Patient claims medical billing practices "morally wrong"

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Washington consumers have been gouged by unexpected medical bills despite going to a doctor or clinic in their insurer’s network, but Washington patients are not the only ones hit by a practice called balance billing.

States nationwide have experienced instances of balance billing and many report complaints are on the rise.

Currently, the Consumers Union estimates around 30 states are working on laws to protect consumers from these unexpected medical bills.

The organization credits about four with passing comprehensive legislation.

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Congress is also considering legislation coined the “End Surprise Billing Act” is so important.

“It’s just overwhelming,” said Tiffany, who received a surprising medical bill after experiencing complications while she was giving birth to her daughter. “Compared to my salary, this bill is, I'd say, about three and half times more than I make annually.”

A Denver man named Dave was charged more than $3,500 by a hospital for 10 bags of saline.

“I don’t get understand, I don’t get it,” Dave said.

“This is crazy,” said Lisa, who received a bill for more than $1,000.

The charges were for special equipment used in her back surgery near Austin, Texas. Doctors hadn’t warned her they’d be using.

“Why didn’t you mention this to me when I called you months ago,” Lisa asked.

A man named James also received a surprising bill for roughly $4,200 near Phoenix, Arizona after rushing to the ER with violent stomach cramps.

“It’s just way out of my budget,” James said.

Around the country, the stories are mounting.

Balance Billing happens when a patient gets stuck in the middle of a reimbursement battle between an insurance company and a medical provider then winds up with the bill.

“It can be impossible or very difficult to avoid these bills even if you have done everything right,” said Stacey Pogue, consumer advocate with the Center for Public Policy Priorities in Texas.

Pogue says balance billing needs to stop.

“Enough saying that the problem is that the consumer is not educated enough about the healthcare system,” Pogue said. “When we have a system so complex that even experts can’t navigate it, it doesn’t make sense to turn around and blame the consumer.”

The Consumer’s Union estimates nearly one in three Americans with private health insurance have had a surprising medical bill in the past two years.

New York recently passed what’s considered the most comprehensive approach to ending those surprises. In most cases, it requires medical providers and insurance companies to sort out their differences on their own.

“It makes sure it’s not giving away the store to the provider or the insurers,” said Washington State Insurance Commissioner Mike Kreidler. “I think New York probably has the best approach I have seen so far.”

Kreidler hopes to model a Washington law after New York’s example but so far he’s been unsuccessful, facing resistance from doctors, insurance companies and lawmakers.

“I think by teeing it up this last legislative session knowing it was going to be a tough haul it’s at least getting them to think about it,” Kreidler said.

Congress is also taking on the issue. Texas Rep. Lloyd Doggett is proposing the “End Surprise Billing Act.” It bans out-of-network providers from billing patients who visit an in-network hospital during an emergency. In all other cases, it requires advance notice about additional charges.

 “It’s outrageous,” Texas Rep. Doggett said. “There needs to be some certainty for the consumer who is acting responsibly to plan for their situation.”

Kreidler believes momentum at the federal and state level simultaneously could convince insurance companies, doctors and other medical providers to compromise.

“The longer this goes on and becomes a problem for consumers, the more likely it becomes they might get saddled with a solution that was really disagreeable to them, when they should have sat down at the table,” Kreidler said.

No one actually believes patients should be stuck in the middle. The point of disagreement is over how to address the problem and where responsibility lies.

“Who referred them to that service? Did they know they were going to an out-of-network provider? And for the out-of-network provider they did get paid? Why did the provider choose to balance bill?” asked Beth Johnson, Senior Vice President of Healthcare Delivery Systems for Premera.

“We have high deductible plans people can’t afford, networks that are so small people can’t access them, and then balance billing,” said Dr. Nathan Schlicher, Assistant Secretary-Treasurer for the Washington State Medical Association. “That is a problem that is not sustainable into our future.”

Doggett recognizes bridging those opposing positions will be difficult.

So far, his bill introduced last fall hasn’t had a hearing or made it out of the House Energy and Commerce subcommittee on Health.

“This legislation, like any legislation, in the current Congress is an uphill struggle,” Doggett said.

Of the “End Surprise Billing Act,” the national association representing insurance companies, America’s Health Insurance Plans, said in a statement:

“While we have not taken a formal position on this bill, it does have some positive transparency requirements - that a hospital has to provide a form to the patient saying that non-participating providers will charge the patient directly.  If a hospital is not in compliance, then the patient only has to pay the cost sharing as if the facility or provider was in network.  This last part is good for the patient, but it leaves unresolved the balance of the bill between the health plan and the out-of-network provider.  If the health plan pays the cost, then that still has an impact on premiums. The bill requires ER services for OON providers to only charge patients the amount of cost-sharing for in-network provider rates. This is similar to ACA requirements for ER services.”

The American Hospital Association, the national organization representing hospitals and health care networks, also did not take a direct position on the bill but said in a statement:

“AHA also supports the National Association of Insurance Commissioners’ model legislation that would use a structured mediation process to address out-of-network bills. Many states, such as New York and Texas, have implemented policies to help consumers. Working together across the health care system, there is still more to do to end consumer surprise and improve billing transparency. As with all information that consumers need to make good health care and treatment decision, the AHA’s remains strongly committed to the goal of transparency.”

The issue is complex, but while lawmakers and industry leaders haggle over a national solution, patients say they have been left to struggle on their own.

“That is just morally wrong,” Dave said. “There is not even any wiggle room in this.”

There are some steps patients can take to protect themselves from balance billing outside of true emergency situations when avoid a surprising bill can be more difficult.

Those steps include:

  1. Request a list of all staff treating you.
  2. Find out what equipment will be used in the procedure.
  3. Ask if any part of your care will be sent out of house, for instance to a lab.
  4. Get insurance acceptance in writing.
  5. Ask for an itemized bill.

If you have received a surprising medical bill, we want to hear from you.

Go to king5.com/shareyourbills and use the online form to tell us your story or you can email us directly at shareyourbills@king5.com.