Despite such efforts by some hospitals and insurers, the surprise bill problem is likely to persist because hospitals and health systems have no plans to reduce their reliance on physician outsourcing anytime soon. But hospitals could require physicians, as a condition of practicing at their facilities, to join the same health plan networks in which they participate, some hospital officials say.
At Boca Raton Regional, Braccili said contracting anesthesiologists, emergency physicians, pathologists and radiologists “know they have to contract with the plans that we contract with.” The hospital has handled fewer complaints as a result.
Mark Carter, former chief financial officer of Jewish Hospital in Louisville, Ky., who now serves as CEO of Passport Health Plan in Louisville, said Jewish Hospital took the same approach. “We didn't want our anesthesiologists not accepting Humana when the hospital took Humana,” he said. “There's a lot of diplomacy involved in this.”
But many physician groups have not been won over. The fact that commercial insurers such as Aetna, Anthem and UnitedHealth Group have reported record revenue and profits has made it more difficult for doctors to accept rates they believe are unreasonably low.
“The real crux of the problem is that health insurers are refusing to pay fair market rates for the care provided,” Dr. Steven Stack, a Lexington, Ky., emergency physician who is president of the American Medical Association, said in a recent interview. “Then they turn and say to the physician who is billing (for out-of-network services), 'You're the bad guy.' ”
Stack also was critical of the New York approach—which was supported by the Medical Society of the State of New York—for requiring out-of-network physicians and insurers to work out payment through a mandatory dispute-resolution process. “Putting in a methodology to coerce physicians through yet another way to not receive sufficient payment doesn't help patients and certainly is not fair to physicians,” he said.
Sarah Davis, a law professor at the University of Wisconsin and associate director of the Center for Patient Partnerships,
said the underlying problem is that insurers and employers are imposing larger deductibles and coinsurance on consumers. At the same time, providers face pressure not to saddle patients with ruinous out-of-pocket costs. That's putting a big squeeze on providers, said Davis, whose organization counsels patients who face confusing or unexpected medical bills. “I think that's unrealistic,” she said. “That's setting providers up for failure.”
Braccili suggested that insurers should take responsibility for assessing and collecting out-of-network bills from patients. Having hospitals and doctors collect those fees is “a wacky business model,” he said.
He personally has seen the impact of high out-of-network bills. One of his friends recently went to a hospital for a heart attack, and the health plan processed his friend's claim as out-of-network, resulting in a $56,000 out-of-pocket tab. It has since been reduced to about half that amount, but that's little consolation to his friend. “He shouldn't have to suffer that way,” Braccili said. “It is fixable.”
Experts agree that hospitals, physicians and insurers will continue to face heat from the public until more is done to protect patients from unexpected bills.
Kyanko fought her $636 pediatrician bill without the help of the hospital, which she declined to identify. She made nine phone calls, spending three hours in total on the phone with UnitedHealthcare and the out-of-network pediatrician's office. She ultimately succeeded in getting her bill waived. The insurer and doctor worked it out between themselves.
“For a lot of people who are quite ill, they might not have the resources, the knowledge, the energy to be fighting every single bill like I had,” Kyanko said. What's needed, she added, is “removing the consumer from this negotiation.”