‘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.”