‘Sur­prise billing’ by hos­pi­tals costly for pa­tients


Nau­seous and dizzy af­ter fall­ing on ice, Lynne Martino called Geisinger Com­mu­nity Med­i­cal Cen­ter to en­sure the Scran­ton hos­pi­tal ac­cepted her in­sur­ance be­fore she sought treat­ment for a con­cus­sion at its emer­gency room.

Staff as­sured her it did. When the Tay­lor woman re­ceived a $443 bill from the emer­gency room physi­cian she saw in Fe­bru­ary, she was livid to learn a pri­vate com­pany em­ploys the doc­tor and does not par­tic­i­pate with her Blue Cross Blue Shield in­sur­ance plan.

“The doc­tor did not come into the room wear­ing a sign that says ‘I’m out of net­work,’” Martino, 55, said. “How can I ask her some­thing I’m not aware of ?”

Martino is among a grow­ing num­ber of pa­tients na­tion­wide af­fected by “sur­prise bal­ance billing” — where pa­tients re­ceive care at a provider within their in­sur­ance plan’s net­work but then dis­cover an out-of-net­work provider they had no con­trol in se­lect­ing treated them. A 2015 sur­vey con­ducted by Con­sumers Union’s Con­sumer Re­ports Na­tional Re­search Cen­ter found that 30 per­cent of pri­vately in­sured Amer­i­cans got a sur­prise med­i­cal bill be­tween 2013 and 2015.

Dr. An­thony Aquilina, Geisinger North­east’s re­gional pres­i­dent, ac­knowl­edged that sur­prise bal­ance billing is an is­sue at GCMC, par­tic­u­larly for pa­tients with Blue Cross Blue Shield plans, in­clud­ing High­mark Blue Cross Blue Shield, which was the largest in­surer in North­east Penn­syl­va­nia as of 2016, with 52.7 per­cent of the mar­ket.

Dun­more-based Emer­gency Ser­vices PC, which Dr. Louis DeNaples Jr. owns, runs GCMC’s emer­gency room and does not ac­cept any Blue Cross Blue Shield plans.

At­tempts to reach Emer­gency Ser­vices of­fi­cials were un­suc­cess­ful.

Geisinger is in ne­go­ti­a­tions with Emer­gency Ser­vices and is ad­vo­cat­ing that it ac­cepts all the in­sur­ances that the hos­pi­tal does, Aquilina said.

“There have been enough (com­plaints) that we said, hey, we’ve got to look at the best in­ter­est of our pa­tients to try to re­solve this,” Aquilina said. “We want pa­tients of all in­sur­ances and all abil­ity to pay to be able to come to our hos­pi­tal ... We are tak­ing the sit­u­a­tion se­ri­ously and work­ing to­ward a so­lu­tion as we speak.”

Com­mon­wealth Health Sys­tem also uses pri­vate com­pa­nies to run its emer­gency rooms. Apol­loMD, based in At­lanta, runs the emer­gency rooms at Re­gional Hos­pi­tal and Moses Tay­lor Hos­pi­tal, both in Scran­ton, and WilkesBarre Gen­eral Hos­pi­tal. En­vi­sion Health­care, based in Nashville, Ten­nessee, op­er­ates the emer­gency rooms at Tyler Me­mo­rial Hos­pi­tal in Tunkhan­nock and Ber­wick Hos­pi­tal Cen­ter.

Com­mon­wealth Health spokes­woman Renita Fen­nick said its five hos­pi­tals have not had many is­sues with sur­prise billing be­cause the pri­vate firms ac­cept most ma­jor in­sur­ances, in­clud­ing High­mark Blue Cross Blue Shield.

Sur­prise billing is not just a prob­lem in emer­gency rooms. It is also an is­sue with pre-planned ser­vices a pa­tient re­ceives from in-net­work providers who use outof-net­work in­de­pen­dent prac­ti­tion­ers, such as anes­the­si­ol­o­gists, ra­di­ol­o­gists and pathol­o­gists. That leaves pa­tients on the hook for a larger por­tion of their bills be­cause in­sur­ance com­pa­nies only pay the “al­low­able rate” to in-net­work providers. The bal­ance is the pa­tient’s re­spon­si­bil­ity.

“Pa­tients are hostage to the sit­u­a­tion,” said Dr. Kevin Ka­vanagh, ex­ec­u­tive di­rec­tor of Health­watch USA, a pa­tient ad­vo­cacy group in Ken­tucky. “They have in­sur­ance that will pay the hos­pi­tal, yet the physi­cian see­ing them is not an (in-net­work) provider. They could have a huge bill ... they can­not shop for and can­not avoid.”

The fact that pa­tients have few or no op­tions to find out in ad­vance whether they will be treated by an out-of-net­work physi­cian compounds the sit­u­a­tion, said Betsy Imholz, spe­cial projects di­rec­tor for Con­sumers Union.

For pre-planned pro­ce­dures a pa­tient can ask but staff of­ten can­not tell them be­cause they do not know which spe­cial­ist will as­sist the physi­cian un­til the day of the pro­ce­dure.

In emer­gency room sit­u­a­tions, a fed­eral law man­dates hos­pi­tals treat all pa­tients — re­gard­less of their abil­ity to pay — and pre­vents staff from pro­vid­ing any in­for­ma­tion on in­sur­ance cov­er­age un­til af­ter the pa­tient is sta­bi­lized, Aquilina said.

Geisinger and Com­mon­wealth each post signs in their emer­gency rooms that in­di­cate pa­tients will get a sepa- rate bill for the physi­cian. Nei­ther sign warns pa­tients that they could be billed at an outof-net­work rate.

Martino said she had no clue the doc­tor who treated her at GCMC was not a Geisinger em­ployee. The physi­cian charged $593. Her in­surer, Blue Cross Blue Shield Fed­eral Em­ployee Pro­gram, paid $150, leav­ing her the $443 bal­ance.

“They know full well their ER physi­cians are not in-net­work and that’s go­ing to cause prob­lems,” Martino said. “If I had known it had out-of-net­work doc­tors, I would have gone to an­other hos­pi­tal.”

Martino con­tin­ues to fight her bill. She wants Geisinger to cover the dif­fer­ence be­tween the in-net­work and out-of-net­work rates. As a courtesy, Geisinger did waive her $125 emer­gency room co­pay which was in ad­di­tion to the $443 out-of-net­work doc­tor’s bill, she said.

She also is bat­tling Emer­gency Ser­vices, which she says turned her bill over to a col­lec­tion agency less than a month af­ter she made a par­tial pay­ment and ad­vised them she was dis­put­ing their bill.

Linda Ostir, 64, of Moosic, who has the same in­sur­ance as Martino, faced a $465.50 charge for the GCMC emer­gency room doc­tor who treated her in March when she had pain near her rib cage.

“I was hav­ing a lot of pain and wanted to be pre­pared, so I called three days be­fore I went in,” Ostir said. “The girl told me (G)CMC was a par­tic­i­pat­ing hos­pi­tal. I as­sumed the ER was too.”

While fight­ing the charge with her in­sur­ance com­pany and Emer­gency Ser­vices, she said Emer­gency Ser­vices turned her bill over to a col­lec­tion agency.

Af­ter mul­ti­ple calls and let­ters, her in­sur­ance com­pany agreed to pay a larger por­tion of the charge as a one­time courtesy, knock­ing her bill down to $88.95.

“It burns me up they can get away with this,” she said. “I fought this for months and fi­nally got it paid ... I’m so frus­trated with how much ef­fort I had to put into it.”

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