Reprinted from the NYTimes 9.25.2014
It’s not an uncommon situation for patients to be billed by doctors for costly services they did not request or, in some cases, were not even aware they had received.
Egregious examples of this billing practice, described by Elisabeth Rosenthal in The Times on Sunday, include calling in consultants whose services aren’t really needed, ordering unnecessary and costly diagnostic tests, and using doctors who bill for services that nurses can perform. In other dubious tactics, two doctors charged for the same procedures that could easily have been performed by one and out-of network doctors based at a hospital performed services that could have been done by providers in the network.
One man who had a three-hour neck surgery for herniated disks at Lenox Hill Hospital in December received a $117,000 bill from an “assistant surgeon” whom he did not recall meeting but who helped his orthopedic surgeon perform the procedure. This assistant surgeon was outside of Lenox Hill’s network and could charge a lot more than the primary surgeon, who accepted a $6,200 negotiated fee from the insurance company. The patient’s insurer ended up paying the out-of-network neurosurgeon the full fee he requested.
Some insurers have filed lawsuits or sought injunctions to prevent medical providers from harassing their enrollees to pay unexpected medical bills, but other insurers pay the providers all or most of what they want, to keep their enrollees happy and avoid litigation costs.
New York State has a law that will take effect in March requiring that insurers notify patients in advance on whether the health care providers treating them will be in or out of network and what the cost of leaving the network might be, so that the patient can decide which way to go. If out-of-network doctors are used without a patient’s permission or if emergency care is provided by out-of-network doctors, those doctors are not allowed to bill any more than an in-network physician would bill. The law directs insurers and the providers to negotiate any further payment or submit the matter to arbitration.
Australia and other countries that rely on private insurance already recognize a patient’s right to be informed of out-of-pocket costs before hospitalization. More states need to follow New York’s pioneering law, which consumer advocates have praised as the toughest in the nation. Patients everywhere need similar protection from unexpectedly high bills.