qotd: Outrageous out-of-network billings

The New York Times
September 20, 2014
After Surgery, Surprise $117,000 Medical Bill From Doctor He Didn't Know
By Elisabeth Rosenthal

Before his three-hour neck surgery for herniated disks in December,
Peter Drier, 37, signed a pile of consent forms. A bank technology
manager who had researched his insurance coverage, Mr. Drier was
prepared when the bills started arriving: $56,000 from Lenox Hill
Hospital in Manhattan, $4,300 from the anesthesiologist and even
$133,000 from his orthopedist, who he knew would accept a fraction of
that fee.

He was blindsided, though, by a bill of about $117,000 from an
"assistant surgeon," a Queens-based neurosurgeon whom Mr. Drier did not
recall meeting.

In Mr. Drier's case, the primary surgeon, Dr. Nathaniel L. Tindel, had
said he would accept a negotiated fee determined through Mr. Drier's
insurance company, which ended up being about $6,200. (Mr. Drier had to
pay $3,000 of that to meet his deductible.) But the assistant, Dr.
Harrison T. Mu, was out of network and sent the $117,000 bill.

When Mr. Drier complained to his insurer, Anthem Blue Cross Blue Shield,
that he should not have to pay the out-of-network assistant surgeon,
Anthem agreed it was not his responsibility. Instead, the company cut a
check to Dr. Mu for $116,862, the full amount.

For months, Mr. Drier stewed over what to do with the $117,000 check
Anthem Blue Cross had sent him to pass on to Dr. Mu, refusing to sign
over a payment he considered "outrageous and immoral."

Mr. Drier tried to negotiate with the surgeons to divvy up the $117,000
payment in a way he believed was more fair; he liked Dr. Tindel and felt
he was being underpaid. Mr. Drier's idea, he wrote in an email, was to
settle on "a reasonable fee for both the surgeon and assistant and
return the rest of the check to the insurance company/employees" of his
company.

But in July, he received a threatening letter from Dr. Mu's lawyer
noting that he had failed to forward the $117,000 check. So he sent it
along, with regret.

If the surgery had been for a Medicare patient, the assistant would have
been permitted to bill only 16 percent of the primary surgeon's fee.
With current Medicare rates, that would have been about $800, less than
1 percent of what Dr. Mu was paid.

In recent years, unexpected out-of-network charges have become the top
complaint to the New York State agency that regulates insurance companies.

http://www.nytimes.com/2014/09/21/us/drive-by-doctoring-surprise-medical-bills.html

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Comment by Don McCanne

Although this is an outrageous example of the perversities of private
insurers using provider networks to manipulate health care spending, it
nevertheless helps us understand why we should reject the private
insurers and their patient-unfriendly, investor- or board-pleasing
business tools of health care.

Depending on which state regulations, which insurer, and which specific
insurance plan, this out-of-network billing for Mr. Drier's assistant
surgeon could have had different outcomes. The worst is that he could
have been responsible for the entire $117,000 fee and that it would not
have applied to his deductible nor to his maximum out-of-pocket benefit
cap. In this case, Mr. Drier did not experience a major financial loss,
but those who pay insurance premiums will have to pay more when
considering the cumulative effect of all such benefit overpayments.

It just doesn't seem right when you try to buy the best insurance that
you can afford, and the insurers then tell you which physicians and
hospitals you can use if you want full coverage. Plus they frequently
expose you to high out-of-pocket costs - costs that you would think
insurance should cover - when you end up under the care of an
out-of-network provider, often through no fault of your own as in this
instance with Mr. Drier.

Had the procedure been provided under Medicare, the assistant surgeon's
fee would have been determined automatically, and at a fraction of the
billed price. An improved Medicare for all not only would have set the
fee at a fair level, it also would not have had network issues to deal
with since the entire health care system would be one single "network"
(integrated systems such as Kaiser Permanente merely being additional
providers of one's personal choice within the universal health care
delivery system).

The full New York Times article by Elisabeth Rosenthal describes many
other instances of surprises and misunderstandings that stem from the
complexities of various plans and their networks - surprises that would
not occur in a well designed, single payer national health program.
Under single payer, you get the health care that you need, wherever it's
needed, and it's simply paid for by our own public insurer.