Medical Cost Reduction

Same Doctor Visit, Double the Cost

J Roberts

Read about an alarming trend concerning physician practices that will most likely result in greater out of pocket costs to you. Consumers beware; you may pay more for your doctor’s visit than you previously thought. This growing movement is occurring nationwide and is becoming more prevalent as hospitals seek to increase their revenue streams in preparation for the upcoming implementation of the Affordable Care Act.

Insurers Say Rates Can Surge After Hospitals Buy Private Physician Practices; Medicare Spending Rises, Too

Wall Street Journal, August 27, 2012

After David Hubbard underwent a routine echocardiogram at his cardiologist’s office last year, he was surprised to learn that the heart scan cost his insurer $1,605. That was more than four times the $373 it paid when the 61-year-old optometrist from Reno, Nev., had the same procedure at the same office just six months earlier.

“Nothing had changed, it was the same equipment, the same room,” said Dr. Hubbard, who has a high-deductible health plan and had to pay about $1,000 of the larger bill out of his own pocket. “I was very upset.”

But something had changed: his cardiologist’s practice had been bought by Renown Health, a local hospital system. Dr. Hubbard was caught up in a structural shift that is sweeping through health care in the U.S.—hospitals are increasingly acquiring private physician practices.

Hospitals say the acquisitions will make health care more efficient. But the phenomenon, in some cases, also is having another effect: higher prices.

As physicians are subsumed into hospital systems, they can get paid for services at the systems’ rates, which are typically more generous than what insurers pay independent doctors. What’s more, some services that physicians previously performed at independent facilities, such as imaging scans, may start to be billed as hospital outpatient procedures, sometimes more than doubling the cost.

The result is that the same service, even sometimes provided in the same location, can cost more once a practice signs on with a hospital.

Major health insurers say a growing number of rate increases are tied to physician-practice acquisitions. The elevated prices also affect employers, many of which pay for their workers’ coverage. A federal watchdog agency said doctor tie-ups are likely resulting in higher Medicare spending as well, because the program pays more for some services performed in a hospital facility.

Renown said in a statement that cardiologists moving into hospital employment helps “eliminate duplication, improve coordination, and reduce hospitalizations,” and with “more proactive management of patients with heart disease, we are working to improve the health and well being of our patients.”

This year, nearly one-quarter of all specialty physicians who see patients at hospitals are actually employed by the hospitals, according to an estimate from the Advisory Board Co. That is more than four times as many as the 5% in 2000. The equivalent share of primary-care physicians has doubled to about 40% in the same time frame. Traditionally, most doctors who see patients at hospitals are in independent practice.

The structural shift is being driven partly by declining reimbursements for physicians, particularly in certain specialties like cardiology. Doctors are also being pressed to make new investments, such as introducing electronic medical records, and some are attracted to the idea of more regular hours with fewer administrative headaches.

Hospitals say they are bringing in physicians to improve care, integrate services and reduce waste, efforts encouraged by the Obama administration’s federal health-overhaul law. Higher reimbursement is needed in some cases, they say, because it costs more to operate outpatient clinics, which must meet strict regulatory requirements and often treat patients who lack insurance.

“You put a hospital name on something, and the expectations change immediately,” said Richard Umbdenstock, chief executive of the American Hospital Association. Indeed, hospital systems often struggle to break even on their physicians, industry officials said.

(more…)

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Hospital Bills Disputed by Patients

admin

As the Health Care Reform Act is implemented over the next two years there will continue to be disputes between Insurers and providers regarding payment. Providers often take large discounts to be in network in return for a greater volume of patients through networks with insurers. It’s a  price for volume trade-off familiar to those who are economics minded. There are often problems in the interpretation and execution of agreements and the associated health care billing practices. Sometimes this results in balance bills being sent to consumers. This article profiles a dispute in New Jersey. Be prepared for other similar disputes across the country.

Meadowlands Hospital bills disputed by patients, Aetna

By  LINDY WASHBURN -The Record, Wednesday, August 15, 2012

Meadowlands Hospital Medical Center has billed hundreds of patients in the last few weeks for care they thought was covered by their Aetna insurance ­policies. The bills — some for thousands of dollars — demand payment within five days.

Aetna’s advice to the recipients: Don’t pay.

Aetna customers who receive bills from Meadowlands Hospital Medical Center are urged to contact the Department of Banking and Insurance at 800-446-7467, or file a complaint online at state.nj.us/dobi/consumer.htm

The dispute shines a light on the complicated terrain that underlies relationships between hospitals and insurers. When new owners bought the Secaucus medical center in December 2010, the state required that the for-profit company make “a reasonable attempt to continue the ­current commercial insurance contracts” for at least a year.

As a result, Aetna says, its contract with the hospital was in force in 2011 — when the bills were incurred — and so the hospital must accept the lower rate it had negotiated as payment in full.

The hospital, however, has told patients they must pay the difference between that contract rate and its regular, higher charges. The letters to those patients state clearly, “You remain obligated to pay all outstanding invoices.” They ask for payment by credit card, certified check or money order.

Meadowlands President Lynn McVey declined through a spokesman to address the contract question.

“Regrettably,” she said in a prepared statement, “a national health insurer is withholding some payments for its plan members who have previously utilized our services. Until this matter is clarified and resolved through negotiations, our reluctant recourse is to follow standard procedure … and seek payment from individuals who were previously treated by [the hospital] and still have an outstanding balance.”

Eileen O’Donnell of North Arlington was told she owed $4,745 for an emergency-room visit in May 2011 to treat a foot injury. That was more than 20 times Aetna’s member rate of $204. Her total responsibility, according to Aetna’s explanation of benefits, was $68.40.

And Kaarin Varon of East Rutherford received a demand from Meadowlands for $13,004 for the care of her son, who was hospitalized with pneumonia last year. Aetna already had paid $1,596 as its contracted rate for his stay.

“I have to admit, I was not sure how a contract dispute had me involved in all this,” said Varon. “But the [Meadowlands billing] representative basically told me it was now my responsibility.”

The state Department of Banking and Insurance is working with the health department to resolve the issue, according to Marshall McKnight, an insurance department spokesman. “Our goal is to protect consumers as much as possible through this process,” he said. Patients who receive the bills are urged to contact the department, he said.

The dispute comes at a time when questions are being raised about finances at the hospital. An independent draft audit for 2011 showed a 10 percent profit margin — four times the state average. A year after MHA LLC, a private investment group, bought Meadowlands in December 2010, the new owners had reversed the $10.4 million operating loss reported for 2010 and posted a $9 million profit, according to the draft submitted to the state.

The dispute also highlights the vast difference between a hospital’s customary charges and the rates negotiated with insurance companies for hospital care. The negotiated rates are often a fraction — 5 percent or 10 percent — of those customary charges.

Some hospitals opt to stay out of insurance contracts as a strategy to increase revenues.

(more…)

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Three Ways to Slash Your Medical Bills

J Roberts

Medical Cost Advocate’s CEO Derek Fitteron was recently interviewed for Fox Business. Read the following BLOG post to learn more about reducing medical costs. Dont forget to negotiate your medical bills and save money. It’s worth the effort. In these difficult economic times, why pay list price when you may be able to save.

By: Donna Fuscaldo

FOXBusiness

Published July 10, 2012

Many things in life are negotiable, including medical bills.

“More and more billing offices, whether it’s a hospital or doctor’s office, are much more receptive to bargaining,” says Nancy Fase Guernon, director of operations at CareCounsel, an health advocacy firm. “There’s definitely ways to negotiate the bill.”

 According to a survey of Angie’s List members who asked for discounts from their doctors, 74% said they were successful. “We’ve heard some great success stories from members who have successfully negotiated with their health care provider,” says Angie Hicks, founder of the peer-review website. “It doesn’t hurt to ask. You’ll be amazed at what you can save and still get great care.”

 From making sure your bill is correct to negotiating ahead of a procedure there are ways to get as much as 40% off your medical bill. Here’s how:

Step One: Check the accuracy of the bill

Medical billing mistakes are common, so review the invoice carefully before submitting payment.  Experts say it’s common for a procedure to be coded wrong by the doctor’s office and lead to excess charges.

 Patients should review their health insurance plan to know what is and is not covered. “You want to make sure if it’s the insurance company’s responsibility to pay it, it’s paying what it should according to the plan,” says Fase Guernon.

 If you don’t have insurance or are going out of network and are paying out of pocket, Derek Fitteron, founder and CEO of Medical Cost Advocate, advises getting a full cost estimate of the procedure upfront to avoid any surprises at the end and you avoid getting overcharged.

 Fitteron also suggests asking for an itemized bill so you can review the charge for every procedure. “Sometimes there are mistakes and those mistakes might include bills for the wrong procedures or procedures that didn’t happen.”

 Step Two: Negotiate Up Front

Think of negotiating health care like shopping for a car. A dealership wants your business and will working with you—same idea applies to a doctor. For instance, many times doctors will reduce their price if you pay in cash or pay for the procedure ahead of time.

 According to Hicks, some hospitals and doctors will cut a health-care bill by as much as 50% if you pay in cash on the day of service. “We had a member from Washington D.C. who saved $9,000 on his mother’s in-home care by bargaining ahead of her treatment.”

 To negotiate ahead of time, experts say it pays to do your homework. Procedure prices vary be region, so know what know what is common in your area before negotiating. “Do the research so you are not throwing out numbers. That can be insulting,” says Fitteron.

 Step Three: Be honest about your financial situation

 If you get hit with a medical bill that you can’t afford, the best thing to do is call your doctor or hospital and honestly explain your financial situation. Often times the medical facility will be willing to reduce the bill as long as you agree to pay something.

 “If you ask the billing office for a discount and you are willing to pay something right then more times than not they will knock down the bill 30% to 40%,” says Fase Guernon.

 Some providers will set up interest-free payment plans. Hicks points to one member who saved $4,000 by talking to her doctor about her financial concerns. The member couldn’t afford the costs that weren’t covered by the insurer so the doctor agreed to collect just the insurance portion, she says.

 “Too many consumers aren’t aware of just how much power they have to negotiate their health-care costs. There are many great doctors, dentists and other health-care specialists out there who are willing and eager to work with their patients to provide them with high quality, affordable care,” says Hicks.

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Healthcare Costs Top $20K Per Family

J Roberts

Here’s some more discouraging news: Healthcare for a family of four now costs as much as small family sedan. For many consumers the price to pay is too much. Even employers are grappling with rise in costs as they struggle to provide healthcare benefits to employees. Read the below article to learn just how much the cost of healthcare has risen in the past few years.

 

Margaret Dick Tocknell, for HealthLeaders Media , May 16, 2012

The national annual cost of medical care for a typical family of four with PPO coverage has edged up over $20,000 for the first time, according to the actuarial and consulting firm, Milliman.

The 2012 Milliman Medical Index estimates the annual cost at $20,728. That’s a record $1,335 increase in the total cost of care compared with 2011, and the first time the cost has notched above the $20K mark since Milliman started reporting on these costs twelve years ago. Through a combination of copayments, deductions, and premiums, the prototypical family of four will be responsible for a record share—42%—of its medical costs.

A combination of factors is driving the increase, including the comparative lack of control insurers exert on outpatients costs, a slowdown in hospital bed utilization, and the cost of technology in patient care, explains Chris Girod, principal and consulting actuary in Milliman’s San Diego office and a co-author of the report.

The good news? The pace of the increase is slowing. The 6.9% increase in total costs is the lowest annual rate of increase in more than a decade.

The MMI is comprised of five components: inpatient facility care, outpatient facility care, physician services, pharmacy, and miscellaneous other.

Among the MMI findings:

Outpatient facility costs posted its first single digit increase, 8.6%, in four years, but for the fifth year that increase outpaced all the other MMI components.

Outpatient facility care costs totaled $3,699, or 18% of a family of four’s annual healthcare bill. Girod explains that the level of insurer control is improving under contractual discount arrangements, but still isn’t on par with inpatient controls.

Inpatient facility utilization or the number of inpatient days for a covered population in a year has remained unchanged for several years. However, the patients who are hospitalized tend to require more intensive and expensive services that have helped boost the cost of treatment contributing to a 7.6% increase in the average charge per day costs.

Physician care costs reversed a four-year trend and increased by 5%. Girod says a number of things may have contributed to this cost bump, including evidence of some pushback by physicians in their contract negotiations with health plans.

Hospital inpatient costs ($6,531) and physician costs ($6,647) each account for 32% of a family of four’s total annual healthcare bill.

Pharmacy costs continued their roller coaster ride of cost increases and exceeded $3,000 for the first time. The 7.3% increase is down slightly from 2011’s 8%, but a significant increase over 2010’s 6%. Pharmacy costs totaled $3,056 or 15% of the family’s total annual healthcare bill. Girod says that while the shift to generics has helped slowed the growth in pharmacy costs, the expense of specialty drugs will have a growing impact on this cost trend.

The cost of miscellaneous other services such as durable medical equipment, ambulance services and home health posted a 6.7% increase to $795.

In addition to looking at costs on a nationwide basis, for the last five years the Index has looked at comparative healthcare costs in the same 14 cities across the country, including Chicago, Denver, and Los Angeles.

With a current annual cost of $24,965, Miami has topped the list for five years. Girod explains that Miami has a large number of healthcare practitioners and capacity helps drive the demand for healthcare services. Also, the practice of defensive medicine is more prevalent in the Miami area.

Phoenix was the least expensive with a cost of $18,365 for a family of four.

For the 2012 study, healthcare costs in 11 of the 14 cities exceeded $20,000 annually for a typical family of four. In 2011 only six of the 14 cities posted costs in excess of $20,000. While that could suggest an easing in the geographic differences in the cost of healthcare, Girod says a more likely explanation is that “the entire scale is shifting up, both at the bottom and the top, so we just ended up with more cities over that $20,000 threshold.”

The report notes that so far the Patient Protection and Affordable Care Act has had “only a limited effect on total healthcare costs for the illustrative family of four.”

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Medical Cost Advocate Nominated for Health Care Heroes Award

Doug

Medical Cost Advocate, Inc. has been named a finalist in the corporate achievement category in the 2012 NJBIZ Healthcare Heroes awards program. The Healthcare Heroes awards program honors individuals and organizations making a significant impact on the quality of healthcare in New Jersey. Shameless promotion but somebody’s got to do it!

Wyckoff, NJ (PRWEB) May 22, 2012 — Medical Cost Advocate, Inc., MedicalCostAdvocate.com has been named a finalist in the corporate achievement category in the 2012 NJBIZ Healthcare Heroes awards program.  The Healthcare Heroes award program, produced by NJBIZ, New Jersey’s premiere business news publication, is sponsored by Horizon Blue Cross Blue Shield of New Jersey, Hackensack University Medical Center, McElroy, Deutsch, Mulvaney & Carpenter, LLP, the New Jersey Hospital Association and WithumSmith+Brown, PC.
Finalists and winners were chosen by an independent panel of judges who are leaders in New Jersey Healthcare. Medical Cost Advocate was selected in the Corporate Achievement category. Finalists were also selected in ten other categories: Education Hero-Individual, Education Hero-Organization, Hospital of the Year, Innovation Hero-Individual, Innovation Hero-Organization, Nurse of the Year, Nursing Home/Assisted Living Facility of the Year, Physical Therapy Rehabilitation Center of the Year, Physician of the Year and Volunteer of the Year.

“Healthcare continues to grow in cost and complexity and families often have difficulty navigating these challenges without an expert,” commented Derek Fitteron, Medical Cost Advocate’s CEO. “We are honored that our advocates are being recognized for their hard work in providing assistance with medical bills for clients.”

The Healthcare Heroes awards finalists will be recognized and the winners in each category will be announced during a breakfast awards ceremony on June 19, 2012 at the Palace in Somerset Park in Somerset, New Jersey.
For more information about the NJBIZ Healthcare Heroes awards program or to reserve seats to the event, please contact Sarah Spangler of NJBIZ at (732) 246-5713.

About Medical Cost Advocate:
Medical Cost Advocate helps clients nationwide realize more value from health care through services that save time, reduce cost and provide expert guidance. The firm leverages years of experience and proprietary technology to reduce administrative burdens, solve healthcare claim issues and negotiate medical bills. As health care cost and complexity continue to increase, Medical Cost Advocate provides the assistance clients need to save money and achieve peace of mind.  To learn how a dedicated Medical Cost Advocate can manage your healthcare challenges, please visitlocalhost/wp1 or call (201) 891-8989.

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Billing Errors in Health Care Abound as System Heads for More Complexity

J Roberts

New coding requirements may create even more disarray in an already complex industry. The result could leave consumers with a greater sense of confusion in understanding medical bills.

Written by: Ruth McCambridge

Source: Cleveland Plain Dealer

As health care systems prepare for all of the many changes that the Affordable Care Act will entail, there is one that is relatively hidden from view: the ten-fold increase in billing codes that the federal government is planning to roll out next year (pushed back from a planned launch this year).

Stephen Parente, a professor of health finance and insurance at the University of Minnesota, claims that his research on medical billing found that up to 40 percent of claims sent between insurers and hospitals have errors. These errors, often caused by human error but sometimes the result of alleged fraud, may include double billing, billing for the wrong treatment, unexpected costs, or billing that is more than what an insurance contract allows. The American Medical Association claims these mistakes cost health care providers $17 billion last year and it blames insurance company practices, but others say the blame can be shared, and this article details many problems with hospital billing practices as well.

According to Kevin Theiss, a vice president at the Summa Health System, at the Summa Akron City Hospital, as many as 250 people may take part in the billing process, including intake workers, doctors and nurses and those who assign billing codes. He says that the potential for mistakes at the hospitals is “astronomical.” In the midst of all of this, a change is brewing that is likely to make the whole system even more impenetrable for consumers. That is, the federal government, which requires that all medical billing use the same set of 16,000 universal codes (called ICD-9 codes) to identify medical problems and treatments, is planning to increase the number of codes to 155,000. While rolling out these new codes has been delayed by a year, the project is apparently moving forward apace. Some, including the American Medical Association, are heralding the delay. Even before new codes are introduced, the complexity of the current system has created what the article describes as a “cottage industry” of experts that are there to advocate between institutional players.

“There are certified coders, ‘revenue cycle’ consultants, auditors who check claims, ‘denial management’ experts who step in for hospitals and doctors to help negotiate with payers for more money, and debt collectors who specialize in ‘accounts payable,’ or the bills hospitals and doctors think they can get the patients to pay if they press hard enough.

Consumers, in contrast, have no army of experts. They pretty much just have themselves and their bills.”

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Insurers Alter Cost Formula, and Patients Pay More

J Roberts

Beware of even greater out-of-pocket healthcare costs. Read the following article and learn how insurers are shifting the cost of out-of-network care to consumers.

Doug Benz / The New York Times

Despite a landmark settlement that was expected to increase coverage for out-of-network care, the nation’s largest health insurers have been switching to a new payment method that in most cases significantly increases the cost to the patient.

Jennifer C. Jaff, founder of Advocacy for Patients with Chronic Illness. She has Crohn’s disease.

The settlement, reached in 2009, followed New York State’s accusation that the companies  manipulated data they used to price such care, shortchanging the nation’s patients by hundreds of millions of dollars.

The agreement required the companies to finance an objective database of doctors’ fees that patients and insurers nationally could rely on. Gov. Andrew M. Cuomo, then the attorney general, said it would increase reimbursements by as much as 28 percent.

It has not turned out that way. Though the settlement required the companies to underwrite the new database with $95 million, it did not obligate them to use it. So by the time the database was finally up and running last year, the same companies, across the country, were rapidly shifting to another calculation method, based on Medicare rates, that usually reduces reimbursement substantially.

“It’s deplorable,” said Chad Glaser, a sales manager for a seafood company near Buffalo, who learned that he was facing hundreds of dollars more in out-of-pocket costs for his son’s checkups with a specialist who had performed a lifesaving liver transplant. “I could get balance-billed hundreds of thousands of dollars, and I have no protection.”

Insurance companies defend the shift toward Medicare-based rates under the settlement, which allowed any clear, objective method of calculating reimbursement. They say that premiums would be even costlier if reimbursements were more generous, and that exorbitant doctors’ fees are largely to blame.

But few dispute that as the nation debates an overhaul aimed at insuring everybody, the new realpolitik of reimbursement is leaving millions of insured families more vulnerable to catastrophic medical bills, even though they are paying higher premiums, co-payments and deductibles.

“They’re not getting what they think they’re paying for,” said Benjamin M. Lawsky, the superintendent of the New York State Department of Financial Services, whose investigators recently found that under the switch, 4.7 million New York State residents — 76 percent of those with out-of-network coverage — are facing reimbursement reductions of 50 percent or more.

The switch “certainly creates the appearance that insurers are trying to end-run the settlement and keep out-of-network payments low,” Mr. Lawsky said.

Mr. Lawsky, who worked for Mr. Cuomo when he was attorney general, is seeking legislation in New York State to require that minimum reimbursements be linked to the new database, known as Fair Health. (more…)

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Health care mandate is about personal responsibility

J Roberts

Is ObamaCare dead? The decision lies with the Supreme Court which is expected to rule sometime in June. Onething is for certain, the current model of paying for and subsidizing healthcare can not remain. Whether the law is repealed or not, the current system has to change. This, all of us can agree on.

Issac J.Bailey | The Myrtle Beach Sun

“Now, it is as plain as the spectacles on Antonin Scalia’s nose that opting out of the health-care market is about as realistic as opting out of dying.” – John Cassidy of the New Yorker.

Following the debate over the Affordable Care Act has reminded me of that old saw, everybody wants to get to heaven but nobody wants to die.

The public doesn’t want private insurance companies to be able to throw people off their rolls for the sin of getting too sick, or for denying them coverage because of a pre-existing condition, something they will no longer be able to do under the Affordable Care Act come 2014.

The public wants to keep in place the Reagan-era federal law that compels emergency rooms to treat whoever shows up, no matter if that person has not a dime to his name and won’t pay no matter how many harassing phone calls bill collectors make to their home.

But the public doesn’t want to be compelled to pay for those rights.

According to a variety of studies, from the independent Congressional scorekeeper the Congressional Budget Office to independent health care industry analysts, those with insurance are subsidizing those without to the tune of maybe $43 billion every year.

The annual premiums for those with health insurance are roughly $1,000 higher to make up for the unpaid bills of the uninsured.

According to the National Coalition on Healthcare, hospitals lose about $34 billion a year providing unpaid for care – services they are required to render because of federal law dating back to 1986. The group also said that “private insurance and some public payers pay an additional $37 billion on behalf of those with no insurance.”

What’s worse is that this is probably the least efficient, most wasteful way to operate the world’s most expensive health care system.

Justice Antonin Scalia alluded to it during this week’s debate when he said that one way to solve the problem would be to simply allow insurance companies the to right to throw sick patients off their rolls.

In fact, it is. Another way to solve the problem is to no longer guarantee access to emergency medical care, meaning that if you get into a car accident and can’t speak and your insurance card isn’t visible – or you don’t have insurance – medical officials should be able to deny you care, no matter how urgently you need it.

That’ll learn Americans who are not responsible enough to either purchase insurance without being compelled or have their insurance information tattooed to their forehead in case of an emergency. (Of course, if you suffer an ugly head trauma, that tattoo wouldn’t do any good.)

The Affordable Care Act has already done a variety of things, including slowing the rise in health care costs, convincing more medical institutions to go to a pay-for-quality rather than pay-for-quantity of care model, saving seniors tens of billions of dollars in drug costs and uncovering billions of dollars in fraud.

Because it has become a political lightning rod, all of those things and the contradictions being made by opponents are being overshadowed.

Conservatives have long claimed that they are the party of personal responsibility, yet conservatives have joined with a sizable number of liberals in opposition to the individual mandate, which will require everyone above a certain age who can afford it to buy health insurance.

The individual mandate is designed to make sure as many Americans as possible are paying into a system for which each of us is benefitting, to defray some of that $43 billion bill of annual uncompensated services, to assure that the insured no longer have to pay an extra $1,000 a year to pay for the uninsured.

If not the individual mandate, then something needs to be implemented that will accomplish the same goal – something those same conservatives seem to not want to do.

Or, we can take Justice Scalia’s advice and repeal all federal laws that compel medical officials to provide services to people who can’t pay for them, emergency or not.

The problem we’ve long had with balancing our books is that we too frequently demand things for which we don’t want to pay.

The individual mandate is unpopular largely because it threatens to shift that paradigm.

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Insurance companies to blame for ‘surprise’ medical bills: state report

J Roberts

Are you paying more for healthcare even when using an in-network provider? A recent report from the Department of Financial Services in New York State found that an alarming amount of consumers are faced with a greater out-of-pocket expense as insurers and providers are shifting the cost of care to them.

Greg B. Smith / NEW YORK DAILY NEWS

Big insurance companies and some greedy doctors are to blame for the growing number of New Yorkers whacked with “surprise” medical bills, a state inquiry has found.

Department of Financial Services Superintendent Benjamin Lawsky Wednesday released the results of his probe into the unanticipated bills that are slamming consumers.

“Simply put, surprise medical bills are causing some consumers to go broke,” the report states.

The Daily News has highlighted this problem with a series of stories over the last two months. Lawsky promised to push for reforms.

“Every time I have mentioned this issue to a crowd of people, I see nodding heads,” he said. “If that’s happening, it is a huge issue.”

His agency reviewed 2,000 complaints from 2011 and surveyed the 11 big insurers and HMOs who cover 95% of the New Yorkers who have health insurance.

The review found that patients who went out of their way to make sure the non-emergency treatment they sought was covered by their plan still wound up with bills from specialists — such as assistant surgeons, anesthesiologists and radiologists — who were outside their plan.

That’s because insurers often don’t make clear who will be involved and how much it will cost, the report found.

One patient who complained to the Financial Services department made sure to go to an in-network hospital for brain surgery but wound up with a surgeon who wasn’t in his plan. The surgeon billed him $40,091 and the insurer covered only $8,386 – leaving him to cough up $31,704.

Sherry Tomasky, advocacy director of the American Cancer Society, praised the report and criticized the “undue financial burdens that are often placed on (patients) at a time when they are least able to handle it – both financially and emotionally.”

DFS quoted ridiculously complex language one insurer cited in claiming it met its disclosure requirements: “reimbursement is based on a percentile of national prevailing charge data compiled for a specific procedure and adjusted for geographic differences.”

“Unfortunately, language such as this does not provide consumers with meaningful information,” the department wrote.

The review also documented complaints that a “small but significant number” of doctors “appear to take advantage of the fact that emergency care must be delivered” by inflating bills for treatment that’s not covered.

The survey found out-of-pocket costs for out-of-network radiology or x-ray services during emergency care averaged $2,910; for anesthesiology it was $1,794.

The Health Plan Association, the lobby group representing insurers, praised the report for shining a light on excessive bills by doctors for ER care.

“These egregious practices contribute to the rising cost of health insurance for New Yorkers,” Paul F. Macielak, HPA president, said.

The report also noted that insurers have been reducing coverage for out-of-network care and making it tougher to file claims.



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Medical Debts Put Patients at Risk of Financial Collapse

Doug

The crisis of American health care is not limited to uninsured people, unable to pay for their care. This article shows a deepening problem of working people with insurance unable to pay for treatment of serious illnesses.

By Lindy Washburn – The Bergen Record
First Posted: January 27, 2012

HACKENSACK, N.J. — Frances Giordano found out she had lung cancer in June. After that, the bad news just kept coming.
First, she discovered that even with a good job and health insurance, her medical expenses were more than she could afford on disability.

Then she started slipping into debt, like millions of other Americans who don’t have the cash to cover their medical bills. Hospitals expect to be paid promptly and offer little leeway to insured patients. Unpaid bills go to collection agencies, damaging a person’s credit history for years.

Finally, she learned that fighting for her life was not her only battle or maybe even her toughest. When she finished her chemotherapy in December, she was fired. “Due to changes in business operations,” wrote her employer of more than six years, “We can no longer hold your position open.”

It arrived nine days before Christmas.

“I’m a good person,” the 58-year-old Giordano said in an interview, crying. “I worked hard. Isn’t having cancer enough?”
The crisis in American health care is not limited to hospital emergency rooms where uninsured people wait for care. It also is found in a neat, three-bedroom house in Dumont, N.J., occupied by a widow who worked full time, raised two kids and likes to get her nails done occasionally.

In less than a year, Giordano lost her health and her job. Now, she’s afraid she’ll lose her good credit and her health coverage.

In the lonely hours of the night, she said she thinks about giving up.

Giordano had health insurance throughout her illness. She didn’t have to beg for treatment and was not denied it. She loves the surgeon and oncologist and nurses whose care, she hopes, will give her many more good days with her first grandchild, born in July.

But she may be ruined financially. In this country, people can go broke if they get sick.

(more…)

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