Originally reported in, “The New York Times,” by Elisabeth Rosenthal on 9/20/2014, http://www.nytimes.com/2014/09/21/us/drive-by-doctoring-surprise-medical-bills.html?partner=rss&emc=rss&_r=0, is the story of Peter Drier who went in for surgery and was unknowingly seen by a Dr. Mu, “assistant surgeon,” and billed for out-of-network services to the tune of $117,000.
Start with the Obama-blab (hot air used to sell Obamacare). In an oft-cited Presidential pitch, the President sold Obamacare as a means of preventing people from being one illness away from bankruptcy…It’s not true.
For instance on 11/4/2013, as quoted in an article in the “Washington Post,” by David Nakamura, “Obama on health care: ‘I’ve got one more campaign in me...to make sure this law works,’” http://www.washingtonpost.com/blogs/post-politics/wp/2013/11/04/obama-on-health-care-ive-got-one-more-campaign-in-me-to-make-sure-this-law-works/, Obama was quoted as saying:
"If we allowed these old plans to be downgraded ... when the law was already passed, we would have broken an even more important promise: making sure Americans get access to health care that doesn't leave them one illness away from financial ruin," the president told more than 200 members of Organizing for Action…(see cite above).
If not a deliberate lie, at the very least this “promise” shows how badly the President understood the US health care environment and the law he helped pass that he could state in 2013 by implication that his actions had somehow KEPT the promise to Americans of having access to health care that “doesn’t leave them one illness away from financial ruin.” Not true. Was never true.
Ms. Rosenthal somehow writes her long article without ever addressing the issue by its name: BALANCE BILLING. I discussed Balance Billing in my post of 6/4/2014, “Balance Billing: What Consumers Require,” http://conoutofconsumer.blogspot.com/2014/06/balance-billing-what-consumers-require.html.
Balance billing is exactly as indicated, the practice of billing the patient and holding the patient liable for amounts NOT covered by insurance. In the case of an out-of-network provider, these amounts can be enormous.
Balance Billing is also addressed by HealthCare.gov if you look up Out-of-pocket maximum/limit where consumers are warned that, “The maximum out-of-pocket cost limit for any individual Marketplace plan for 2014 can be no more than $6,350 for an individual plan and $12,700 for a family plan,” BUT…” This limit does not have to count premiums, BALANCE BILLING amounts for non-network providers and other out-of-network cost-sharing, or spending for non-essential health benefits,” (caps added).
Currently, as I disclosed in June, there is little help for consumers. 13 states have some sort of legislation that tries to address the problem, but the issue is significant in every state.
Obamacare did NOT create the problem of balance billing, but it may have made it worse by encouraging the work-arounds discussed in the article in order to keep physician pockets bulging in instances where Obamacare prevails. For instance, Ms. Rosenthal quotes Dr. Abeel A. Mangi of Yale stating, “The idea of having an assistant in the O.R. has become an opportunity to make up for surgical fees that have been slashed.”
The same Dr. Mangi disclosed that “You can cut fees, but institutions find ways” to make the money back, he said. “There’s been a mushrooming industry of mandatory consultants for services that neither doctors nor patients want.”
There was even the mention that doctors who participate in plans may make deals to bring in non-participating providers and split the fees those non-participating providers charge, naturally not admitted to since it would not be a legal practice.
Based on the article it seems that New York is trying to address the issue with a law that becomes effective in March that according to the article will require these out-of-network, out-of-pocket balance billing fees in many instances to become the doctor-insurance company problem and “directs insurers and hospitals to negotiate any further payment or enter mediation,” “The New York Times,” by Elisabeth Rosenthal on 9/20/2014, http://www.nytimes.com/2014/09/21/us/drive-by-doctoring-surprise-medical-bills.html?partner=rss&emc=rss&_r=0.
In a 1/6/2014 article by Zack Budryk, “Hospital charge-to-cost ration on the rise says nursing group,” http://www.fiercehealthfinance.com/story/hospital-charge-cost-ratio-rise-says-nursing-group/2014-01-06, another reason for outrageous pricing is provided by Jean Ross, Co-president of NNU who states, "The higher the starting point on a charge, the higher the ultimate reimbursement."
It should be noted that in this instance, the insurer did pay the fee to the physicians after Drier complained. Not everyone is that lucky.
