(Photo of Dr. Laura Richey: Don Kadair)
It’s the stuff of parents’ nightmares: A child takes a bad fall on the playground and comes away limping, and bleeding from a cut on his forehead. A broken bone? Concussion?
Panic often follows such incidents, and the inclination of many parents is to rush the child to the nearest emergency room. While that move likely will get the child the care he or she needs–the obvious priority at the time–certain other factors that are not top of mind at that moment can affect the ultimate financial cost of the parents’ decision.
Patients across the country are becoming increasingly aware of the possibility that health care services they receive in various settings may carry unforeseen charges. The charges often result from “balance billing,” a practice in which doctors and other health care providers may bill patients for charges not fully covered by their insurance policy.
Typically, balance billing occurs when a patient receives services from a provider who is not associated with–or is outside the network of–that patient’s insurance carrier. Because the insurance reimburses an out-of-network provider at a discount relative to the provider’s normal rates, the provider is legally allowed to bill the patient for the difference. Depending on the type and level of service rendered, a patient can incur hundreds, or even thousands, of dollars in unanticipated charges.
Some types of care that commonly trigger these patient invoices involve anesthesiology, radiology, laboratory and emergency room services. Doctors in these areas often do not work directly for a hospital but are independent contractors or members of a practice group that contracts with the hospital. As such, it is up to them to sign–or not sign–their own deals with insurance companies.
In some states, the inconsistencies in insurance coverage related to provider networks have become big issues.
In Texas, for instance, a public policy research group that analyzed hospital emergency billing by the state’s three biggest insurers recently found a large number of out-of-network doctors working in the emergency departments of those insurers’ in-network hospitals. In fact, in many cases, none of the ER doctors working in the hospitals were in-network providers.
As a result, the research group said, Texas patients incurred charges they could neither foresee nor avoid.
While balance billing is not an unknown practice in Louisiana, some say it is not as pervasive as in some other states.
A spokeswoman for Blue Cross and Blue Shield of Louisiana, which writes the lion’s share of both group and individual health policies in the state, says the company tries to make sure that in-network providers in every specialty area, including emergency departments, are available to its policyholders.
“More than 70 percent of the ER doctors in the state are in our network,” Blue Cross spokeswoman Robin Mayhall says.
Mayhall says Blue Cross generally covers its policyholders, or members, for emergency care regardless of which medical professional rendered the care. “In a true emergency, our members receive full benefits according to their [health] plans when they receive covered emergency services, no matter if the provider is in the network or not,” she says.
Mayhall notes, however, that the company may reimburse out-of-network physicians at a lower rate, and “we cannot protect the member from being billed for more by the out-of-network provider.”
NO CHANGE IN THE LAW
While many patients who have received hospital-based services in Louisiana may never have encountered balance billing, some lawmakers consider it a serious enough problem to merit the Legislature’s attention. Bills seeking to alleviate the impact of the practice pop up in nearly every legislative session, but thus far none have passed muster.
Insurance Commissioner Jim Donelon, who says he supports the measures, has said that the reason the bills do not survive is because providers and insurers who benefit from the practice successfully lobby against their passage.
But emergency room doctor Laura Richey says the issue is a complicated one that may not be fully addressed through legislation.
A board-certified emergency physician and current president of the Louisiana chapter of American College of Emergency Physicians, Richey says most members of that group are not in the networks of major insurance carriers “because, in general, the rates provided for in-network services will not cover our costs.”
Richey notes that under a 1986 federal law called the Emergency Medical Treatment and Labor Act, emergency service providers must render care regardless of a patient’s ability to pay. “That leaves us with a lot of uncompensated care … and a lot of bad debt,” she says.
She adds that not only private insurance, but also federal programs such as Medicaid can leave ER physicians in the lurch because the reimbursements they provide fall short of covering costs. “Sometimes, to make up the difference, we have to remain out-of-network in order to maintain the ability to balance the bill,” Richey says.
Richey and others acknowledge that, from a patient’s point of view, it can be futile to try to determine in advance who is a network provider and who isn’t.
“In the ER department, if you’re having a heart attack, it’s kind of hard for me to have a discussion with you about whether I’m in or out of your network,” she says.
Insurers and physicians alike say that their best advice to consumers is to understand their coverage and prepare in advance for potential emergency situations. This involves knowing, among other things, how your insurance company defines a “true emergency” and what specific types of care the company considers “covered services.”
Mayhall says that Blue Cross members receive an information kit that advises them on how to know when it’s appropriate to seek emergency care and what types of situations are better handled through “urgent care” provided on an outpatient basis in a neighborhood clinic.
“A rule of thumb is, if a reasonable person would believe you are in imminent danger of losing life or a limb, that is a true emergency,” she says.