Peter Drier thought he had done his homework regarding his insurance coverage and medical costs prior to a neck surgery to repair herniated disks last December, but an unexpected bill for $117,000 from an assistant surgeon he did not know about was an extremely unpleasant surprise. The New York City bank technology manager was prepared for the bills from the surgeon, the anesthesiologist and the hospital, all of whom were covered “in network” by his insurance and would accept negotiated fees on their charges. However, the assistant surgeon was out of network, and expected to be paid the full amount of his bill.
It is not an uncommon scenario. Medical care, particularly hospitalization, is full of unexpected and unwelcome costs, even if it is for a planned procedure that the patient has carefully researched prior to admission. A hospital stay of several days may involve visits from hospitalists, who are general medical professionals specializing in the care of hospitalized patients, but who bill separately. Depending on the reason for the visit there may be physical or occupational therapists involved. Frequently X-rays or echocardiograms are required, both of which require doctors to interpret them. Blood work or organs removed during surgery, such as an appendix or gall bladder, may be sent to a pathologist.
The additional providers may or may not be part of the patient’s insurance plan, and, particularly if they are contracted with the hospital to provide the service, the patient may have no choice in where the services, and ultimately the billing, come from. Common wording on financial consents typically states something along the lines of “I understand that the physician services I receive (including attending and consulting physicians, surgeons, anesthesiologists, pathologists and radiologists) are usually hired separately and that any attending and consulting providers may bill me separately.”
Consents also typically include the statement, “I agree to pay for all services rendered to me without regard to benefit limitations that may be imposed by any insurance carrier, unless prohibited by law or contract.” This becomes a problem for the patient who does not necessarily know who is going to be providing those services, what the costs of those services will be or whether their insurance company will cover them.
It can be virtually impossible to avoid unexpected medical bills, especially when surgery and a hospital stay are required. Even the most health insurance savvy patient has trouble tracking down the information they need, as the pieces to the puzzle they are trying to assemble are held by different entities. The physicians’ surgery coordinator will know who the assistant surgeon is going to be, the expected length of the hospital stay and the cost of the procedure that the physician expects to do, but most likely has no information on the costs from the hospital, outside tests interpretations or other services that will be provided.
Even with this information there can be unknowns, as the entire U.S. medical system and the way it is financed is extremely complicated, and nearly impossible for even the most knowledgeable patient to navigate. For example, once the physician starts the surgery they may find that the expected repair is much more difficult than anticipated, or complications may set in that will increase the charges. The physicians office will also not be able to disclose the assistant surgeon or anesthesiologist’s fee unless that surgeon is part of their own practice, as sharing that information illegal to avoid possible price-fixing.
Asking the hospital about charges will result in talking with more people who have only pieces of the puzzle. Medical costs vary so greatly that it is impossible for the financial counselor to identify every service a prospective patient may need. An additional complication is that consulting physicians, such as hospitalists, pathologists or radiologists, may individually enroll in insurance plans. Depending on which one provides the service (often done on a rotating basis) the patient may receive in-network or out-of-network care.
In Australia and other countries that also rely on private insurance coverage for medical expenses, it is considered the patient’s right to be informed of out-of-pockets costs in advance. The U.S. has not progressed this far. According to the New York State Department of Financial Services, the persistent problem of unexpected medical bills has not yet been directly addressed. A New York state law taking effect in March, which is one of very few nationally, will state that patients are not responsible for unanticipated out-of-network charges that exceed what they would have paid in network.
As yet, unexpected and sometimes excessive medical bills from out-of-network providers continue to contribute to the increasing problem of medical debt, which is a significant cause of personal bankruptcy. Even patients who diligently do their homework may find themselves in a position of dealing with crushing bills.
In Drier’s case his medical insurance company, Anthem Blue Cross Blue Shield, agreed that the unexpected out-of-network bill was not his fault, and that he should not have to pay the assistant surgeon cost, so they cut a check for the full amount to protect him. Even when he received the check from Blue Cross he did not immediately forward it to the assistant surgeon, continuing to try to negotiate a better rate on the surgery to save his insurance company money. Once he received a threatening letter from the assistant surgeon’s lawyer he reluctantly sent them the Blue Cross check.
By Beth A. Balen
NDTV (via New York Times)
New York State Department of Financial Services
University of California, San Diego Department of Medicine
Sparrow Hospital Financial Consent Form