Surprise Balance Billing - A bill for $32,000. Whaaaaaat????


(Interview 10/2015. Oil on linen, 40 ins. x 30 ins. )


Please note: Under the No Surprises Act, an arbitration process is used to negotiate between providers and insurers when a patient is unwittingly treated by an out-of-network doctor or facility, and then receives a large, surprise bill. A federal judge in the eastern district of Texas, set aside key parts of a recent rule that creates a new federal independent dispute resolution between the insurers and providers. (The patient is still not involved in resolving the dispute.) The Commonwealth Fund reports, "The Biden administration is expected to appeal Judge Kernodle’s decision to the Court of Appeals for the Fifth Circuit but has not asked that his decision be stayed while the case is on appeal. This means the court’s decision remains in effect and arbitration will proceed without the rule’s guardrails. Federal officials acknowledged the court’s decision and are considering next steps."


2021 Update

Congress passed national legislation, the No Surprises Act, at the end of 2020. The new law takes affect January 1, 2022. Providers who give care without notifying patients of their out-of-network status can no longer surprise those patients with higher out-of-network charges. Patients pay what they would have paid to an in-network provider


High cost air ambulances are covered by the new law but ground ambulances are not. Providers that want to balance bill because they are out of their patients' network must give the patients 72 hours notice and present an estimate of the charges. We as patients will be forewarned and can refuse treatment from an out-of-network provider.


Michael's experience with surprise balance billing garnered national attention. The Atlantic, WHYY in Philadelphia, and Kaiser Health News covered his story in 2015. I'm grateful to Michael and his wife Susan for being brave, and adding their voices to the momentum to make change happen.


Artist Note (2015)

Take a look at Michael's deformed foot story at the end of this portrait story.


First, the harrowing $32,000 out-of-network charges the couple faced even AFTER checking the hospital treating his mitral valve problem was in-network. So why the outrageous bill if the hospital was in-network?


If the INSURED subject of this story had sought medical care for his heart condition a week earlier than he did, he would have been on the hook for a $32,000 surgeon’s bill.


The doctors may have saved his life. But it was Lady Luck that saved his finances from the scourge known as surprise balance billing -- when an insurer will pay for the hospital bill, but not for services from a doctor in that same hospital who is out-of-network. The patient never knows the provider treating her is out-of-network.


PA.gov explains surprise balance billing this way. “Surprise balance bills happen when a consumer receives emergency care or has made a good faith effort to use health care providers and facilities in the consumer’s health insurance network, but has unexpectedly received a service from a provider or at a facility that is out-of-network, then receives a bill for that service.” Consumer and advocate pushback has been fierce.


Michael Trost is this subject of this story. Art As Social Inquiry shares Michael’s story along with many national publications. The hope is that Michael’s tale about surprise balance billing reaches enough ears to make a difference.


~


Delivering healthcare and boosting stock earnings often find themselves at cross purposes on insurance companies’ and other healthcare for-profit entities' ledger sheets. Can a for-profit health insurance company really advocate for its customers, the patients, when doing so means earning less money? The New England Journal of Medicine raised the question as far back as 1980 in an article by Dr. Relman called The New Medical-Industrial Complex.


Having broad, inclusive networks or no networks at all mean patients like Michael would not get a surprise $32,000 surgeon's bill. One would go to the pre-approved hospital, and the insurance company would pay the bills.


The onus of which provider is in or out of a network should not fall on the patient if the hospital is pre-approved. End of story.


Surprise balance billing illustrates how complicating access to healthcare helps for-profit entities, and bamboozles the consumers. If we are lying on an operating table and an out-of-network doctor consults during our surgery while we are under anesthesia, we would be responsible for that provider's charges in full. Our insurance agreement covers in-network doctors only.


Even under anesthesia we would be responsible for making sure all our medical providers are in-network. Our mistake (while under anesthesia...jeesh) is their profit. So who is the healthcare system working for?


I painted a portrait story about a Dutch national whose son got treatment for a club foot in the US. She knew about surprise balance billing. She saw the practice with an outsider's eye, and had this to say. “Where does my responsibility end trying to figure out who is in-network? The supplier of the intravenous drip? Every nurse? We were expected to pay upfront, and then get money returned if we overpaid? All very murky. I didn’t know what I would end up paying in advance.”


This artist has visions of the patient surveying the medical staff as he’s being wheeled into the operating room, “Are you in my network?” I'm reminded of a children's book I used to read to my kids. "Are You My Mother?" by P.D. Eastman. The anesthesiologist starts the intravenous line. The patient trails off, “Are you in my network?” The patient opens his eyes post surgery and mumbles to an unfamiliar face, “Are you in my network?” before even asking how the surgery went.


For more Harrowing Stories from Uninsured Hell, I’ve added a postscript, Michaels Deformed Foot. (Scroll to end.) These anecdotes do not make it into wonky statistical analyses, but show, nevertheless, how lack of access to medical care can make our lives miserable.


photo courtesy of WHYY

 

A study. Oil on canvas, 24 ins. x 20 ins.

(from a 2015 interview)

Wood Finisher, Age 52, Insured


One morning while walking the dog, Michael felt a shortness of breath -- shocking to a man who, in the past, had cycled as much as 100 miles a week. The subject asked his wife to take him to the emergency room. He thought he had pneumonia. He’d get a chest x-ray, and some antibiotics. And that would be it.


No. That's not what happened. The couple's insurance coverage history is erratic and typical in the US.


Michael works in a woodworking shop of about 30 employees.


The Affordable Care Act (Obamacare) considers this business small, and therefore exempt from the provision mandating that businesses provide health insurance for their employees


Today, Michael is insured on his wife’s policy. Many employers permit their employees to pay for a spouse and children to be added to their policies.


Michael and his wife pay a small amount for family coverage on his wife’s policy through her employer. She is a full-time college professor.


Michael considers this arrangement, and the insurance itself good. But it wasn’t always so.


The couple were uninsured before Michaels's wife landed her teaching job with benefits. She was uninsured for approximately five years following a job loss during The Great Recession. Michael was also uninsured for about four years when he worked as a freelancer. The couple could not afford to buy an insurance policy on the individual market, that is, buy a single policy directly from an insurance company. (The Affordable Care Act marketplace policies and consumer protections were not yet in place. The ACA may have offered the couple a way to get affordable insurance had the online marketplaces existed.)


While the couple was uninsured, they were able, however, to insure their daughter through a government insurance program for children called CHIP for $260/month.


~


Michael was working as a self-employed freelance furniture maker and wood finisher during the period he and his wife were uninsured. Michael's wife's employer went bankrupt. She found three part-time teaching positions as an adjunct professor in schools in three different states. None of her employers were required to offer her health benefits. She was a part-time employee at each of the three different jobs although her total hours worked equaled full time.


Before Michael's wife got a full-time teaching job with health benefits, she had not seen a doctor for seven years. Today, Michael and his wife believe they are well insured through her job at a college.



I love seeing my portraits hanging in people's homes.



The ER doctors said Micheal needed emergency surgery for a failed mitral valve. The hospital transferred him to a second hospital where the surgery would be performed. The couple was again assured their insurance would be accepted, and the new hospital was in their network. After surgery, the subject remained in the hospital for four days.


The couple and their daughter live in Pennsylvania. The nearest emergency room was in New Jersey. But the insurance coverage came out of New York, where Michael's wife’s employer is based. The couple wanted to be certain the hospital they chose was in their insurance policy’s network, They did not want to be responsible for any out-of-network charges, a more expensive option. The couple traveled to a New York emergency room where they were told their insurance was accepted, and the hospital was in-network.


The medical bills started coming in the mail not long after the subject was discharged from the hospital. Most were the usual few hundred dollars for this and that service, costs the insurance did not cover.


Michael's post-op instructions were to “avoid stress.” Relaxation became impossible when a $32,000 bill for the cardiac surgeon arrived. The subject and his wife were confused and scared. They panicked.


“There was no way we could pay that. The hospital said to avoid stress. One of the biggest stressors a person can have is a $32,000 hospital bill when you thought you were insured,” Michael said. The couple appealed. The insurance company denied the appeal.


How could Michael get a $32,000 bill when he was assured at both hospitals he visited that his insurance was accepted, and the hospitals were part of his policy’s network of providers? It’s called surprise balance billing.


What is “surprise balance billing”? An insured individual, treated in a hospital that is listed in his insurance policy’s network coverage area, might be seen by a doctor in that same hospital who is NOT in the policy’s network of medical providers. In other words, an insurance company will pay bills from an in-network hospital, but doctors working in that same hospital may not have their charges covered because they are out-of-network.


And how is a patient supposed to know if every single person he or she interacts with in a hospital is in-network? The prospect is mind-boggling. Michael and his wife thought so too.


The couple was afraid. Their insurance company covered the hospital expenses. They also sent the couple approximately $4,000 to cover what they called the customary and reasonable cost of open heart surgery. But the remaining $28,000 was beyond the couple’s ability to pay.


An unpaid bill would ruin their credit, they thought. Michael started thinking they would need a home equity loan to pay the bill. They would not be able to sell their house as soon as they would have liked. How could they? They were looking at a huge medical bill.


The couple checked and double-checked to be sure the hospitals they went to were in-network. To be saddled with an out-of-network charge was too much. “Awful feeling. How could this be? It’s so unfair. We made all the arrangements. We called about the coverage. We thought we were doing what we had to do to not get screwed.”


Michael tried to calm himself. “People are worse off than we are,” he reasoned. “We had a house we could borrow against. Maybe we could raise money that way? Compared to all we have been through in life, this will be OK. “ He felt he and his wife had good jobs. They bought a good car. “Here come the bills, but we’ll carry on,” he thought. But, in truth, they were distraught.


Michael's wife doubled down. She researched online. She contacted her senator’s office. They referred her to New York’s Department of Financial Services. She soon discovered that New York passed a new law prohibiting surprise balance billing. Would it apply to them?


The NY Dept. of Financial Services confirmed that the subject would NOT be responsible for any surprise balance billing charges. New York’s new law prohibiting surprise balance billing for patients went into effect on April 1, 2015. The subject’s surgery took place on April 1, 2015.


Healthcare Finance reports, “The law also sets up an independent dispute resolution process for providers and health plans to use to settle on a fee for emergency services or surprise bills. The independent reviewers consider provider experience and training, case complexity, patient characteristics and usual and customary charges in making a determination, which is binding.”


Life would have been very different if Michael's chest pain happened a week earlier. A week earlier, New York State’s law prohibiting surprise balance billing would not have gone into effect.


If the surgery had taken place a week earlier, the subject and his wife would have been on the hook for the surgeon’s $32,000 bill. In such a scenario, they would have been lucky had they learned that they could negotiate that bill. But they still would have been responsible for thousands. They would have spent hours, days, weeks stressing. They would have postponed life plans in order to pay the bill. All of this because a doctor in the hospital where the subject was treated was not in his insurance policy’s network, and the subject had no way of knowing it.

~

The medical people the couple talked to thought surprise balance billing was wrong. “Doctors get dropped from networks and don’t know it. Insurance companies narrow networks to save money. Everybody knows this is happening and nobody knows what to do about it,” Michael said.


Consumers have been victimized by the practice, and legislators are taking note. Some states are addressing the surprise balance billing problem. Michael testified in front of the Pennsylvania’s insurance commissioner in Harrisburg, PA. Even Washington D.C. has noticed. In October 2015 the End Surprise Billing Act of 2015 was introduced into the House of Representatives where it sits (or languishes?) in committee today.


___________________________________________


Michael’s Deformed Foot

(a.k.a. Is This Any Way To Run A Country?)

During Michael's long period of being uninsured, he hurt his foot badly. He remembers it being “more than a typical pain.” His foot was very swollen. He couldn’t tie his shoe. It was almost Christmas. He was trying to shop for toys. He was hobbling along on the wet snow. His foot hurt. He was unsteady on his feet. He recalls a passer-by saying, “Move your slow ass out of the way.”


Michael was a freelancer with neither insurance nor money to pay for treatment. “What were they going to do for a broken foot anyway?” He reasoned.


He talked himself out of seeking medical care.


“Eventually the foot stopped hurting.” But going untreated, the foot became misshapen. Michael seems somewhat shaken when he confides that his middle toe is now deformed. When he goes shoe shopping he has to find a shoe that will fit his deformed foot.