What do you think? Leave a respectful comment.

The push to eliminate surprise medical bills

The issue of surprise medical bills - when patients are charged by a provider they didn’t know was out of network - is gaining momentum in Washington with policymakers on both sides of the aisle looking for solutions. Last month, President Trump also called for legislative action on the subject. Rachel Bluth, a reporter for Kaiser Health News joins Megan Thompson for more.

Read the Full Transcript

  • Megan Thompson:

    If you've ever gone to the hospital and ended up with a big bill from a provider you didn't realize was out of your insurance network, chances are you got what's called a surprise medical bill. It's a big issue that's getting a lot of attention right now from policymakers on both sides of the aisle. Last month President Trump even called for legislative action on the subject. This isn't a new issue. Three years ago PBS NewsHour Weekend reported on efforts in New Jersey to crack down on these surprise bills. Here are the stories of two patients.

  • Megan Thompson:

    After suffering a heart attack 20 years ago, Leigh Lehman of Hillsdale New Jersey does what he can to eat right and stay in shape. But the 64-year-old computer consultant still has occasional health scares. Last summer doctors told him he needed a quintuple heart bypass. Before the procedure he confirmed both the Valley Hospital in Ridgewood, New Jersey and his surgeon accepted his Aetna health insurance which he gets through his employer, a small consulting company.

    But a few weeks later after the surgery I got a bill in the mail.

    The surprise bill was for nearly $2,200. It was from a critical care doctor in the intensive care unit who did not accept Lehman's insurance.

  • Leigh Lehman:

    Out of nowehere somebody who you never heard of, I don't remember meeting, sends a bill. Why is he not accepting the insurance, why is he out of network?

    Lehman says he contacted the hospital and insurance company but they told him there was nothing they could do to reduce the bill. So he dug into savings to pay it off.

  • Leigh Lehman:

    It's a little stressful. You're trying to recover. It's major surgery. I mean I felt like I was hit by a truck.

  • Megan Thompson:

    Something similar happened to Andrew Heymann, an accountant from Hackensack New Jersey who had health insurance through his employer from Anthem Blue Cross Blue Shield.

  • Andrew Haymann:

    Here was blood and glass all over this whole part of the parking lot.

  • Megan Thompson:

    Two years ago when he was helping a neighbor move, a large glass table shattered and a shard of glass sliced into Hammond's left ankle. An ambulance took him into the closest emergency room at Hackensack University Medical Center which he knew was in-network. His ankle wound was so deep that E.R. called the plastic surgeon on duty.

  • Andrew Haymann:

    And he came in and sewed up my leg in probably about 10 minutes.

  • Megan Thompson:

    But that surgeon did not accept his insurance. Haymann received what's called a balance bill. The doctor charged close to $6,000. Blue Cross covered about $860 and Haymann was stuck owing $5,000.

  • Andrew Haymann:

    I'm thinking there's no way I'm going to pay this. This is insane. It's kind of almost like forever if you want to call it false advertising when you get some kind of a crazy bill from someone who's not in the network and you really had no control over the fact that that that they would be there.

  • Megan Thompson:

    The hospital wouldn't discuss the specifics of Haymann's case but said it recognizes the current system is not optimal. After six months of fighting his bill and appealing with his insurer he even discovered his employer, a large education company, was supposed to cover the charge and the company paid it off.

    Chuck Bell programs director at Consumers Union, the advocacy arm of Consumer Reports, says the frustration of surprise medical bills is growing.

  • Chuck Bell:

    We've received literally thousands of stories from consumers all over the country that are having this problem.

  • Megan Thompson:

    Last year Consumer Reports found that 30 percent of Americans with private health insurance have received a surprise bill where their plan paid less than they expected. Of those 23 percent received a bill from a doctor they didn't expect to get a bill from. And 14 percent said they were charged higher out of network rates by doctors they thought were in network. Bell says one reason for surprise medical bills may be that insurers are increasingly offering narrow networks, cheaper insurance plans that give patients fewer doctors to choose from.

  • Chuck Bell:

    The problem has been that it's very hard to actually use your narrow network in practice that when you actually go to a hospital or an emergency room you inevitably run into physicians and providers that are out of network and then those costs quickly mount up.

  • Megan Thompson:

    Bell says surprise bills have been a problem for a long time but it's possible more people are getting them because more people are insured. Since the Affordable Care Act passed in 2010, 20 million more Americans have health insurance.

  • Chuck Bell:

    And probably most of those patients do not have very rich or generous out of network coverage. So when they get a bill they may have to pay the whole thing by themselves.

  • Megan Thompson:

    Leigh Lehman's $2,200 bill for his heart bypass wasn't his first surprise Bill the year prior he was hit with a $4,500 bill for a visit to an emergency room that turned out to be out of network. Lehman sold some property and used money set aside for his daughter's college tuition to pay his bills.

  • Megan Thompson:

    You make a good salary. You have what you called good health insurance. Did you ever think you'd be struggling to pay medical bills?

  • Leigh Lehman:

    No, it's probably gonna take a couple of years before we get back on track.

  • Megan Thompson:

    We wondered how patients like Lehman end up seeing out of network doctors at an in network hospital.

    Neurologist John Nassar has a private practice in New Jersey and sees patients at the Valley Hospital where Lehman got his bypass. But Nassar is not on staff there. Instead to get paid what he thinks is a fair rate he has to negotiate his own insurance contracts. As a result he's not in network with every plan the hospital accepts.

  • John Nassar:

    Over the years insurance companies have typically reduced payment year after year to the point that many insurance plans pay below what Medicare pays. And this becomes unsustainable. Doctors kind think it's like that.

  • Megan Thompson:

    Nassar says even when he is in network some patients with high deductibles are surprised by what they owe. When he is out of network Nasser is permitted to bill at a higher rate to the insurance company and patient.

  • Megan Thompson:

    So a patient's done his or her research, they found a hospital that's a network. They've found a provider that's a network but then they end up seeing a doctor like you who's not in network. The patient would probably say this isn't fair.

  • John Nassar:

    Yes it is not fair for the patient. I agree with you. As a practice our policy is to work with the patient on the out of network payment so we understand is a hardship for the patient when they are seen urgently by a provider who is out of network and they did not anticipate that.

  • Megan Thompson:

    Doesn't the doctor then have a responsibility to inform the patient, hey I'm not I'm not in your network?

  • John Nassar:

    If I'm taking care of you in an emergency, I don't even look at you insurance because we don't want anything we do to be swayed by insurance.

  • Megan Thompson:

    And neither do hospitals, says Joe Devine the president and CEO of Kennedy Health, a chain of hospitals and clinics in southern New Jersey. He says Kennedy can only require its contracted doctors to participate with the same networks it does.

  • Joe Devine:

    We cannot legally force the independent doctors to participate in contracts. Unfortunately what's happening is they're sending bills to patients and what we'd like to do is come up with a solution where it's not, we do not put the patient in the middle of this.

  • Megan Thompson:

    When a patient walks through your doors, doesn't the hospital have an obligation to say, hey you may be in network at this facility but not all the doctors you see may be in network?

  • Joe Devine:

    In the emergency situation most people are not thinking about it. We're not going to have all of a sudden sunlight come over and say well you know you may get an out of network bill that's not what we're here for when they've decided to do an elective procedure the hospital does have notification forms that actually allows them to understand that and what they may be responsible.

  • Megan Thompson:

    What does that look like you're sending a letter or phone call?

  • Joe Devine:

    We have a voluntary sheet that kind of shows them that they're out of network and they what their responsibilities would be. We also have it on our website.

  • Megan Thompson:

    However patients are notified doctors still complain that they're out of network because insurers don't pay them enough. But Kevin Conlin rejects that argument. He's the chief operating officer of Horizon Blue Cross Blue Shield, New Jersey's largest health insurer.

  • Kevin Conlin:

    More than four out of every five physicians in the state are in network with us. So four out of five find what we make available to them to be reasonable.

  • Megan Thompson:

    Conlin says carriers also take a hit when doctors and hospitals charge them and out of network rates because there's no limit to what they can charge. He estimates New Jersey's insurers pay around two billion dollars a year to cover out of network care.

  • Kevin Conlin:

    It contribute significantly to our premium expense that's absorbed by all New Jerseyans.

  • Megan Thompson:

    And that's why insurers are pushing the state legislature to limit the amount doctors and hospitals can charge. But doctors and hospitals strongly oppose that.

  • Kevin Conlin:

    So as an industry we need to make sure we protect the ability for the individual hospitals to be able to negotiate fair rates with the insurance companies.

  • Megan Thompson:

    This standoff is largely what's holding up a broader bill in the New Jersey legislature. It's one of 28 states considering protections for patients against surprise medical bills. For others Illinois, Florida, New York and Connecticut have already passed laws.

  • Joe Vitale:

    For so many New Jersey families they just can't afford it.

  • Megan Thompson:

    State Senator Joe Vitale is a sponsor of New Jersey's bill. It would mandate most doctors to participate in the same networks as the hospital. Require doctors and hospitals to notify patients if they are not in network, ban doctors from balance billing and set up an arbitration system to press providers to defend their bills and insurers to defend their rates.

  • Joe Vitale:

    In the end there's going to be an understanding. Oh you know what, bill is going to be fair and what reimbursement will be fair. And if your extreme in either one of those circumstances whether you're the provider or the doctor or the insurance company you're not going to win.

  • Megan Thompson:

    But after years of pressure from consumer groups and negotiations including a state assembly hearing this past week the bill has gone nowhere.

  • Megan Thompson:

    Why hasn't this passed?

  • Joe Vitale:

    Well the interest groups whether it's the hospital system or the medical society or the insurance company we kind of try to get to where we're close to an agreement. Suddenly the goalpost shifts a little bit.

  • Megan Thompson:

    So until New Jersey passes a law patients like Leigh Lehman are largely on their own.

    The hospital where Lehman had his bypass wouldn't discuss the specifics of his case but said more than 90 percent of its physicians accept the same insurance that it does and it informs patients about the other doctors who may not.

    After NewsHour contacted Aetna, Lehman's insurer. The company reviewed his case. It told us Lehman was not in fact responsible for the $2,200 balance bill he received and that it will be reimbursing him for what he paid. But Lehman is still paying off that earlier $4,500 emergency room bill.

  • Leigh Lehman:

    It gets a little crazy. It gets to the point where you're reluctant to go see the doctor.

  • Megan Thompson:

    For more on the steps lawmakers are taking to tackle surprise medical bills. I'm joined by Rachel Bluth a reporter for Kaiser Health News. Rachel thank you so much for being here.

  • Rachel Bluth:

    Thanks Megan.

  • Megan Thompson:

    I wanted to first start off by asking you how prevalent this is. I mean after our story aired I actually got a surprise medical bill. It was kind of a text book case I went to an E.R. and I got a bill for over $900 from a doctor who wasn't in my network. I wanted to just ask you it how often does this happen?

  • Rachel Bluth:

    They're really prevalent. Some studies say that up to one in five emergency room visits could result in a surprise bill. Over a $100,00 for a heart attack, $50,000 for an air ambulance ride. It's important to remember that even though this is something that happens a lot in emergency departments, it can happen in planned procedures as well. You pick a hospital that's in network, you pick a surgeon that's in network and then you're seen by an anesthesiologist who doesn't take your insurance and you're hit with a surprise bill.

  • Megan Thompson:

    Is this somehow getting worse or is it happening more often these days?

  • Rachel Bluth:

    I don't know if it's getting worse but you're seeing a lot of high deductible plans nowadays where patients have a lot of upfront costs that they have to pay before their insurance really starts to kick in. So consumers might be a little bit more sensitive to it because they're having higher out-of-pocket costs these days and more of their costs that they have to pay themselves.

  • Megan Thompson:

    This seems like one of the very few issues that is actually gaining momentum in Washington these days. Lawmakers on both sides of the aisle are actually cooperating on. Tell us what's going on down there?

  • Rachel Bluth:

    There's a ton of bipartisan support to fix this problem. President Trump has said that he wants to tackle surprise medical billing. There are proposals in the House, there's proposals in the Senate, there's been a number of congressional hearings about it in the past few months. So there's definitely a lot of momentum going forward.

  • Megan Thompson:

    I mean how likely is it that everyone be able to come to the table and come to an agreement on all this?

  • Rachel Bluth:

    That's the million dollar question. So despite the fact that Republicans and Democrats, Congress and the president are all working together on this, there's still a lot of competing incentives in the health care industry.

    Doctors and hospitals are a little bit nervous about this idea of rate setting. They're worried that they're not going to be reimbursed at a high enough rate to compensate for their services. Insurance companies aren't thrilled with the idea of arbitration because they're worried it could lead to higher medical costs down the line, it could cause some inflation in the industry. So everyone is trying to get on board and get on the same page right now.

    Plus we're dealing with a kind of cramped legislative calendar, there's a lot of other stuff that has to happen this summer. They have to fund the government, raise the debt ceiling, a presidential election season is about to hit, start up. So all of these things are possibly impediments or hurdles that could maybe slow down some of the bipartisan momentum.

    But that being said Senator Lamar Alexander who is the chair of one of the health policymaking committees in the Senate he said that he has a proposal and he wants it on the floor to be voted on by July and hopefully get to the president.

  • Megan Thompson:

    Great. Rachel Bluth from Kaiser Health News. Thank you so much for being with us.

  • Rachel Bluth:

    Thanks, Megan.

  • Correction:

    The University of Southern California was left out of the credit for a graphic about 11 minutes into this segment that displays the percentage of visits leading to a potential surprise out-of-network bill. The credit should read, "USC-Brookings Schaeffer Initiative for Health Policy."

The Latest