By Dr. Marion Mass
Here are six “dots” to remember. We’ll connect them later.
- Health insurance companies created “networks” by negotiating and contracting with physicians and hospitals to provide services to insured patients at certain rates of payment.
- Some physicians and hospitals agreed to be “in” the networks; others didn’t or simply couldn’t because the contracts were too restrictive.
- The supply of physicians and rural hospitals is shrinking, partly because more and more can’t stay in business on the rates that insurers offer, a trend made worse by the pandemic.
- When a patient receives care from a physician or hospital “in” the network, the insurer pays the bills at the negotiated rate.
- However, when a patient receives care from parties “outside” the network, the insurer isn’t obligated to pay.
- In 1986, the Emergency Medical Treatment and Labor Act (EMTALA) became law, requiring that anyone who comes to an emergency room must be treated, regardless of insurance status or ability to pay. The penalties for flouting EMTALA are severe.
Now, let’s connect the dots with a scenario — a dangerous, nasty emergency.
A drunk driver hits your child. Femur: broken. Fracture: compound. Blood: abundant.
Your child is rushed to the nearest emergency room.
Compassion, a professional oath, and the EMTALA all demand that the hospital spring into action.
Someone will take your insurance card; but at that moment, nobody (especially you) cares about insurance networks.
Maybe the hospital is “in” the network. Maybe the ER physician who examines your child, the radiologist who reads the x-ray, the anesthesiologist who puts your child under, and the orthopedic surgeon who sets the bone and closes the wound… maybe all, some, or none are “in” the network and must accept the insurer’s payment.
In any case, you expect your insurer to cover the emergency treatment and to pay the people who saved your child — the professionals whose role is to render such service.
Instead, because the insurer follows the Golden Rule — “He who has the gold makes the rules” — the following may be your experience.
You may receive surprising bills from parties involved in your child’s treatment who were “outside” the network. You may think that you’re being gouged, but think again.
Astounded at your insurer’s denial of payment, you may go back and forth with your insurer and with those who sent the bills. You will be up to your neck in the fine print of your policy.
You will be disgusted and probably very worried.
And you, not the insurer, may end up on the hook for those “surprise bills.”
Can you spot the villain?
Given the forces at work in the health care industry, “surprise billing” has become so commonplace that it’s now on the radar of lawmakers in Washington.
They have two solutions in front of them. Both would prevent you, the patient, from receiving surprise bills.
One is “benchmarking.” It favors insurance companies by…