COVID relief bill and balance billing

[MillCreek]

https://www.npr.org/sections/health-shots/2020/12/22/949047358/congress-acts-to-spare-consumers-from-costly-surprise-medical-bills

This is a good part of the COVID relief bill just passed.  Many patients, especially those needing emergency care, are careful to go to a hospital in their insurance network.  But it turns out that the emergency medicine group, the surgery group, the radiology group, the anesthesia group, or the lab group at the hospital is not in their network and the patient is sent a large bill between what their insurance covers and what the group bills.  The new bill limits the type and amount of these balance bills.  The new bill is not a panacea since there are several situations in which it does not apply, but it is a start.  Remember that almost 2/3rds of bankruptcies are due to medical bills, and balance billing contributes to that.

[Cliffh]

Ran into that during a colonoscopy.  I'm prepped, lying on the table ready to go - sleepy shot and all - and they tell me that the anesthesiologist isn't in my network.

We worked it out with the anesthesiologist after receiving the bill.  Got them to agree to what my co-pay would have been.

[makattak]

Remember that almost 2/3rds of bankruptcies are due to medical bills, and balance billing contributes to that.

That's a damnable lie and based on extremely loose "research."

2/3 of bankruptcies INCLUDE medical bills. Which was then translated by the researchers with an agenda as "due to medical bills."

Not commenting on the rest of the post, but I can't let a blatant lie like that continue to propagate.

[MillCreek]

https://pnhp.org/new_bankruptcy_study/Bankruptcy-2009.pdf

Is there a more recent study in the literature?

[RoadKingLarry]

RE: medical bills -

Having had a very recent (still ongoing) issue with medical billing I'll relate my situation.

I had shoulder surgery (again)on 10/23.  This go around was a "Superior Capsular Reconstruction with Allograft". That was what was discussed with the surgeon in his office when the surgery was scheduled.
In late November I Received a bill for $12,429.25,  my insurance denied payment for the allograft because it was "not scientifically proven" for the condition. They kindly informed me that if I couldn't pay all at once I could make 12 easy payments of $1,035.77.
I went back and forth with the billing folks and was constantly told that they were "working with the nurses" to get this taken care of.
The insurance payout on the original $12,429.25 would have been probably about 50%-60% of the billed amount.I'm fairly certain that there would have still been a profit at that payout.
A week ago I contacted them again and was informed that they were going to grant me a 70% self pay discount. $3,728.77. I'm going to go out on a limb and bet that there is still profit in that figure.
During my review of records I pulled up the insurance company approval letter showing approval for "29806 Arthroscopy, shoulder, surgical; capsulorrhaphy". I had never encountered the term capsulorrhaphy prior to seeing it in the insurance document and the term was not used in the two previous shoulder surgeries I've had this year. I had to look it up. I also reviewed all the documents from the surgeon and nowhere is that term to be found. It is my suspicion that a coding error occurred and they either haven't figured that out or are unwilling to accept that they screwed up.
I suspect that my situation is not particularly rare and I doubt that I will resolve this in my favor and I will be stuck with the $3728.77 bill.

The total lack of transparency and a total lack of available information regarding pricing and costs of medical treatment is at best immoral. No other field demands customers agree to paying for a service up front with no idea of what the service will cost till after it is done. Of course I understand that there are situations where the unexpected is found mid-procedure but I doubt that is the overwhelming norm. That kind of crap is why we are going to end up with government run socialist style health care.

[MillCreek]

The balance billing issue is why I signed my wife and I up for a membership in the local air ambulance company.  They generally send a bill for several thousands or higher dollars for air ambulance services, and the local insurance companies have a relatively low air ambulance benefit.  The local company (Airlift NW) is notorious for aggressively collecting their bills and going after the patient's assets.  I have read lots of stories about people who had no choice about being transported by the helicopter, and they ended up with crushing debt as a consequence.  Buying a membership means they cut the bill a bit, but with the new Federal law, perhaps it will be cut even further.

[makattak]

https://pnhp.org/new_bankruptcy_study/Bankruptcy-2009.pdf

Is there a more recent study in the literature?

A, yes, the Elizabeth Warren study, which is EXACTLY what I was referring to as faulty, loose, and written with an agenda.

Quite a few have been published since, on both sides of the issue. Here's a recent couple: https://pnhp.org/news/the-myth-that-medical-bankruptcies-are-rare/ (A response and the original.)

Let me note for you, from their own study, that their definition of a "medical bankruptcy" was they have $5000 in medical debt.

$5K caused the bankruptcy. Riiiiiight.

[MillCreek]

Thanks so much for the cites! I will read the articles.

[JN01]

In October, I suffered a stroke caused by undiagnosed afib.  My wife took me to the local in-network feeder hospital ER where they did a CT scan and shipped me out via ambulance to the in-network main hospital.  Had a blood clot removed from my brain, spent 2 days in ICU and was released (I thank God that I suffered no lasting effects, back to 100% 3 days after).

It wasn't until I started getting statements from the insurance company that I found out that the ambulance service, lab work, and doctor who did the procedure were out of network. Insurance paid part of it, but the bulk is stuck on me.  Luckily, it appears that the $72k hospital bill will be covered.

[Cliffh]

DW had to take an ambulance ride from an in-network clinic to an in-network hospital using the hospitals' ambulance.  We were stuck with over $1k after the insurance settled. 

The local ambulance company offers a family plan for $48/year - and that's all you pay.  They take what the insurance company pays and the member never sees a bill.

Of course, that only covers the area they serve.  If a member ends up having to go out of their area or uses a different company, well, the member's going to pay.

[230RN]

The balance billing issue is why I signed my wife and I up for a membership in the local air ambulance company.  They generally send a bill for several thousands or higher dollars for air ambulance services, and the local insurance companies have a relatively low air ambulance benefit.  The local company (Airlift NW) is notorious for aggressively collecting their bills and going after the patient's assets.  I have read lots of stories about people who had no choice about being transported by the helicopter, and they ended up with crushing debt as a consequence.  Buying a membership means they cut the bill a bit, but with the new Federal law, perhaps it will be cut even further.

Ditto here except ground ambulance.  I was walking, but in great pain.  Got stung with an enormous bill after insurer paid a small amount.

"If you pay now we can offer a 20% discount."

Having previously (10 yeas before) had contact with the rapacity of medical bill collectors, I gritted my teeth and paid up with the discount.  The extra would have paid for about ten cab rides.

[MillCreek]

https://www.npr.org/sections/health-shots/2020/12/23/949287668/retiree-living-the-rv-dream-fights-a-nightmare-12-387-lab-fee?utm_source=facebook.com&utm_medium=social&utm_campaign=npr&utm_term=nprnews&fbclid=IwAR1BErXROBEyU7D_CwRqoG6VXOailO81J61YtgWlCrDYXdHy_C24CQX8Hb0

Holy moly, what a bill.

[dogmush]

From ^ that article:

Although a doctor doesn't need a patient's authorization to run tests, it's not good practice to do so without informing the patient, says Dr. Ina Park, an associate professor of family community medicine at the University of California-San Francisco School of Medicine. That is particularly true with tests of a sensitive nature, like STIs. It is doubly true when the tests are going to costs thousands of dollars.

If the doctor doesn't need the patient's authorization, it seems like the Dr. is responsible for the bill.  They made the choice to do the test.

I think non-emergant medical care needs similar laws to what mechanics work under:  Anything over $100 (in FL) requires a signed, written quote.  If you exceed the quoted amount by 10%, you need to stop and obtain a new signed quote and authorization to proceed. 

[RoadKingLarry]

Legal but corrupt *expletive deleted*it like that is why we are going to end up with government run, single payer healthcare.

[dogmush]

Legal but corrupt *expletive deleted*it like that is why we are going to end up with government run, single payer healthcare.

Or medical centers burned to the ground.  Or both.

[DittoHead]

I think non-emergant medical care needs similar laws to what mechanics work under:  Anything over $100 (in FL) requires a signed, written quote.  If you exceed the quoted amount by 10%, you need to stop and obtain a new signed quote and authorization to proceed. 

There is a lot of tricky stuff in medical billing that I don't even pretend to have a good solution for, but this seems like a pretty straightforward & reasonable approach to at least try.

[MillCreek]

I would say that one of the sticky wickets is that the typical provider has no idea what a lab test costs.  For example, my healthcare system is served by one of the largest commercial lab chains in the country (LabCorp) and they don't post prices for the majority of tests.  I am pretty sure they have at least two different price schedules: one for insurance billed and one for self-pay.  So neither the provider nor the patient know the true cost of what is being ordered.  I could probably eventually find out the cost of a test, but it would probably take several emails or phone calls to do so.

[DittoHead]

one of the largest commercial lab chains in the country (LabCorp) and they don't post prices for the majority of tests.

So isn't that kind of a root problem that needs to be fixed?

[MillCreek]

So isn't that kind of a root problem that needs to be fixed?

You would think, and both the current Administration and CMS require hospitals to post prices, but there is much concern this will lead to collusion in the healthcare industry to artificially raise prices.

https://www.insidesources.com/the-problem-with-transparent-health-care-prices/

[Ron]

It would be nice if these issues were dealt with in clean bills or at least more focused bills.

The omnibus bills are just a nightmare.

[Fly320s]

Just make it like car and house insurance.  Your car insurance is good at any body shop and your house insurance will write a check to you or the contractor.

No need to get the fedgov involved.

[charby]

Just make it like car and house insurance.  Your car insurance is good at any body shop and your house insurance will write a check to you or the contractor.

No need to get the fedgov involved.

I agree but some areas only have one health care provider option (so they could have higher prices), where as there are usually at least 2 body shops and several building contractors. I live in a town of 25k and we are dominated by MercyOne who I think the founding Catholics would throat punch the board of directors on how the it has evolved over time. 

Sometimes I wish healthcare providers were treated like a utilities, where they have to give justification to their prices to a state board, especially in areas of little to no competition.

[dogmush]

I would say that one of the sticky wickets is that the typical provider has no idea what a lab test costs.  For example, my healthcare system is served by one of the largest commercial lab chains in the country (LabCorp) and they don't post prices for the majority of tests.  I am pretty sure they have at least two different price schedules: one for insurance billed and one for self-pay.  So neither the provider nor the patient know the true cost of what is being ordered.  I could probably eventually find out the cost of a test, but it would probably take several emails or phone calls to do so.

I know at least part of the answer, but:

[Devil's advocate]

Why does your healthcare system do business like that?  Why are they willing to subject their providers and patients to a system that, at best, is hopelessly opaque, and, at worst, is designed to make it easier to cheat patients.  Why should your patients trust your healthcare system when it forces them to be victims of such a predatory pricing policy on labs?  In what other ways does your healthcare system cheat it's patients?

[/Devil's advocate]


I agree with RKL that we are going to end up with some gods-awful chimera of Medicare-for-all and expensive care for rich people run by GS-7's in the end.  

[MillCreek]

^^^If I had to boil it down to a simple concept, it would be compliance with the Stark regulations, and not running afoul of the Feds for anti-trust and collusion requirements.  Legal and regulatory requirements and prohibitions are a major driver of the current system.

[RocketMan]

Legal but corrupt *expletive deleted*it like that is why we are going to end up with government run, single payer healthcare.

And Death Panels.  Don't forget the Death Panels.