'Balance bills' take patients by surprise

When Ethan Silver injured his knee during a high school wrestling match, his parents took him to the hospital to have it checked.

It wasn't a life-and-death situation, so the Silvers went to a hospital they knew accepted the Highmark Blue Cross Blue Shield insurance they had through work. Ethan's sprained knee was taped, and he was given crutches and told to follow up with an orthopedist. The Silvers paid their $100 co-pay and headed home to Blue Bell.

A few weeks later, they received a $200 bill from a doctor who examined Ethan in the emergency room. Confused, Hillary Silver called Highmark. She was told the doctor wasn't in the insurer's network. She and her husband were both incredulous.

"I said, 'Wait a minute,' " Lewis Silver remembers. "We went to an in-network hospital purposely knowing that I only wanted to pay the $100 co-pay and now I have to figure out, when it's an emergency, are [the doctors] in my plan? Seriously?"

Seriously.

It's called balance billing, or surprise balance billing, and it means that even though you have health insurance, pay your monthly premium, choose an in-network hospital, and pay the co-pay on the spot, you can still get blindsided with a bill.

In a life-threatening emergency - a heart attack, stroke, or serious accident - most insurance companies will cover the cost of an emergency room visit, regardless of whether the provider is in or out of network.

But a lot of visits, like the Silvers', aren't so dramatic. And surprise balance bills aren't limited to emergency room visits. People who have surgery often receive bills for hundreds to thousands of dollars from specialists who participated in their procedure but not in their insurance plan. A common scenario: Your surgeon is in your network but the anesthesiologist isn't.

Further, out-of-network services can be more costly to consumers, notes Antoinette Kraus, director of the Pennsylvania Health Access Network, because they aren't limited by the insurance company contracts that govern in-network care.

By ignoring the bills, consumers run the risk of facing a collections agency.

With more people newly insured due to the Affordable Care Act, surprise billing complaints are mounting to the point that on Oct. 1, Pennsylvania Insurance Commissioner Teresa Miller held a hearing to consider ways to deal with the issue.

"We must work to find a way to protect consumers from these bills," Miller said in a statement. "When someone undergoes a major medical procedure, they need to focus on their recovery, not an unexpected fee."

Andy Carter, president and CEO of the Hospital and Healthsystem Association of Pennsylvania, agrees that hospitals and insurance companies need to fix the surprise balance problem.

"Nobody should be endorsing the fact that someone could go through that surprise," he said. However, there are very little data available on the extent of the problem, he said.

To give some idea, in March, the Consumer Reports National Research Center polled more than 2,000 consumers online and found 37 percent had received a bill toward which their insurance plan paid less than expected. One-quarter of those surprises came from a doctor they did not realize was out of their network.

So why is surprise billing an issue if you go to an in-network hospital? One reason is the growing trend among hospitals to farm out their emergency departments to independent vendors who hire the doctors to staff the units. The doctors are employees of the vendors, who often are out of network.

"This is posing significant challenges to patients who purposely choose in-network hospitals only to find some out-of-network ER physicians," Mary McElrath-Jones, director of public relations for UnitedHealthcare, wrote in an email.

Many people don't realize that a lot of medical professionals who work in hospitals don't actually work for the hospitals but are independent contractors or work for an outside vendor.

"When we credential a clinical professional to operate within the four walls of a hospital, we do so with an eye toward their license, their qualifications as a physician, nurse, or other professional, their criminal background, and their medical board complaints," Carter said. "We don't evaluate the insurance plans that they participate in."

Carter said hospitals were trying to do a better job of explaining to patients the costs they may encounter during a visit. Some hospitals have added a price estimator tool to help patients roughly figure the cost of certain procedures. But, he said, insurance companies must do more.

"For an insurance company to say blankly, 'Yep, such and such a hospital is in network and you're good to go,' is irresponsible," he said.

In her email, McElrath-Jones said UnitedHealthcare would "continue to educate and raise awareness" among its members about surprise billing. An Aetna representative emailed that the company "pays for out-of-network emergency room physicians based on the appropriateness of the services and billing" according to the customer's specific plan.

Don Liss, an Independence Blue Cross vice president, said in a statement that customers should contact the company if they receive an out-of-network bill "for an amount beyond what we have paid for emergency services."

"We will take it from there and work directly with the doctor to resolve the issue," Liss wrote.

After several months of telephone calls, Highmark paid the Silvers' surprise balance.

What can you do if you are stuck with a surprise bill? Start by calling the provider that sent the bill. Then go to your insurer. You also can contact the Pennsylvania Department of Insurance at 877-881-6388 or the Pennsylvania Health Access Network at 877-570-3642.

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