Surprise Bills for Many Under Health Law

Thursday, June 11, 2015

Out-of-network charges often aren’t flagged before treatment, consumers say; states tightening laws

Many consumers with health coverage through the Affordable Care Act are facing unexpected medical bills that in some cases greatly exceed the law’s caps on out-of-pocket expenses.

The law’s limits don’t apply to charges from out-of-network providers, and many insurance plans sold on ACA exchanges have limited networks—amplifying the risk of surprise bills.

Health plans offered by employers also have been slimming down the number of doctors and hospitals in their networks. But what have come to be known as narrow networks are more prevalent in plans offered on the health law’s exchanges, one tactic insurers are using to curtail costs because they can’t exclude consumers with existing medical conditions.

When Arturo Paramo, a 50-year-old construction worker, experienced chest pains last year, he was admitted to St. Francis Hospital in Bartlett, Tenn., after a doctor sent him there following an electrocardiogram. His wife, Bainey, said they weren’t told the hospital in suburban Memphis didn’t accept her family plan. They got a $22,945 bill—above the ACA’s $12,700 cap for a family plan in 2014—in the mail.

“It was out of network. Why didn’t they tell me when we entered? We would have gone to the right hospital,” said Ms. Paramo, a homemaker in nearby Arlington with four children.

The couple appealed the charge, which the hospital reduced to $600—but only after the bill had been sent to a collections agency, which Ms. Paramo worries will hurt the family’s credit rating.

Under the ACA, patients generally can’t be charged higher coinsurance or copayments for out-of-network emergency-room services—but they can be charged for the amount insurance doesn’t cover, which could be thousands of dollars. The law caps out-of-pocket costs in 2015 at $6,600 for an individual and $13,200 for a family. But that doesn’t apply to out-of-network providers who charge patients for the part of bills that their insurance doesn’t pay.

More states are passing laws that aim to halt unexpected out-of-network bills. Under California legislation approved this month, consumers who go to an in-network facility but are treated by an out-of-network provider there only have to pay what they would have been charged if the provider participated in their plan.

A New York law providing a number of out-of-network safeguards went into effect in April, and legislation has been introduced in Texas.

“This is part of a growing movement in states. It’s really important to fulfill the promise of the ACA,” said California Democratic Assembly member Rob Bonta.


·         Check if your provider is in network before you get services.
·         Get authorization from your insurer to go out of network if you need specialty care that isn’t provided in your plan’s network. Appeal decisions if necessary.
·         Get an itemized copy of your bill and review all charges.
·         Ask your insurer if they will cover out-of-network charges you accrue.
·         If insurer won’t cover out-of-network charges, try to negotiate with providers.
·         Check with consumer-assistance programs if you have billing disputes over out-of-network charges.

Source: Kaiser Family Foundation

It can be easy for patients to accidentally step outside their plan because of outdated information about provider networks. Moreover, a patient who picks a hospital that is in network may discover that some of the doctors who provide treatment there aren’t.

“This issue is becoming more urgent because you have more people covered under the ACA, and more of them are in the lower-income levels and can’t afford financial surprises,” saidAnthony Wright, executive director of Health Access California, a consumer advocacy coalition.

Dr. Jay Kaplan, president-elect of the American College of Emergency Physicians, said insurance reimbursements are so low that doctors have to bill for the difference or go out of business.

America’s Health Insurance Plans, a trade group for insurers, says out-of-network physician charges can be significantly higher that customary rates.

The group has supported protections for consumers against balance billing—charging patients for the part of the bill that insurance doesn’t pay.

Plans with narrow networks make up about half of all health-law exchange networks in the U.S., and about two-thirds of the networks in the largest cities, according to a 2015 report by McKinsey & Co. Among companies with 50 or more workers that provide insurance, 8% offered a narrow-network plan in 2014, according to a report by the Kaiser Family Foundation.

More than half of Americans say making sure health plans have sufficient networks to provide a wide choice of doctors and hospitals should be a top health-care priority for the president and Congress, according to an April poll by the foundation.

“We are concerned about the way some health insurers are marketing their products and setting arbitrary limitations on out-of-network coverage that negatively impact patients’ out of network costs,” said Dr. Robert Wah, whose terms as president of the American Medical Association ended this week.

Kelly Dignam, 53, of York, Maine, got a colonoscopy in 2014 at nearby Portsmouth Regional Hospital in New Hampshire, which she said was in network under her federal exchange policy. But she received a $1,290 bill from the radiologist and anesthesiologist because they were out of network.

“At no point along the way did anybody raise any flags,” said Ms. Dignam, a mother of two who works at her parents’ retail store. “It’s an insult. It was an in-network hospital.”

She said she filed an appeal and the claim was reprocessed as in network, leaving her owing nothing because she had already met her deductible. Portsmouth Regional Hospital didn’t respond to an email seeking comment.

The Centers for Medicare and Medicaid Services is strengthening standards for insurance directories later this year to ensure they are accurate and updated.

Anthem Blue Cross of California, Cigna Corp. and Blue Shield of California are facing lawsuits filed in 2014 by beneficiaries who say they were misled about the size of the networks when obtaining coverage on the state’s ACA exchange. The insurers either declined to comment or didn’t respond to an email seeking comment.
In many states, consumers say they feel vulnerable. Angela Giboney, 47, a financial adviser in Mill Creek, Wash., who is covered through a state exchange, got a mammogram in 2014 she thought was in network. It wasn’t—a fact she said she wasn’t told until after her screening—and she received a $932 bill from Seattle Cancer Care Alliance.

The Seattle Cancer Care Alliance said it endeavors to tell patients whether care will be covered in network. Ms. Giboney appealed the charge but was unsuccessful. “It was never made clear to me that it was out of network,” she said.