headache could range from $15 to a whopping $17,797. As for a sprained ankle, it could
set someone back a paltry $4 or up to $24,110!
So what gives with these wildly fluctuating price points?
For starters, most emergency room prices are inflated based on the rates at which insurance companies
will reimburse the hospital on a patient's behalf. That's why a single aspirin can cost $30 per pill
in the E.R., which is more than six times the price for a bottle of them at the drug store.
On the flip side, patients will often contact the hospital or surgeon's billing office to ask
for a cost reduction, further adding to the inconsistency in pricing. It's a practice that often
works in a patient's favor, says billing advocacy specialist Sharon Salters of Medical Cost Advocatea
professional medical bill negotiation service.
And then there's also the fact that most hospitals offer discounts to self-paying individuals-especially
if there's a risk that they might not pay at all.
So to help shed some light on the complexities of hospital medical billing for the average consumer,
we asked three people to share their craziest emergency room stories, the even crazier bills that
followed-and the steps they took to remedy them.
... ... ...
The Emergency: Head Injury
The Bill: $9,000
A few months ago, Amanda Harris, 27, of Morristown, N.J., fainted at work, hitting her head in
the process. Due to liability concerns, her production company required Harris to take an ambulance
to the emergency room, despite her refusal. "I didn't even have a cut on my head, just a slight bump.
No headache, no nausea, no confusion, nothing," she says.
Harris waited for over an hour in the E.R. before her husband told the nurse that they were leaving.
Minutes later, a doctor spoke to Harris for under a minute, confirming that she was fine to go. "He
didn't do any tests-no light in my eyes, no blood pressure," says Harris. "I left thinking I wouldn't
even get a bill."
But the bill did come-all $9,000 of it. The ambulance company charged $6,500, including a
$300 fee for the linens and a $30 charge for aspirin. The E.R. billed the remaining $2,500.
"My mouth literally dropped open when I saw the cost," she says.
What This Patient Did: Harris called her insurer and fought the bill. Luckily,
her insurance covered all but a $3,000 deductible-but she was too exhausted to push for more. "I've
always heard emergency room visits were costly, but $9,000 for nothing more than a conversation that
lasted one minute? That's robbery," she says.
What the Expert Says: Even though Harris didn't want to take an ambulance, Salters
says that her company's suggestion was well-advised. "However, she should consider working with her
employer to file the claim with her company's worker's compensation carrier," says Salters. "Employers
often try to stay away from filing a claim under worker's compensation, so it does not impact their
experience rating or trigger an [occupational safety and health administration] review, but it would
save her money."
"... Price-gouging by ambulance services, including those run by municipalities, was always a disreputable exercise, preying on people who suffer emergency illnesses or injuries. ..."
"... The federal Medicare rate isn't usually high enough to cover all the ambulance costs, so the Legislature is right to go above it. But 300 percent is too high. ..."
When the Legislature finally produced a measure to prevent ambulance companies from gouging out-of-network
patients and their insurers, it set a limit of 300 percent of the federal Medicare reimbursement
rate or the ambulance's regular fee, whichever is lower. This is a ceiling that might function more
like a floor, pushing ambulance firms to raise their rates to 300 percent of Medicare. It's a bad
idea.
Price-gouging by ambulance services, including those run by municipalities, was always a disreputable
exercise, preying on people who suffer emergency illnesses or injuries. And when insurers decided
to fight back by reimbursing patients a set amount, rather than pay whatever the ambulance demanded,
they, too, threw patients under the wheels: Ambulances expected the patients to make up the difference
between the insurers' rate and the ambulance's. Few situations better illustrate patients' frustrations
with the health care system.
So the unwanted task of deciding on an appropriate level of reimbursement fell to the state. And
it should surprise no one that both insurers and ambulance services are lobbying for the best possible
deal, while grumbling about government interference. Fire departments and other municipal offices
that operate ambulances are hoping their friends in the Legislature can deliver a generous fee.
The federal Medicare rate isn't usually high enough to cover all the ambulance costs, so the
Legislature is right to go above it. But 300 percent is too high. Patrick should veto the bill
and ask the House and Senate to send it back to him with a lower price ceiling.
"... Also consider using Medicare rates as a guide; the federal health system for people 65 and older typically has the lowest reimbursement rate for hospitals and medical providers. Your hospital may not agree to charge you its Medicare fee, but this figure is a good starting point for any negotiation. ..."
"... don't hesitate to appeal its decisions. You'd be surprised how often carriers overturn their earlier rejections. ..."
Conversely, you may be able to wrangle a cash discount for agreeing to pay your entire cost at
once.
You may also be able to successfully bargain down the particular dollar amounts you've been charged.
Tell the billing department that if your insurance requires, say, a 20% co-payment to the hospital,
you'll pay only 20% of the insurer's negotiated rate with that hospital. That's usually far less
than the initial rate quoted - the figure charged to uninsured patients.
Go online to check the rates other local hospitals charge for the procedure you had. Then, if
you find your bill was way out of line, use this data as ammunition to try to get your fees lowered.
You can get this type of information at such sites as
Clear
Health Costs, Healthcare
Blue Book and FAIR Health.
Also consider using
Medicare rates as a guide; the federal health system for people 65 and older typically has the
lowest reimbursement rate for hospitals and medical providers. Your hospital may not agree to charge
you its Medicare fee, but this figure is a good starting point for any negotiation.
2. Vigilantly review the bills. "It's very common for hospital bills to contain
errors and overcharges, so make sure you've actually received the services they said you did," Detweiler
says.
Candice Butcher, vice president of
Medical Billing Advocates of America,
says if you're discharged in the morning (as most patients are), protest if you're socked with a
full daily-room rate for the date you left the hospital.
And if you brought your medications with you, make sure you weren't charged for them by the hospital.
"This frequently happens," Butcher says.
Also, dispute any additional fees on the bill for routine supplies, like gowns, gloves or sheets.
These items should be factored into the hospital daily-room charge, because, Butcher says, they are
"considered the cost of doing business."
3. Challenge your health insurer's decisions, when warranted. Keep track of any
hospital bills the company rejects on grounds that the procedure or drug isn't covered by your policy.
If you believe the insurer should be paying more, don't hesitate to appeal its decisions. You'd
be surprised how often carriers overturn their earlier rejections.
4. Negotiate billsonce you know how much you'll have to pay out of pocket.
If you just want extra time to send the money, Dale says, "it is relatively easy to speak with hospital
or clinic business office staff to arrange a payment plan."
Conversely, you may be able to wrangle a cash discount for agreeing to pay your entire cost at
once.
You may also be able to successfully bargain down the particular dollar amounts you've been charged.
Tell the billing department that if your insurance requires, say, a 20% co-payment to the hospital,
you'll pay only 20% of the insurer's negotiated rate with that hospital. That's usually far less
than the initial rate quoted - the figure charged to uninsured patients.
Go online to check the rates other local hospitals charge for the procedure you had. Then, if
you find your bill was way out of line, use this data as ammunition to try to get your fees lowered.
You can get this type of information at such sites as
Clear
Health Costs, Healthcare
Blue Book and FAIR Health.
Also consider using
Medicare rates as a guide; the federal health system for people 65 and older typically has the
lowest reimbursement rate for hospitals and medical providers. Your hospital may not agree to charge
you its Medicare fee, but this figure is a good starting point for any negotiation.
5. Consider hiring a pro. Since hospital bills are hairy, messy beasts, it may
be worth your while to bring in a patient- or medical-billing advocate (Detweiler recommends the
advocacy firm Copatient.com, which charges
30% of what it saves you) or an attorney. "It's like hiring a CPA to do your taxes," Dale says.
Be sure you won't be required to pay this expert any fees upfront. Patient advocates typically
charge 20 to 30% of your savings; some put a cap on their fees. Karis' firm, for example, charges
no more than $3,000. Attorneys often charge 30% of the savings they achieve.
... ... ...
Caroline Mayer is a consumer reporter who spent 25 years working for The Washington Post.
Follow her on
Twitter
TWTR -0.69% @consumermayer.
"... My husband suffered a heart attack when we were on vacation, and I called an ambulance. He's OK now, but we've been billed more than $6,000 for his 15-minute ride to the hospital. As it turns out, the ambulance service wasn't in our health insurer's network, so they paid only a small portion of the bill. We're making small payments on the balance, but the initial bill seems so high. The collector calls all the time to demand we pay the balance in full. Is there anything we can do to get the bill looked at and possibly lowered? ..."
"... Fortunately, medical bills are not always set in stone, and there may be ways for you to negotiate a lower balance. ..."
"... I recommend you first review an itemized copy of the bill for any errors. Look for duplicate charges, inaccurate service dates or incorrect mileage. If you spot any errors, take it up with the billing department immediately. ..."
"... Standard practice for insurers is to negotiate with providers to pay merely a fraction of the cost. ..."
"... Medicare negotiates, on average, a 73% discount. ..."
"... Negotiating with an ambulance service or any medical provider is not easy, but it is possible. Be persistent. If your efforts prove fruitless, you can always consider hiring a professional ..."
My husband suffered a heart attack when we were on vacation, and I called an ambulance.
He's OK now, but we've been billed more than $6,000 for his 15-minute ride to the hospital. As
it turns out, the ambulance service wasn't in our health insurer's network, so they paid only
a small portion of the bill. We're making small payments on the balance, but the initial bill
seems so high. The collector calls all the time to demand we pay the balance in full. Is there
anything we can do to get the bill looked at and possibly lowered?
Answer:
I'm glad to hear your husband is recovering, but I am sure the stress of an unexpected medical
bill isn't helping him heal. Ambulance bills are notoriously costly, but yours seems to be inflated.
Fortunately, medical bills are not always set in stone, and there may be ways for you to negotiate
a lower balance.
I recommend you first review an itemized copy of the bill for any errors. Look for duplicate charges,
inaccurate service dates or incorrect mileage. If you spot any errors, take it up with the billing
department immediately.
Even if the bill is correct, you should still set up a time to speak with someone in the billing
office-someone with the authority to negotiate on your balance. Go into the conversation equipped
with the knowledge that Medicare and insurance companies rarely pay the hefty price tags that consumers
see.
Standard practice for insurers is to negotiate with providers to pay merely a fraction of the
cost. In the case of inpatient hospital bills, for example, a NerdWallet
study
found Medicare negotiates, on average, a 73% discount. While the ambulance service
may not agree to such a large discount for you, coming to any negotiation equipped with such knowledge
will put the company on notice that you aren't going to lay down and take its bullying or an inflated
bill.
... ... ...
Negotiating with an ambulance service or any medical provider is not easy, but it is possible.
Be persistent. If your efforts prove fruitless, you can always consider hiring a professional
. A
medical billing advocate
is able to represent clients' interests much in the way an attorney
would advocate for you in a courtroom. Their experience and expertise in the field can sometimes
prove more effective (and less stressful) than taking on a stubborn provider alone.
"... As a practicing physician who is fed up with the way insurance carriers have managed to take over the delivery of health care in this country, my comments, I warn you, will be brutally frank. The way the game is played, the providers of health care bill as much as they believe they can get away with. ..."
"... That's because they are in business to make money - that's why it's called "for profit" health care. The insurance carriers try their damn best to find excuses to not pay as many of these charges as they can. Same reason. These two conspirators become co-conspirators when they play the game of "crap runs down hill". ..."
"... So here's my advice. Don't pay any "balance billing" no matter what they choose to call it. Activate the pump that sends the crap back uphill. Write letters to the provider asking for specifics as to the balance billing. ..."
Unfortunately sometimes the only way to get around denial of precertification is to ask your
doctor to lie. I had an MRI after a fainting episode that showed possible MS, which runs in my
family. All other diseases were excluded. The medical recommendation is to get a follow-up MRI
in 6-months. Because I wasn't having active symptoms, the follow-up MRI was not precertified when
ordered by my neurologist. I went to my family physician for help, she requested the MRI, saying
I was having headaches (everybody gets one occasionally, right?). I immediately got the necessary
MRI and am now being treated. I think the insurance company didn't really want to deny the MRI,
they wanted to delay expensive treatment, which was the likely outcome.
I am currently appealing a claim with HealthLink. Too long to go into but it involves an Intensive
Outpatient Treatement program for my 20 year old son. There own guidelines state that this may
well be the best initial choice for treatment. However, they advised us when they would not precertify
that he needs to fail at out patient treatment and community support. Really? So I get to the
External appeal process. Healthlink contracts with MCMC to provide the physician to do the reveiw.
Can we say conflict of interest? She spits out the same verbage used to deny the precertification
but mentions criteria that is no longer being used to asses such cases. Or and then there is the
mention of my son's "wearable cardioverter defibrillor" has nothing to do with our case. So I
appeal to the State of Illinois (eye roll) and am told I cannot appeal a denial of a precertification.
I must have a denied claim. OK, but I can't get to the denied claim as HealthLInk won't even percert
the care. Who are these people?
I recently had to deal with the insurance company VS primary care provider VS patient VS lab
test provider. Its a cluster-expletive. Even trying to keep track of who said what when is difficult.
Not too mention the hours upon hours of your precious time it *will* consume.
Short summary:
I had a severe flu (possibly swine flu) and made a doctor's appointment. They were very busy and
couldn't see me for 2 weeks. When I came in for my appointment, I had recovered from the flu.
My appointment was reclassified as well-care. My job's health insurance plan was revised two months
prior to exclude well-care. I was now on the hook for 100% of the cost of the visit. The doctor
ordered a full blood work since I was a new patient.
I realize it was my fault that I didn't know well-care wasn't covered. Lesson learned - I've
read my EOB a couple times now, cover to cover. Unfortunately, I still only kind of know what
is covered.
As a practicing physician who is fed up with the way insurance carriers have managed to
take over the delivery of health care in this country, my comments, I warn you, will be brutally
frank. The way the game is played, the providers of health care bill as much as they believe they
can get away with.
That's because they are in business to make money - that's why it's called "for profit"
health care. The insurance carriers try their damn best to find excuses to not pay as many of
these charges as they can. Same reason. These two conspirators become co-conspirators when they
play the game of "crap runs down hill".
That's when they come up with things like "co-pays", "deductibles", "co-insurance", and a whole
host of creative ways of attempting to coerce the patient to pick up the tab.
So here's my advice. Don't pay any "balance billing" no matter what they choose to call
it. Activate the pump that sends the crap back uphill. Write letters to the provider asking for
specifics as to the balance billing.
Don't accept their response. Write again. Write to the insurance carrier and appeal.
Then write the provider with the appeal number from the insurance company. Keep it going round
and round. If contacted by a collection agency, write back explaining your appeals and that your
financial condition won't allow you to pay without getting a disposition from your claim, and
a better explanation from the provider as to why the procedure wasn't covered. Tell them to not
contact you again. Tell them that you refuse to pay until you get a decent explanation. Dare them
to sue you. CC a law firm on all correspondence. Make the providers get hurt enough to fight against
the carrier. Bust up their friendship. Neither will hire a lawyer to get you. The publicity is
the only thing they are afraid of.
I am in the process of filing a claim for the first time ever. Cigna denied coverage for an
operation after the fact. This was not even a marginal case, it was an obvious medical need. I
suspect that insurance companies simply play the odds, deny and spread the costs to hospitals,
surgeons, patients and maybe themselves. A lot less than paying the whole thing. This has nothing
to do with medicine, as I have discovered. It is about how to boost revenues and damn fairness
and the patient. Plan to fight and publicize my fight. This is as clean cut a case that can be
found.
Having handled over 4000 health care appeals over the past 15 years, this article is a pretty
good basic overview (so long as most of the Comments are ignored). The Affordable Care Act may
ultimately be helpful in making this hodgepodge of rules more uniform, but that remains to be
seen. The ultimate message for patients must remain clear: It is imperative to FIGHT for the care
you need using all available resources and expertise at your disposal!
#7 is correct: it is a game to the health insurance companies. They routinely deny perhaps
40% of all claims thinking that most people will just shrug off the denial and go away. The key
is to keep calling, resubmitting and fighting the portion that they have denied. I have received
initial denials for the most ludicrous reasons: the doctor retired; there is no such doctor at
that address, etc... It is a game designed for the health insurance companies to win UNLESS you
fight back.
"If you feel too frail or overwhelmed to pursue an appeal yourself, nonprofit groups like the
Patient Advocate Foundation can provide guidance for free."
A single person battling a life-threatening illness or condition is, of course, going to be
overwhelmed and frail. Insurance companies bank on it. My suggestion is to start with advocacy
first. Insurance companies make things difficult because they are in the business of making money,
not helping patients. They want you to give up. When you have another person or two in your corner
everything moves along better. Especially when the advocate knows how to fight hard and isn't
afraid to speak frankly. There are witnesses to what is happening and you are taken more seriously.
It is ironic that there is now Health Proponent, a company that will fleece you in order to
"advocate" for you. Only in America, folks.
I had to have all my teeth extracted before I could begin treatment for throat cancer. I did
not have enough dental insurance, and the oral surgeon's office told me that medical had informed
them it would not pay the remainder.
I contacted mymedical insurance company, which recommended that I wait for a denial and then
appeal. I pointed out that by that time I would be quite sick from the radiation, and would like
to deal with it while I was still capable. Turns out there is a board that considers these things,
so I had both of the oral surgeons, my oncologist, and my ENT all write letters to this board.
The medical insurance company paid for the whole thing, since it was proven to be a medical necessity.
Now, if we could just get the oral surgery place to refund all that we paid, plus the dental
insurance, so that the dental insurance can in turn use my benefit to help repay us for the dentures
. . .
This happens all the time. There are gajillions of codes used by the insurance companies. If
your healthcare provider uses an incorrect code, then the insurance company won't pay the bill.
Call the insurance company and find out what the codes should be. Then call or visit your health
care provider and bring them up to date on the codes. Blue Cross and Blue Shield have all of their
codes listed on their Internet site.
I have a friend who broke his back in a car accident and as a result has had ongoing medical
issues. He told me that he treats the denials as a game. You submit the entire claim, they reject
part of it, you resubmit the rejected part, they pay part and reject part, and you keep on going
until you get your money. It seems cruel, but an insurance company's profit is the amount of money
each year that they do not pay out in claims, so the incentive to deny is very strong.
After some back and forth, Medicare paid its share of a claim that I, rather than my doctor,
submitted,
I then submitted the claim to my secondary insurer who, after further back and forth, said that
it could not pay the claim because it had been agent for my former employer and no longer had
access to the employer's funds. The employer in turn, after more back and forth, says it plans
tosubmit this and other claims to the current secondary employer for payment rather than pay them
directl y. The process seems to go on forever.
mary browning is a trusted commenter miami beach, FL
July 11, 2011
Good heavens, why should it take instructions that would require a graduate degree? In other
countries none of this mess would be required. Disgraceful.
If you are sick and don't feel up to doing things, how, indeed could you do what you are said
to do to simply get what is required or due to you?
Stop. Just sue them and put them on the defensive. Denial of claims is the way the criminal
health insurance companies provide record salaries to the gangsters who run the companies, and
big dividends to their share holders.
Appealing a health insurance denial which involves a substantial financial liability can be
viewed like any other do-it-yourself endeavor. If you are comfortable handling a matter upon which,
say, $75,000 or more is at stake (which is not uncommon), good luck. On the other hand, if the
stakes are high, you may want consider having it handled by an attorney who specializes in this
area of practice
As someone who went through this process recently, I would make the following suggestions:
1) Be very legalistic in your approach to the appeal, and quote appropriately from the policy
and from law (this of course assumes you have a solid legal basis for your appeal).
2) Inform the insurance company in writing that if they require a full appeal, you will hire legal
counsel to research and document your appeal.
3) Remind the insurance company that under ERISA, if you ultimately win, you are entitled to reimbursement
of your legal fees and expenses.
This won't win obviously if you are on shaky legal ground. But if the insurance company is
on shaky ground and just trying to avoid paying a claim (which was the case with us), this sort
of saber rattling can help resolve the question quickly before you end up in a formal appeal.
The insurance company doesn't want you to hire a lawyer if you have a good chance of winning.
Assistance with appeals and grievances from denials of health insurance claims is a service
that many state Attorneys General provide for free, so check with your Attorney General's office
before paying someone to assist you with the process.
"... As part of her husband's benefits package, Isaac had access to a medical billing assistance company called Health Advocate . It negotiated with the physician's health-care group to reduce her bill to $7,000. ..."
When Annrose Isaac's twins were born prematurely, she thought her insurer would cover their stay
in the neonatal intensive care unit. "The hospital was in our network, but it turned out the physician
in the NICU who saw our daughters didn't participate with our insurer," says the Westwood (New Jersey)-based
financial planner. "All of a sudden we were getting bills for over $30,000."
As part of her husband's benefits package, Isaac had access to a medical billing assistance
company called Health Advocate.
It negotiated with the physician's health-care group to reduce her bill to $7,000.
More than 60 percent of all U.S. personal bankruptcies are linked to illness and unpaid medical
bills, according to a 2009 Harvard University study, even though 78 percent of those filing for bankruptcy
because of illness have some form of health insurance. So hiring a medical billing advocate can be
an essential part of the cure to financial ills.
Yet finding the right advocate can be tough, and those in the direst situations can ill afford
the typical $75- to $130-an-hour rate. "This business is painfully slow-growing," says Becky Stephenson,
co-president of the Alliance of Claims Assistance Professionals
(ACAP), an advocate trade group. "There are a lot of people with problems but not a lot of people
willing to pay you to help them." Despite long experience, Stephenson herself has trouble making
a good living purely from advocacy, so she supplements her income by serving as an expert witness
in medical lawsuits.
Employees working at sizable companies may already have access to a health advocate. Just over
half of U.S. companies with more than 500 employees offer it as a benefit, according to Steven Noeldner,
a senior consultant for Mercer's Total Health Management practice. Many employees don't know the
benefit exists, he says, and the services generally aren't as customized as those of an independent
billing advocate.
Credential Check
Unlike with more established professions such as accounting or law, there is no standard credential
to look for when seeking a qualified advocate. At the most basic level you should ask if an advocate
has certifications in medical bill coding from either the American
Academy of Professional Coders or the American Health Information
Management Association.
Many people with those designations aren't advocates, however, working instead for hospitals or
insurers. And understanding the codes is only half the battle. Because of the complexity of our health-care
system, you'll need someone who specializes in your specific kind of billing problem.
A good place to start is Claims.org, ACAP's website. It lets
you search for experienced advocates by state. In a case like Isaac's, you'd need someone who specializes
in hospital bills. Other advocates specialize in Medicare appeals, long-term care insurance, workers'
compensation and insurance for special needs children.
Privacy Issues
The best way to find the right specialist is to ask the advocate for a resume and references.
This can be tricky, because laws about disclosing private medical information are so strict that
some advocates have difficulty providing references. In order to do so, their clients must agree
to discuss their medical history.
Stephenson specializes in hospital bill audits. She studies itemized bills line by line, identifies
padding and mistakes and negotiates lower rates. Prior to starting her Austin (Texas)-based advocacy
firm VersaClaim in 2002, she ran an organization that helped
doctors affiliated with hospitals set up their practices. That included all aspects of hospital billing.
A registered nurse for 12 years, Stephenson has an intimate knowledge of medical terminology and
hospital procedures. "I ask questions like, Are there dosages of medications that are not compatible
with my medical experience in real life?" she says. "Do the charges look realistic, or is there an
$85 Tylenol?"
Location Matters
Another important factor to consider is an advocate's location. State laws vary in how they regulate
insurers and hospitals. For Katalin Goencz, an advocate in Stamford, Connecticut, location is often
irrelevant because she specializes in Medicare appeals: "The rules for Medicare are federal and pretty
much universal, so the client's location doesn't really matter."
For a patient negotiating a lower bill directly with a local hospital or private insurer, having
an advocate who knows the specific state regulations helps. State rules for advocates can also vary
dramatically. Florida has some of the strictest. "Due to the large senior population in our state,
we have a strong urge to make sure our people adjusting medical claims are licensed, competent and
held to a high standard," says Matthew Guy, a spokesman for
Florida's Division
of Agent and Agency Services, which licenses and regulates advocates.
The state's Public Adjuster license for advocates requires licensees to be fingerprinted, have
a criminal background check and hold a $50,000 surety bond. "If there's any wrongdoing by the adjuster,
we can take the bond amount and use that towards restitution for the consumer," Guy says. Adjusters
must pass an exam and take 24 hours of continuing education classes every two years.
Contingency Basis
A handful of advocates will work on contingency if they think you have a negotiable claim. Most
will impose strict conditions to ensure they get paid if they win. "When I started my practice, I
did everything on contingency but learned very quickly that a lot of consumers who want you to take
their case on contingency in the end don't want to pay you," says Sheri Samotin, a billing advocate
at Life Bridge Solutions in Naples, Florida.
Now Samotin requires a credit-card authorization up front for an amount sufficient to cover what
her estimated contingency fee will be if her work succeeds. If the client doesn't pay within 10 days
of a settlement being reached, she charges the card. Her fee is 35 percent of the client's medical
bill savings.
Samotin is unusual in the advocacy world as she is more of a generalist, taking on all kinds of
medical billing problems, including those of the uninsured. She has 25 years of experience in the
health-care industry, so she has the knowledge to handle different kinds of problems, Samotin says.
For a monthly $285 fee she will manage her clients' entire billing life -- a common need for seniors
who have lost their capacity or desire to manage daily finances.
Instead of being a member of ACAP, Samotin is a member of the
American Association of Daily Money Managers, a trade group for generalists. Only a handful of
the AADMM's 700-plus members have the skills to also handle medical billing advocacy, Samotin says.
Nor does she expect rapid growth in the field.
"Because this is a disorganized profession, people entering the field have to be entrepreneurs,"
she says. "They have to hang out their shingle and go out and get clients. In my experience, the
majority of people who are good medical analysts and advocates are not necessarily good business
getters."
So until the profession matures, finding a good advocate will remain difficult, no matter how
vital the service is.
(Lewis Braham is a freelance writer based in Pittsburgh.)
To contact the editor responsible for this story: Suzanne Woolley at
[email protected]
"... There are also companies who claim they have a network of physicians throughout the state who offer medical services for 50 percent off or more. ..."
But you can fight back against skyrocketing medical costs.
"I've heard discounts up in the area
of 30 percent sometimes, which can be pretty significant," said Cathryn Perron, director of program
development with Consumer Credit Counseling.
She says it's possible to negotiate down your medical bills - everything from ambulance rides
to surgery. She says you can also bargain with your dentist, the lab that does your blood tests,
the eye doctor - even the company that makes you prescription medication.
"Each company has a specific number you can call to fill out an application and many times, you'll
get a discount, or you'll get the product free through the drug companies, if you qualify financially,"
Perron said.
All you have to do, with or without insurance, is make a call. Each case is handled differently.
In most cases, everyone wants to pay the bill, but they're afraid to contact their doctor or hospital.
They'll work with you to make sure the cost is paid.
So how do you pay less?
There are a number of options:
Offer to pay in cash - You may get an up-front discount of 10 percent or more.
Ask about a payment plan - They're usually interest-free and determined by your budget.
If you don't have insurance - Some hospitals will give you a discount that is equal to what it
may have given the insurance company.
Charity care - Bills are forgiven, based on your income and expenses, but you'll have to fill
out hardship paperwork.
"You'll most likely have to provide proof of income, they'll ask about your monthly living expenses
and your other bills that you have to pay every month," said Perron.
Sholar called Indianapolis EMS.
"He says, 'Sir, you got to pay for the ambulance, all the stuff in the ambulance, the two people
who drive the ambulance. That's just the way it is'," he said.
But he didn't give up.
"This bill says $1,300. She said, 'Yeah, that sounds about right.' I said, 'Let me talk to a supervisor',"
Sholar said. "The supervisor's name is John. John wasn't too happy."
Mike put on the pressure and the bill was reduced by $532. The wounds to his buttocks are healed,
but the other injury he got that night, on his thumb, is a constant reminder of the cost of healthcare.
"I don't need no X-rays, I don't need no other stuff. Just give me the stitches and I still haven't
received a bill for that," he said.
But he's ready to negotiate and he says, in the future, he'll also weigh the costs before calling
911.
"I would have put a rag over it and got a ride here," he said.
Tips to Negotiate Your Medical Costs
Consumer Credit Counseling and Apprisen offer tips to get your medical bills reduced:
First and foremost be informed. Understand what type of medical insurance coverage you have and
what your co-pays or financial responsibilities are. Some insurance companies have contracts with
certain medical providers to offer a discount if you receive treatment from a "preferred provider."
We encourage individuals to meet with their Human Resource department or contact their insurance
company to speak with a representative about their coverage and benefits prior to receiving medical
treatment. This could reduce your financial responsibility significantly.
Apprisen recommends for you to review your itemized statement from your medical provider. If you
feel there are discrepancies or charges in question, contact your medical provider to meet with their
Patient Account Specialist to discuss your questions or discrepancies. Communication is a vital part
of resolving your issues. Simply ignoring communication from your medical provider will not resolve
the issue and could potentially lead to a negative impact on your credit rating if resolution is
not reached.
Whether you have insurance or not, you are encouraged to contact your medical provider prior to
treatment (if possible) to discuss costs associated with your treatment and to work out the possibility
of negotiating those costs down. Many medical providers will consider giving discounts to individuals
who are willing to pay the balance in full upon services rendered or within a short period
of time after receiving treatment. If you find yourself in a position where you are not able to pay
the balance in full, consider negotiating with your medical provider for a monthly repayment plan
interest free. You are encourage to analyze your personal budget to insure you are able to make the
financial commitment to your medical provider. Negotiating your medical bill then failing to follow
through with the financial payment arrangement could negate your hard effort to reduce your medical
bill.
If you are uninsured, you are encouraged to meet with a Patient Account Specialist or a "decision
maker" to see if you qualify for any financial hardship programs. Most hardship programs require
you to provide evidence of your financial situation and the award is based on financial need. Be
prepared to give a full budget disclosure in order to be considered for the hardship program.
Apprisen's mission is "To help people improve their financial well-being through counseling, community
outreach and financial education."
You can call Apprisen at 1-800-355-2227 or visit
apprisen.com.
There are also companies who claim they have a network of physicians throughout the state who
offer medical services for 50 percent off or more. You can find out more about those companies at
objectivedx.com.
Lealea - thanks for asking - he did make the team! So, that is the good news...and, he did learn a lesson about taking charge
of your needs, even if it isn't convenient or easy.. the charges from that, though, pretty much wipe out the scholarship award,
so at least financially he is in the hole from the get-go
I'd still give the ambulance company a call and see what you may be able to negotiate. Sometimes, they will cut you
a break because of circumstances. Good luck to you and your son.
The California Department of Consumer Affairs ( www.dca.ca.gov ) says nothing
more than to contact your local consumer agency, by which I can only assume they mean the Better Business Bureau.
You might want to give the DCA a call at 800-952-5210 for clarification.
No, you need to go over her head and speak to the owner of the company.
A representative of the Department of Consumer Affairs in Sacramento gave me the following information:
The state Ambulance association's number is: 915-735-0154
The California State EMS Authority number is: 916-322-4336, and their website is: www.emsa.ca.gov.
Consumer Affairs regulates most medical providers in California, but not ambulance/EMS services. The two organizations I gave
above, and particularly the second, should be able to help.
If you have insurance, they will more than likely cover this, which makes it their problem, not yours.
If ambulance companies overcharge, and the insurance companies pay it, then said insurance companies will raise their rates. You
pay it now, or you pay it later. In a specific incident like this one, you're not shoving the problem off on some nameless, faceless,
corporation--you're spreading it around to a bunch of other folks just like yourself.
Arrosen is taking the more responsible approach of trying to fix the problem rather than pawn it off on other people.
__________________ ---
Yes, I have joined the ranks of former moderators. Being a mod was eating my life. Now I'm a member just like you. Except smarter
and better looking.
If ambulance companies overcharge, and the insurance companies pay it, then said insurance companies will raise their rates.
You pay it now, or you pay it later. In a specific incident like this one, you're not shoving the problem off on some nameless,
faceless, corporation--you're spreading it around to a bunch of other folks just like yourself.
Arrosen is taking the more responsible approach of trying to fix the problem rather than pawn it off on other people.
No, because he has a contract with the insurance company. They pay the bill, arrosen pays the difference.
That said, I'm sure the insurance company would be very interested in this ambulance company. They have a fraud division that
investigates overcharging and improper billing. Try talking to them, too.
The American College of Emergency Physicians Foundation[5]
offers a guide to when to call an ambulance in an emergency.
What should be included:
In an emergency, the ambulance provider that services the location typically will respond immediately to a call. The dispatcher
will determine if only emergency medical technicians are needed, for basic life support, or if paramedics are needed, for advanced
life support.
The ambulance crew will assess the patient's medical condition and check vital signs such as pulse, blood pressure and respiratory
rate, and will determine if transport to a nearby hospital emergency room is needed. If so, the crew will provide needed care
during the ambulance ride. Basic life support care, typically for non-life-threatening emergencies, includes minor treatment,
continued monitoring, and possibly administration of oxygen. Advanced life support care, for life-threatening emergencies, also
can include CPR, administration of medication, breathing tube insertion and other needed treatments.
Additional costs:
Medical supplies -- for example, sterile gloves, needles, IV supplies, catheters, and saline -- used during the trip can add
hundreds or even thousands of dollars to the final bill. For example, providers in Los Angeles County[3]
can charge $24.75 for an oxygen mask, as well as for bandages, dressings ice packs; they can charge $45.25 for a
burn kit or obstetrical kit; and can charge $80.25 for an infusion pump or pulse oximeter.
If a critical care nurse or respiratory therapist is required during an ambulance ride, it can add hundreds of dollars
to the cost.
Discounts:
Some providers will negotiate a discount of up to 20% or more for uninsured patients who pay cash or pay within a certain
timeframe. For example, Lincoln County Ambulance Service[4]
in Kansas offers a 20% discount for payment within 30 days and a 10% discount to uninsured patients. And Woodburn Ambulance Service
in Oregon offers a 10% discount for payment made within 30 days of service.
Shopping for an ambulance:
The American College of Emergency Physicians Foundation[5]
offers a guide to when to call an ambulance in an emergency. In a 9-1-1 emergency, the ambulance provider that services that location
will respond; in some locations, there is more than one provider and it might be possible to request a certain provider.
For a scheduled transport, a hospital or physician should be able to provide a referral for an ambulance service. Or, the
American Ambulance Association[6]
offers a provider directory by state and city.
Material on this page is for informational purposes only and should not be construed as medical advice. Always consult your physician
or pharmacist regarding medications or medical procedures.
To respond to the Virginia Beach person voicing that those that are complaining of Ambulance fees are a "bunch of whiners;"
In the State of Illinois an ambulance fee ranges from $7,000.00 to 10,000.00, I think we have a right to be concerned as to the
high cost, not that I am not appreciative of the EMT themselves but the cost for an ambulance is ridiculous!
Yes, Insurance will cover some cost but did you know that for a Dialysis patient that requires (per physician) an ambulance
as a Medcar would not be appropriate, that person pays the cost of 5,000.00 to 7,000.00, that the Insurance and Medicare will
not pay. So now, Virginia Beach, these people have every right to be concerned and are not "whiners" especially if they can not
afford that exorbitant amount. Tell what is their alternative, will you pay for it for them?
Posted by: Scammed by Superior in Libertyville, IL.
Posted: December 22nd, 2014 09:12PM
Ambulance Provider: Superior
Distance: 39 miles
Charged roughly $7500 to transfer from one hospital to another for a non-emergency. The hospital told us it was mandatory
we take an ambulance. Insurance covered only $700 b/c Superior is out of network (I called...they do not participate in
ANY networks).
Left with an out of pocket bill for $6800 for a glorified taxi service. I don't know what to do. BCBS was no help whatsoever.
I can sincerely appreciate the appearance of outlandish costs for ambulance services in our country. However, as a volunteer
helping to manage a non-profit ambulance service, I would offer an explanation. On average, ambulance services recover only a
small portion of their billings, about 60% but can go as low as 40% depending on the area. In short, those that do pay are also
paying for those that do not. Even with this consideration, most may feel the costs too high. I would ask them to appreciate the
costs of providing highly trained personnel, available within minutes, 24 hours a day, 7 days a week.
Ambulance Provider: Superior Air Ground Amb. Service
Distance: 41 miles
My kid had to be transferred from one hospital to another and Superior Ambulance from Aurora to Park Ridge, IL charged
$7550. Blue Cross paid $4730 (the maximum they would pay) and left me with $2820.
I had no choice and no information ahead of time so I feel gouged. They can charge whatever they want and we are stuck.
"... Most states have laws saying that patients are entitled to an itemized medical bill that details what services and supplies are included in their charges. ..."
"... In 2006, California passed a law to prevent hospitals from collecting more money from uninsured patients than what Medicare or other public programs would pay for the same service. ..."
"... "Once a patient contacts the hospital and shows evidence of their financial situation, state law requires us to offer a discount based on Medicare rates," says Jan Emerson-Shea, vice president of external affairs for the California Hospital Assn. ..."
"... All communications with a provider should be in writing, experts say. Insist that your account be placed on hold until the dispute is resolved to avoid having the bill sent to collections. ..."
"... If you meet with resistance, don't waste time by calling back the customer service line or billing department. Go straight to the top. ..."
"... filing a complaint with your state's department of insurance. ..."
For those with confusing or huge hospital bills, experts advise knowing rights, getting written
explanations, turning to the right places for help and filing complaints if necessary.
When Keith
Yaskin and his wife, Loren, rushed their 2-year-old son to the hospital with a dangerous infection
in his neck, they weren't thinking about how much his care would cost. After his three-day inpatient
stay with nonstop intravenous antibiotics, they were hit with $8,900 in charges.
But the toughest lesson for the Scottsdale, Ariz., couple came a month or so later when they began
to sort out the hospital bills. Their insurance policy had a $10,000 deductible. So they scrutinized
every item, made some calls and had a few surprises.
When, for instance, they asked a medical group they had never heard of why it was charging them
$839.25, they said they got no clear answers, just threats if they failed to pay.
After 21/2 months of calls and a complaint to their state attorney general, the Yaskins finally
learned that a pediatrician affiliated with the group had treated their son in the hospital. The
medical group eventually cut the bill in half.
None of this surprises Pat Palmer, the founder of Medical
Billing Advocates of America. "We get feedback from consumers saying that providers are telling
them 'We can't give you an itemized statement' or 'You should have asked for it before you left the
hospital.'"
The idea is to discourage patients from asking for the details behind the charges, she said.
Experts offer a range of suggestions for dealing with medical billing problems.
Know your rights.Most states have laws saying that patients are entitled
to an itemized medical bill that details what services and supplies are included in their charges.
"You can't be billed if they can't tell you what they are charging for," Palmer says.
Contact the billing department at either the hospital or medical group where you received services,
she said. Let them know that you want an itemized bill, and tell them you are aware of your legal
right to have it.
Also, a few states have laws limiting how much hospitals can charge patients who pay for care
on their own. In 2006, California passed a law to prevent hospitals from collecting more money
from uninsured patients than what Medicare or other public programs would pay for the same service.
"Once a patient contacts the hospital and shows evidence of their financial situation, state
law requires us to offer a discount based on Medicare rates," says Jan Emerson-Shea, vice president
of external affairs for the California Hospital Assn.
Get explanations in writing and take protests to the top.All communications
with a provider should be in writing, experts say. Insist that your account be placed on hold until
the dispute is resolved to avoid having the bill sent to collections.
If you meet with resistance, don't waste time by calling back the customer service line or
billing department. Go straight to the top.
Address a certified letter to the chief executive or chief financial officer of the hospital
or medical group explaining that you have tried to resolve billing issues but have hit a brick wall.
"The CEO and CFO will take it very seriously," Palmer says.
Get help from your insurer. In the Yaskins' case, both the hospital and the medical
group were in their insurer's network and had contracts to provide services at a negotiated discount.
"If you are in network - and this is one of the good reasons to stay in network - you can go to
your insurer for help. It has a responsibility to some degree to what happens between you and a contracted
physician," says Susan Pisano, spokeswoman for the trade group America's
Health Insurance Plans.
Also, ask to make sure you're getting the rate your insurer has negotiated with in-network providers,
says Lynn Quincy, senior health policy analyst for Consumers
Union, the policy arm of Consumer Reports. Insurers often pass claims through without processing
them at the reduced rate. Ask your insurer to re-process the claim if the discount wasn't applied.
Seek help and file complaints. If your bill is large or you're having a hard
time making headway, patient advocates can help sort things out. For either a flat fee or a share
of the money you save, organizations such as Medical Billing Advocates of America
(www.billadvocates.com) and Health Proponent
(www.healthproponent.com) can help you fight charges
or lower your bill.
If you're being stonewalled by your healthcare provider, and your insurer hasn't helped, Quincy
of Consumers Union suggests filing a complaint with your state's department of insurance.
In California, patients with HMO coverage can file a complaint with the California Department of
Managed Health Care by calling (888) 466-2219 or visiting healthhelp.ca.gov.
Californians with PPO coverage should try the Department of Insurance at (800) 927-HELP (4357) or
visit http://www.insurance.ca.gov. If your provider isn't
contracted with your insurer, your state's attorney general's office is a place to turn for help.
The Yaskins ultimately enlisted the services of an advocate to help them sort through all their
billing questions.
The Last but not LeastTechnology is dominated by
two types of people: those who understand what they do not manage and those who manage what they do not understand ~Archibald Putt.
Ph.D
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