A patient goes to a medical facility for a surgery. Maybe a hospital or outpatient clinic. He checks to ensure the facility is part of his health-insurance network, and that it will cover his bills.
Then after the surgery … a surprise: A whopping bill from an out-of-network anesthesiologist who doesn’t take the patient’s insurance. The stunned patient has to pay several thousand dollars from his own pocket.
The facility is in-network, the primary medical provider is in-network. Then a consulting provider is brought in to treat the patient, and that person is out-of-network.
Many such charges could be unfair and abusive. Some could be fraudulent.
Uninsured billings are occurring more often. Consumers and insurers both are surprised. Yet the finger of public opinion typically points at insurers for supposedly having too few providers the patient could turn to. Or for simply not paying bills in general.
One insurer has sued hospitals and other facilities, alleging fraudulent out-of-network billing and kickbacks. Fraudsters may have discovered a large loophole in the healthcare billing system.
More states are stepping up to the plate and working to control this practice.
At least a dozen states restrict surprise billing. They should go farther.
New York, for example, requires insurers and health facilities to notify patients of expected out-of-network billings. New York also has a dispute- resolution procedure requiring providers to bill only for in-network cost sharing.
The National Conference of Insurance Legislators is developing a model bill based on New York’s law. NCOIL is working to complete the model in 2016.
California requires contracts between the network providers and insurers to disclose up-front to patients out-of-network providers who may provide care — and the estimated cost of that uninsured care.
Many health plans also are doing away with annual caps for policyholders’ out-of-network costs, leaving consumers facing unlimited financial exposure.
Patients shouldn’t be forced to pay high, surprise bills from in-network facilities. And insurers should be protected from billing and kickback scams disguised as routine out-of-network billings. There’s nothing routine about these charges.
About the author: Howard Goldblatt is director of government affairs for the Coalition Against Insurance Fraud.